Critical care rotation impact on pediatric resident mental health and burnout

Resident Burnout on the Internal Medicine Ward

BACKGROUND

Burnout is common among medical trainees. Whether brief periods of training on the internal medicine ward leads to resident burnout is unknown.

METHODS

A survey-based study was conducted at a single academic institution. Medical residents undertaking four-week rotations on the internal medicine ward were included. Burnout was measured at the beginning and end of each rotation using the Maslach Burnout Inventory - Human Services Survey. Burnout was defined as either an emotional exhaustion score of ≥ 27 or a depersonalization score of ≥ 10. Self-reported workplace conditions, behaviors and attitudes were recorded.

RESULTS

The survey response rate was 71% and included 148 participants. The overall prevalence of burnout was 17% higher at the end of the rotation compared to the beginning of the rotation (71% vs. 54%; P < 0.001). Forty-three percent of residents without pre-rotation burnout developed post-rotation burnout. Residents with post-rotation burnout were more likely to report at least one suboptimal behavior or attitude related to patient care or professionalism (84% vs. 35%; P < 0.001). Respondents with new onset burnout were less likely to report being appreciated for their work, having their role as a learner emphasized, and receiving satisfactory support from allied healthcare professionals. New onset burnout was inversely associated with completing a second consecutive internal medicine ward rotation (adjusted OR 0.19; 95% CI, 0.04-0.90; P = 0.04).

CONCLUSION

Seven in ten residents are in a state of burnout after completing internal medicine ward rotations. Interventions to mitigate burnout development during periods of high intensity clinical training are needed.

Preparing for the PICU: A Qualitative Study of Residents as They Prepare for Their First Pediatric Critical Care Rotation

Learning critical care medicine in the pediatric intensive care unit (PICU) can be stressful. Through semistructured interviews ( n  = 16), this study explored the emotions, perceptions, and motivations of pediatric medicine (PM) and emergency medicine (EM) residents, as they prepared for their first PICU rotation. Qualitative data were collected and analyzed using the grounded theory method. Three resultant themes emerged: (1) residents entered the PICU with a range of intense emotions and heightened expectations; (2) they experienced prior history of psychologically traumatic learning events (adverse learning experiences or ALEs); and (3) informed by ALEs, residents prepared for their rotation by focusing heavily on their most basic level of physiological needs and adopting a survival mindset prior to the start of the rotation. These three themes led to a substantive, or working, theory that ALE-associated events may affect how residents approach upcoming learning opportunities. Consequently, adapting a trauma-informed approach as a component of medical education may improve resident learning experiences in the PICU and beyond.

"Still Caring for the Family": Condolence Expression Training for Pediatric Residents

CONTEXT

Insufficient communication from the medical team following a child's death may compound parental grief. Pediatric residents care for children who die, yet the landscape of condolence expression education within residency programs has not been studied.

OBJECTIVES

The objective of this study was to evaluate pediatric residents' levels of experience and comfort with condolence expression and to assess their needs and desires for training in condolence expression.

METHODS

A cross-sectional, mixed-methods survey was developed by palliative care clinicians in collaboration with bereaved parents. In 2020, following pilot testing, an electronic survey measuring resident experience with, comfort with, and training on condolence expression was distributed to 202 third-year pediatric residents across 17 Accreditation Council for Graduate Medical Education-accredited programs representing varying sizes and geographic regions.

RESULTS

Ten percent of pediatric residents surveyed reported having training on condolence expression. Almost all residents considered condolence expression to be beneficial for bereaved families and most for clinicians, too, yet very very few had formally expressed condolences in their roles as physicians: 83.1% had never written a condolence letter; 85% had never made a condolence phone call; and 90.5% had never attended a memorial event. Commonly reported barriers to condolence expression included lack of experience and training, as well as concern about upsetting families.

CONCLUSIONS

Pediatric residents lack comfort with and training in condolence expression and desire education to address these gaps. These findings should inform development and investigation of educational resources and training opportunities for residents to learn and practice compassionate provision of condolences to grieving families.

