"It's Not Just Time Off": A Framework for Understanding Factors Promoting Recovery From Burnout Among Internal Medicine Residents

Prevalence and Associated Factors of Burnout in Pediatric General Surgery Fellows

INTRODUCTION

Pediatric surgeons are experiencing burnout at similar rates to other subspecialists; however, little is known about the prevalence of burnout in pediatric general surgery fellows. This study aims to determine the prevalence of burnout in pediatric general surgery trainees.

METHODS

The Maslach Burnout Inventory and a survey of personal and training characteristics were distributed to current and recently graduated pediatric surgery fellows. Higher Maslach Burnout Inventory subscores of emotional exhaustion (EE) and depersonalization (DP) indicate higher levels of burnout. Descriptive statistics were used to describe respondent characteristics. Burnout, as a dichotomous variable, was compared by chi-square test, and subscale scores werecompared by nonparametric tests for a variety of factors.

RESULTS

The response rate was 41% (52/126); 15% were first-year fellows, 54% were second-year fellows, and 31% were recent graduates. The majority were 30-39 y old (83%) and female (71%). The median [IQR] scores for EE, DP, and personal accomplishment were 23 [17-36], 8 [2-12.3], and 38 [34-41], respectively, with no significant differences by training year. Eighteen percent of respondents met burnout criteria based on high-risk EE subscores in combination with high-risk DP subscores, and 44% and 23.1% of respondents had high-risk EE and DP subscores, respectively. Factors associated with higher EE subscores were fewer hours of sleep and taking home call.

CONCLUSIONS

Pediatric surgery fellows experience high levels of burnout along with a high frequency of high-risk EE and DP scores. Lack of sleep and home call may be contributory, and efforts to combat burnout should specifically address these factors.

Best Practices: Burnout Is More Than Binary

Burnout among radiologists is increasingly prevalent, with potential for substantial negative impact on physician well-being, care delivery, and health outcomes. To evaluate this phenomenon using reliable and accurate means, validated quantitative instruments are essential. Variation in measurement can contribute to wide-ranging findings. This article evaluates radiologist burnout rates globally and dimensions of burnout as reported using different validated instruments and provide guidance on best practices to characterize burnout. Fifty-seven studies between 1990 and 2023 were included in a systematic review, and 43 studies were included in a meta-analysis of burnout prevalence using random effects models. Reported burnout ranged from 5% to 85%. With the Maslach Burnout Inventory (MBI), burnout prevalence varied significantly depending on instrument version. Among MBI subcategories, the prevalence of emotional exhaustion was 54% (95% CI, 45-63%), depersonalization was 52% (95% CI, 41-63%), and low personal accomplishment was 36% (95% CI, 27-47%). Other validated burnout instruments showed less heterogeneous results; studies using the Stanford Professional Fulfillment Index yielded burnout prevalence of 39% (95% CI, 34-45%), whereas the Validated Single-Item instrument yielded 34% (95% CI, 29-39%). Standardized instruments for prevalence alongside multidimensional profiles capturing experiences may better characterize radiologist burnout, including change over time.

The role of spirituality, religiosity, and self-care on infection preventionist well-being: Results from a national survey in the United States

BACKGROUND

The degree to which religiosity, spirituality, and self-care practices can improve well-being among infection preventionists is not well understood.

METHODS

We surveyed infection preventionists from a random sample of United States hospitals in 2021. Multivariable logistic regression models were used to examine the associations between measures of spirituality, religiosity, and self-care and well-being.

RESULTS

Our response rate was 47% (415/881). A total of 49% of respondents reported burnout, 17% reported increased feelings of uncaring, and 69% would choose to become an infection preventionist again. Most respondents found importance in spiritual well-being (88%), religious beliefs (82%), and self-care practices (87%). Spiritual well-being was associated with increased odds of choosing to become an infection preventionist again (odds ratio = 2.32, 95% confidence interval = 1.19-4.53, P = .01).

DISCUSSION

Our national survey provides evidence that spiritual importance is associated with career satisfaction among infection preventionists. Our findings contribute to a general body of evidence suggesting spiritual importance may translate to higher flourishing and well-being via serving a higher purpose.

CONCLUSIONS

Promoting spiritual well-being may positively influence career satisfaction and overall well-being among infection preventionists.