What is the prevalence and risk factors of burnout among pediatric intensive care staff (PICU)? A review

Staff in the paediatric intensive care unit work with children and their families in an area of high acuity, mortality, and morbidity. There is complexity due to technological advancements and confronting psychosocial situations. With increasing reports of the threat of burnout to healthcare professionals it is imperative to understand the prevalence of burnout and the determinants of risk factors for staff to work in the paediatric intensive care unit (PICU) in order to inform interventions that reduce risk and support growth and wellbeing of this specialised workforce. We conducted electronic searches of PUBMED, Medline, CINAHL and PsychINFO. Studies meeting eligibility inclusion criteria comprised English text, publication dates 1995 to 2019, use of standardized measures to assess prevalence and risk factors for burnout where the PICU staff data was reported separately and contained sample sizes ≥10 PICU staff. Two reviewers independently identified and extracted citations and assessed the quality of papers using two standardised reporting tools. Twenty studies were included in the final review. Due to the heterogeneity of the included studies a descriptive account of the studies was developed. Outcomes reported included prevalence and levels of burnout reported across professional disciplines, reported scoring criteria for burnout, risk and protective factors for burnout, comparative populations, systems and social context associated with burnout and study strengths and limitations. Most studies were cross-sectional, used a single measure of burnout and focussed on either physicians or nurses. Of the 20 studies reported 62% reported high burnout, 19% moderate burnout, and 19% reported low levels of burnout. Inconsistency was identified in adherence to recommended cut-off scores or reporting for the categorisation of burnout, which contributed to a lack of clarity in the interpretation of prevalence and severity. Reports of factors associated with increased risk and likely protective factors for burnout were often contradictory suggesting that burnout may be situational; dependent upon personal, environmental, leadership, cultural and patient factors within the PICU. This review revealed that determining levels and risk of burnout in PICU staff remains problematic. Further research which examines the experiences of all members of the multidisciplinary team and identification of factors that affect the development of burnout, including those which are protective, is required.

Death Cafés for prevention of burnout in intensive care unit employees: study protocol for a randomized controlled trial (STOPTHEBURN)

BACKGROUND

Burnout is an occupational syndrome that leads to mental health problems, job turnover, and patient safety events. Those caring for critically ill patients are especially susceptible due to high patient mortality, long hours, and regular encounters with trauma and ethical issues. Interventions to prevent burnout in this population are needed. Preliminary studies suggest debriefing sessions may reduce burnout. This study aims to assess whether participation in regular debriefing can prevent burnout in intensive care unit (ICU) clinicians.

METHODS

A randomized controlled trial will be conducted in two large academic medical centers. Two hundred ICU clinicians will be recruited with target enrollment of 100 physicians and 100 non-physicians (nurses, pharmacists, therapists). Participants must have worked in the ICU for the equivalent of at least 1 full time work week in the preceding 4 weeks. Enrolled subjects will be randomized to virtually attend biweekly debriefing sessions facilitated by a psychotherapist for 3 months or to a control arm without sessions. Our debriefs are modeled after Death Cafés, which are informal discussions focusing on death, dying, loss, grief, and illness. These sessions allow for reflection on distressing events and offer community and collaboration among hospital employees outside of work. The primary outcome is clinician burnout as measured by the Maslach Burnout Inventory (MBI) Score. Secondary outcomes include depression and anxiety, as measured by the Patient Health Questionnaire 8 (PHQ-8) and Generalized Anxiety Disorder 7-item scale (GAD-7), respectively. Questionnaires will be administered prior to the intervention, at 1 month, at 3 months, and at 6 months after enrollment. These values will be compared between groups temporally. Qualitative feedback will also be collected and analyzed.

DISCUSSION

With ICU clinician burnout rates exceeding 50%, Death Café debriefing sessions may prove to be an effective tool to avert this debilitating syndrome. With COVID-19 limiting social interactions and overloading ICUs worldwide, the virtual administration of the Death Café for ICU clinicians provides an innovative strategy to potentially mitigate burnout in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04347811 . Registered on 15 April 2020.

Improving the Resident Educational Experience in a Level IV Neonatal/Infant Intensive Care Unit

Supplemental Digital Content is available in the text.

The neonatal/infant intensive care unit (N/IICU) at the Children’s Hospital of Philadelphia is a 98-bed, level IV unit through which second-year pediatric residents rotate monthly. We developed a quality improvement project to improve the resident educational experience using goal setting. Primary objectives were to increase resident educational goal identification to 65% and goal achievement to 85% by June 2017. Secondary objectives were to (1) increase in-person feedback from fellows and/or attendings to 90% by June 2017 and (2) sustain improvements through June 2018.

Impact of Caring for Terminally Ill Children on Physicians: A Systematic Scoping Review

INTRODUCTION

Caring for terminally ill children influences nurses' and allied health provider's quality of life, ability to provide personalized, dignified and empathetic care and even their concepts of personhood. In the absence of data this review utilizes the Ring Theory of Personhood (RToP) to evaluate how a physician's concept of personhood is affected caring for terminally ill children in order to better support them holistically.

METHODS

Using PRISMA Guidelines, 14 researchers carried out independent searches of PubMed, CINAHL, PsycINFO, Cochrane Library and gray literature databases for articles published between 2000 to 2019. Concurrent and independent employment of content and thematic analysis (Split Approach) was used to enhance the trustworthiness of the analysis.

RESULTS

13,424 titles and abstracts were retrieved, 188 full texts were evaluated, and 39 articles were included and analyzed. Identical categories and themes identified using the Split Approach suggest that caring for dying children in PPC impacts the physician's professional identity, clinical decision making, personal well-being and relationships. The data also suggests that the magnitude of these effects depends on the presence of protective and risk factors.

CONCLUSION

Aside from providing a novel insight into the upon the physician, this review proffers a unique approach to accounting for the presence, magnitude and influence of incoming catalysts, resultant conflicts, and protective and risk factors upon the physician's personhood. Further studies into the changes in personhood are required. Design of a personalized assessment tool based on the RToP will help direct timely, appropriate and personalized support to these physicians.

Burnout in Pediatric Residents: Three Years of National Survey Data

BACKGROUND

We aimed to describe the national epidemiology of burnout in pediatric residents.

METHODS

We conducted surveys of residents at 34 programs in 2016, 43 programs in 2017, and 49 programs in 2018. Survey items included the Maslach Burnout Inventory, demographics, program characteristics, personal qualities, experiences, and satisfaction with support, work-life balance, and learning environment. Analyses included cross-sectional comparisons and cross-sectional and longitudinal regression.

RESULTS

More than 60% of eligible residents participated; burnout rates were >50% in all years and not consistently associated with any demographic or residency characteristics. Cross-sectional associations were significant between burnout and stress, sleepiness, quality of life, mindfulness, self-compassion, empathy, confidence in providing compassionate care (CCC), being on a high-acuity rotation, recent major medical error, recent time off, satisfaction with support and career choice, and attitudes about residency. In cross-sectional logistic regression analyses, 4 factors were associated with an increased risk of burnout: stress, sleepiness, dissatisfaction with work-life balance, and recent medical error; 4 factors were associated with lower risk: empathy, self-compassion, quality of life, and CCC. Longitudinally, after controlling for 2017 burnout and 2018 risk factors (eg, recent error, sleepiness, rotation, and time off), 2017 quality of life was associated with 2018 burnout; 2017 self-compassion was associated with lower 2018 stress; and 2017 mindfulness, empathy, and satisfaction with learning environment and career choice were associated with 2018 CCC.

CONCLUSIONS

A majority of residents met burnout criteria. Several identified factors (eg, stress, sleepiness, medical errors, empathy, CCC, and self-compassion) suggest targets for interventions to reduce burnout in future studies.

Pediatric Resident Experience Caring for Children at the End of Life in a Children's Hospital

OBJECTIVE

Pediatric residents are expected to be competent in end-of-life (EOL) care. We aimed to quantify pediatric resident exposure to patient deaths, and the context of these exposures.

METHODS

Retrospective chart review of all deceased patients at one children's hospital over 3 years collected patient demographics, time, and location of death. Mode of death was determined after chart review. Each death was cross-referenced with pediatric resident call schedules to determine residents involved within 48 hours of death. Descriptive statistics are presented.

RESULTS

Of 579 patients who died during the study period, 46% had resident involvement. Most deaths occurred in the NICU (30% of all deaths); however, resident exposure to EOL care most commonly occurred in the PICU (52% of resident exposures) and were after withdrawals of life-sustaining therapy (41%), followed by nonescalation (31%) and failed resuscitation (15%). During their postgraduate year (PGY)-1, <1% of residents encountered a patient death. During PGY-2 and PGY-3, 96% and 78%, respectively, of residents encountered at least 1 death. During PGY-2, residents encountered a mean of 3.5 patient deaths (range 0-12); during PGY-3, residents encountered a mean of 1.4 deaths (range 0-5). Residents observed for their full 3-year residency encountered a mean of 5.6 deaths (range 2-10).