Burnout in Graduate Medical Education: Uncovering Resident Burnout Profiles Using Cluster Analysis

Background

Burnout is common among residents and negatively impacts patient care and professional development. Residents vary in terms of their experience of burnout. Our objective was to employ cluster analysis, a statistical method of separating participants into discrete groups based on response patterns, to uncover resident burnout profiles using the exhaustion and engagement sub-scales of the Oldenburg Burnout Inventory (OLBI) in a cross-sectional, multispecialty survey of United States medical residents.

Methods

The 2017 ACGME resident survey provided residents with an optional, anonymous addendum containing 3 engagement and 3 exhaustion items from the OBLI, a 2-item depression screen (PHQ-2), general queries about health and satisfaction, and whether respondents would still choose medicine as a career. Gaussian finite mixture models were fit to exhaustion and disengagement scores, with the resultant clusters compared across PHQ-2 depression screen results. Other variables were used to demonstrate evidence for the validity and utility of this approach.

Results

From 14 088 responses, 4 clusters were identified as statistically and theoretically distinct: Highly Engaged (25.8% of respondents), Engaged (55.2%), Disengaged (9.4%), and Highly Exhausted (9.5%). Only 2% of Highly Engaged respondents screened positive for depression, compared with 8% of Engaged respondents, 29% of Disengaged respondents, and 53% of Highly Exhausted respondents. Similar patterns emerged for the general query about health, satisfaction, and whether respondents would choose medicine as a career again.

Conclusion

Clustering based on exhaustion and disengagement scores differentiated residents into 4 meaningful groups. Interventions that mitigate resident burnout should account for differences among clusters.

Giving Literal Thanks: An ACGME-Sponsored Initiative to Bring Residents Back to the Bedside

Background Resident burnout is at an all-time high. In response, the Accreditation Council for Graduate Medical Education (ACGME) developed the Back to Bedside grant for resident-led burnout interventions that increase the time residents spend with patients. Objective We designed a resident-patient reading intervention, Giving Literal Thanks (GLT), intended to increase meaningful time residents spend with patients and thereby decrease burnout. Methods All 65 pediatric residents rotating through our academic hospital's inpatient units from Fall 2019 through Fall 2021 were invited to read and gift books to their patients. We studied our intervention's relationship to resident burnout using a convergent mixed-methods design, including anonymous, unlinked pre-, peri-, and post-intervention surveys and focus groups. Qualitative and quantitative data were analyzed separately, then integrated to describe burnout pre- and post-intervention. Results Forty-one of 65 residents (63.1%) completed pre-intervention surveys, and 8 of 65 (12.3%) completed post-intervention surveys. Twenty-seven resident-patient reading interactions were recorded, and 2 focus groups were held (1 pre- and 1 post-intervention). Five themes were identified: (1) limited opportunities exist to spend time at the bedside; (2) spending time at the bedside is valuable; (3) other responsibilities may preclude time at the bedside; (4) GLT could promote positive outcomes; and (5) GLT might not be the right tool to reduce burnout. Further quantitative data analysis was prevented by low survey response rates. While GLT was positively received and feasible, we were unable to show an improvement in burnout. Conclusions GLT was well-regarded but may not improve resident burnout.

Implementation of a Near-Peer Support Program to Improve Trainee Well-Being after Patient Safety Events

Adverse events can take an emotional toll on physicians, which, left unprocessed, can have negative impacts on well-being, including burnout and depression. Peer support can help mitigate these negative effects. Structured programs train physicians to aid colleagues in processing work-related experiences and emotions such as guilt and self-doubt. Although such programs are common for faculty, peer support for resident physicians has not been adequately addressed, and few programs have been described in the literature. Residency is a vulnerable time of professional identity formation, and providing support has specific challenges. The power dynamics and distance between lived experiences limit the utility of faculty peer support programs. Some institutions have trained residents to provide peer support, but widespread implementation may be difficult because of limited resident time and comfort in providing support. Chief residents (CRs), however, are close to residents in training yet experienced enough to afford perspective and are uniquely situated to provide "near-peer" support. We describe the implementation of a CR near-peer support program in which an established peer support framework was adapted to add elements specific to resident stressors and CR-resident relationships. One faculty member and two outgoing CRs lead a 2-hour workshop that is built into existing CR onboarding to ensure sustainability. The workshop combines large-group didactics and small-group breakouts, using clinical vignettes and simulated near-peer support conversations. To date, 36 CRs have been trained. CR near-peer support can serve as a model for programs in which true resident peer support is not feasible.