CONCLUSIONS

Pediatric residents have limited but variable exposure to EOL care, with most exposures in the ICU after withdrawal of life-sustaining technology. Educators should consider how to optimize EOL education with limited clinical exposure, and design resident support and education with these variable exposures in mind.

Exploring burnout and the association with the educational climate in pediatric residents in Thailand

BACKGROUND

This study, undertaken in Bangkok, Thailand, explored the extent to which paediatric residents in a non-Western setting experienced burnout and the potential association with factors in the medical educational climate and work-related quality of life.

METHODS

An exploratory sequential mixed methods design was employed in a cross-sectional study. The initial, quantitative phase used the validated Maslach Burnout Inventory, the Postgraduate Hospital Educational Environmental Measure (PHEEM) and Work-Related Quality of Life scale (WRQoL). Regression analysis was used to identify the correlation between burnout and educational climate. Thereafter, residents in all years with high levels of burnout on subscales were interviewed individually.

RESULTS

Forty-one paediatric residents completed the three questionnaires. None had high levels related to burnout in all three domains (emotional exhaustion, high level of depersonalization and perceived low personal accomplishment), seven (17%) showed high levels in two out of three domains. Emotional exhaustion and educational climate (perceptions of role autonomy, perceptions of teaching, perceptions of social support) were correlated with work-related quality of life. In the interviews, the main themes related to burnout were inappropriate tasks, teachers and teaching styles, the perception of knowledge insecurity relating to task performance, time dimensions, life crisis during training, role expectations and work allocation clarity, and facilities such as accommodation.

CONCLUSIONS

The study, in a non-Western setting, demonstrated a positive relation between educational climate and work-related quality of life. To help reduce the risk of burnout, the following factors were identified: minimize unnecessary or duplicated workload, schedule time arrangements to avoid extension of regular duty hours, and clearly define role expectations. The impact of inappropriate tasks, teachers and teaching styles (including unsafe environment) on the incidence of burnout was also highlighted. Additional studies focusing on teaching styles, safe learning climate and mistreatment in a non-Western context are needed.

Do Mindfulness and Self-Compassion Predict Burnout in Pediatric Residents?

PURPOSE

Burnout symptoms are common among health professionals. Gaps remain in understanding both the stability of burnout and compassion over time and relationships among burnout, self-compassion, stress, and mindfulness in pediatric residents.

METHOD

The authors conducted a prospective cohort study of residents at 31 U.S. residency programs affiliated with the Pediatric Resident Burnout-Resilience Study Consortium. Residents completed online cross-sectional surveys in spring 2016 and 2017. The authors assessed demographic characteristics and standardized measures of mindfulness, self-compassion, stress, burnout, and confidence in providing compassionate care.

RESULTS

Of 1,108 eligible residents, 872 (79%) completed both surveys. Of these, 72% were women. The prevalence of burnout was 58% and the level of mindfulness was 2.8 in both years; levels of stress (16.4 and 16.2) and self-compassion (37.2 and 37.6) were also nearly identical in both years. After controlling for baseline burnout levels in linear mixed-model regression analyses, mindfulness in 2016 was protective for levels of stress and confidence in providing compassionate care in 2017. Self-compassion in 2016 was protective for burnout, stress, and confidence in providing compassionate care in 2017; a one-standard-deviation increase in self-compassion score was associated with a decrease in the probability of burnout from 58% to 48%.

CONCLUSIONS

Burnout and stress were prevalent and stable over at least 12 months among pediatric residents. Mindfulness and self-compassion were longitudinally associated with lower stress and greater confidence in providing compassionate care. Future studies are needed to evaluate the effectiveness of training that promotes mindfulness and self-compassion in pediatric residents.

The physician as person framework: How human nature impacts empathy, depression, burnout, and the practice of medicine

Troubling trends of depression, burnout, and declines in empathy have been demonstrated amongst residents. I argue that while interventions in medical education are helpful, a new perspective on the issue requires a more fundamental understanding of this problem. Rather than training physicians to act in certain ways, we must first recognize that physicians are first and foremost people. This core principle forms the basis of the framework that educators can use to help learners. Five areas of humanity with implications for physicians are discussed: 1) Physicians and patients share their humanity; 2) People are self-integrated in both personal and professional lives; 3) People are dynamic, thoughtful, and emotional; 4) People are finite; and 5) People are moral beings. Recognizing these can mitigate various factors contributing to current struggles. I also discuss practical implications of this framework to help residents flourish.