Professional identity formation: linking meaning to well-being

Trainee distress and burnout continue to be serious concerns for educational programs in medicine, prompting the implementation of numerous interventions. Although an expansive body of literature suggests that the experience of meaning at work is critical to professional wellbeing, relatively little attention has been paid to how this might be leveraged in the educational milieu. We propose that professional identity formation (PIF), the process by which trainees come to not only attain competence, but additionally to "think, act and feel" like physicians, affords us a unique opportunity to ground trainees in the meaningfulness of their work. Using the widely accepted tri-partite model of meaning, we outline how this process can contribute to wellbeing. We suggest strategies to optimize the influence of PIF on wellbeing, offering curricular suggestions, as well as ideas regarding the respective roles of communities of practice, teachers, and formative educational experiences. Collectively, these encourage trainees to act as intentional agents in the making of their novel professional selves, anchoring them to the meaningfulness of their work, and supporting their short and long-term wellbeing.

Proactive Coaching in General Surgery Internship: Incorporating Well-being Practices into Resident Professional Life

OBJECTIVE

Coaching can provide learners with space to reflect on their performance while ensuring well-being and encouraging professional achievement and personal satisfaction outside of traditional mentorship and teaching models. We hypothesized that a proactive coaching program for general surgery interns coupled with individualized learning plans would help build foundational skills necessary for residency success and facilitate the incorporation of well-being practices into resident professional life. Here, we present the development, implementation, and outcomes of a novel well-being coaching program for surgical interns.

DESIGN AND SETTING

A well-being coaching program was developed and implemented from July 2020 through June 2021 at a single university-based surgical residency program. To assess impact of the coaching program, we designed a mixed-methods study incorporating end-of-program survey results as well as participant narratives from commitment-to-act statements for thematic content.

PARTICIPANTS

All 32 general surgery interns participated in aspects of the coaching program.

RESULTS

The end-of-program survey was completed by 19/32 (59%) interns and commitment-to-act statements were completed by 22/32 (69%). The majority (89%) of survey respondents "agreed" or "strongly agreed" that the longitudinal intern coaching program helped them reach goals they had set for themselves this academic year; 15/19 (79%) noted that the coaching experience was effective in promoting well-being practices in their life. Well-being and professional goals were identified as major themes in the end-of-the-year commitment-to-act statements. Statements specifically mentioned resources highlighted and skills taught in our coaching program such as mindfulness techniques, gratitude journals, and self-compassion strategies.

CONCLUSIONS

Our study illustrates the effectiveness of a coaching pilot program on promoting well-being practices in a university-based general surgery internship and can be a roadmap with proven efficacy and measurable outcomes.

"Going through the motions": A qualitative exploration of the impact of emergency medicine resident burnout on patient care

Objectives

Burnout occurs frequently in emergency medicine (EM) residents and has been shown to have a negative impact on patient care. The specific effects of burnout on patient care are less well understood. This study qualitatively explores how burnout may change the way EM residents provide patient care.

Methods

Qualitative data were obtained from a sample of 29 EM residents in four semistructured focus groups across four institutions in the United States in early 2019. Transcripts were coded and organized into major patient care themes.

Results

Residents described many ways in which feelings of burnout negatively impacted patient care. These detrimental effects most often fit into one of four main themes: reduced motivation to care for patients, poor communication with patients, difficult interactions with health care colleagues, and impaired decision making.

Conclusions

According to EM residents, burnout negatively impacts several important aspects of patient care. Resident engagement with clinical care, communication with patients and colleagues, and clinical care may suffer as a result of burnout.

The moderating role of sociodemographic and work-related variables in burnout and mental health levels of Mexican medical residents

Objective

To explore the moderating effects of sociodemographic and work-related variables on levels of burnout and mental health among medical residents.

Method

A cross-sectional online survey was administered at the beginning of the second wave of COVID-19 at different public teaching hospitals where medical residents practiced in Mexico City. A total of 201 medical residents of different years completed the survey.

Results

Different univariate inferential analyses on the level of burnout and mental health indices showed significant differences between sex, marital status, previous reports of physical illness or psychological conditions, and residency ranking. However, the effect sizes of those differences were of low to medium size. A predictive path analysis revealed that the three stages of burnout (emotional exhaustion, depersonalization, and achievement dissatisfaction) negatively affect psychological wellbeing and positively affect psychological distress. Finally, even though sociodemographic variables showed some significant variation, the effect sizes were small and did not moderate the direct effect of burnout on mental health indices.

Conclusions

Medical residents deling with every day medical situations, will be exposed to stressors that might increase the probability to experience emotional exhaustion. This would negatively affect levels of wellbeing and positively affect distress, despite their sociodemographic characteristics.

Factors Associated With Burnout in Physical Medicine and Rehabilitation Residents in the United States

OBJECTIVES

The aims of the study were to determine the prevalence of burnout in physical medicine and rehabilitation residents in the United States and to identify the personal- and program-specific characteristics most strongly associated with residents reporting burnout.

DESIGN

This was a cross-sectional survey of US physical medicine and rehabilitation residents. Emotional exhaustion, depersonalization, and burnout were assessed using two validated items from the Maslach Burnout Inventory. Associations of burnout with demographics and personal factors, residency program characteristics, perceived program support, and work/life balance were evaluated.

RESULTS

The survey was completed by 296 residents (22.8%), with 35.8% of residents meeting the criteria for burnout. Residents' perception of not having adequate time for personal/family life was the factor most strongly associated with burnout (χ2 = 93.769, P < 0.001). Residents who reported inappropriate clerical burden and working more than 50 hrs/wk on inpatient rotations were most likely to report that they did not have adequate time for personal/family life. Faculty support (χ2 = 41.599, P < 0.001) and performing activities that led residents to choose physical medicine and rehabilitation as a specialty (χ2 = 93.082, P < 0.001) were protective against burnout.

CONCLUSIONS

Residents reporting having inadequate time for their personal/family life was most strongly associated with physical medicine and rehabilitation resident burnout, although many personal and program characteristics were associated with burnout.

Effect of a Novel Online Group-Coaching Program to Reduce Burnout in Female Resident Physicians: A Randomized Clinical Trial

Importance

Female resident physicians are disproportionately affected by burnout, which can have serious consequences for their well-being and career trajectory. Growing evidence supports the use of professional coaching to reduce burnout in resident physicians, yet individual coaching is resource intensive and infeasible for many training programs.

Objective

To assess whether a structured professional group-coaching program for female resident physicians would lead to decreased burnout.

Design, Setting, and Participants

This pilot randomized clinical trial was conducted from January 1 to June 30, 2021, among 101 female resident physicians in graduate medical education at the University of Colorado who voluntarily enrolled in the trial after a recruitment period. Surveys were administered to participants before and after the intervention.

Intervention

With the use of a computer-generated 1:1 algorithm, 50 participants were randomly assigned to the intervention group and 51 participants were randomly assigned to the control group. The intervention group was offered a 6-month, web-based group-coaching program, Better Together Physician Coaching, developed and facilitated by trained life coaches and physicians. The control group received residency training as usual, with no coaching during the study. The control group was offered the 6-month coaching program after study completion.

Main Outcomes and Measures

The primary outcome of burnout was measured using the Maslach Burnout Inventory, defined by 3 Likert-type 7-point subscales: emotional exhaustion, depersonalization, and professional accomplishment. Higher scores on the emotional exhaustion and depersonalization subscales and lower scores on the professional accomplishment subscale indicate higher burnout. Secondary outcomes of impostor syndrome, self-compassion, and moral injury were assessed using the Young Impostor Syndrome Scale, Neff's Self-Compassion Scale-Short Form, and the Moral Injury Symptom Scale-Healthcare Professionals, respectively. An intention-to-treat analysis was performed.

Results

Among the 101 female residents in the study, the mean (SD) age was 29.4 (2.3) years, 96 (95.0%) identified as heterosexual, and 81 (80.2%) identified as White. There were 19 residents (18.8%) from surgical subspecialties, with a range of training levels represented. After 6 months of professional coaching, emotional exhaustion decreased in the intervention group by a mean (SE) of 3.26 (1.25) points compared with a mean (SE) increase of 1.07 (1.12) points in the control group by the end of the study (P = .01). The intervention group experienced a significant reduction in presence of impostor syndrome compared with controls (mean [SE], -1.16 [0.31] vs 0.11 [0.27] points; P = .003). Self-compassion scores increased in the intervention group by a mean (SE) of 5.55 (0.89) points compared with a mean (SE) reduction of 1.32 (0.80) points in the control group (P < .001). No statistically significant differences in depersonalization, professional accomplishment, or moral injury scores were observed. Owing to the differential follow-up response rates in the treatment groups (88.2% in the control group [45 of 51]; 68.0% in the intervention group [34 of 50]), a sensitivity analysis was performed to account for the missing outcomes, with similar findings.

Conclusions and Relevance

In this randomized clinical trial, professional coaching reduced emotional exhaustion and impostor syndrome scores and increased self-compassion scores among female resident physicians.

Trial Registration

ClinicalTrials.gov Identifier: NCT05280964.

"Everybody in this room can understand": A qualitative exploration of peer support during residency training

Objectives

Though peer support groups are often utilized during residency training, the dynamics, content, and impact of social support offered through peer support are poorly understood. We explored trainee perceptions of the benefits, drawbacks, and optimal membership and facilitation of peer support groups.

Methods

After engaging in a peer support program at an emergency medicine residency program, 15 residents and 4 group facilitators participated in four focus groups in 2018. Interview questions explored the dynamics of group interactions, types of support offered, and psychological impacts of participation. The authors conducted a reflexive thematic analysis of data, performing iterative coding and organization of interview transcripts.

Results

Discussions with experienced senior residents and alumni normalized residents' workplace struggles and provided them with insights into the trajectory of their residency experiences. Vulnerable group dialogue was enhanced by the use of "insider" participants; however, residents acknowledged the potential contributions of mental health professionals. Though groups occasionally utilized maladaptive coping strategies and lacked actual solutions, they also enhanced residents' sense of belonging, willingness to share personal struggles, and ability to "reset" in the clinical environment.

Conclusions

Participants offered insights into the benefits and drawbacks of peer support as well as optimal peer group composition and facilitation. Support groups may be more effective if they engage a complementary model of alumni and pre-briefed psychologist facilitators, avoid fatalism, and aim to foster intimate connections among residents. These findings can inform the development of future initiatives aiming to create a safe space for trainees to discuss workplace stressors.

Exploring Resident Physician Wellness at an Allopathic Medical School in West Virginia: A Qualitative Study

INTRODUCTION

Social support is key to wellness, especially during times of stress and uncertainty. The working climate, including the multidisciplinary medical community provides opportunities for both positive and negative wellness experiences. The purpose of this study is to explore residents' concepts of wellness and the influence of programs, faculty, peers, and nursing and ancillary staff.

METHODS

An email with a link to the REDCap survey was sent to each resident (n=450) in the school of medicine at West Virginia University asking them to give examples of ways their wellness has been supported (or not) by faculty members, their program, co-residents, and nursing and ancillary staff. The residents returned 51 completed surveys (11% response rate). Seven residents participated in a face to face interview. A content analysis using Hale's adaptation of resident wellness (based upon Maslow's Hierarchy of Needs) as the theoretical framework was conducted on the data.

RESULTS

Positive wellness elements frequently focused on time, supportive actions, and social connection. Negative examples impacting wellness included feeling disrespected, not being included in decision making, conflicts, and feeling unappreciated. Suggestions from the residents often described low cost interventions such as being" included" and feeling part of the team.

CONCLUSION

The participants described how all members of the healthcare team can support resident wellness in a variety of domains. Peers, support staff in the hospital environment, faculty supervisors, and the program overall can contribute to the basic physiologic needs, safety, belonging, esteem, and self-actualization of resident learners through social support.

Factors associated with professional identity formation within psychiatry residency training: A longitudinal study

INTRODUCTION

Conceptual frameworks for professional identity (PI) formation highlight the importance of developmental stages and socialization as the learner progresses from legitimate peripheral to full participation. Based on extant literature and clinical impressions, the authors aimed to explore factors associated with PI formation in psychiatry residents over time, and hypothesized that time in training, seniority status, and duration of exposure to psychiatry prior to residency would be associated with PI formation.

METHODS

Eighty out of 96 psychiatry residents (response rate, 83.3%) from the National Psychiatry Residency Program in Singapore participated and rated their PI development using the Professional Self Identity Questionnaire (PSIQ) across four timepoints from January 2016-December 2019. The residents were classified as junior (first 3 years) or senior residents (years 4-5). Linear mixed model analyses were conducted, with time in training, seniority status (junior versus senior residents), duration of psychiatry postings prior to residency, and their interaction as associated factors with PI over time.

RESULTS

Time in training, seniority, and duration of psychiatry postings before residency (all p < 0.01) were significantly associated with higher PSIQ scores at baseline. Over time, although all residents had increases in PSIQ scores, this rate of change did not differ significantly between junior and senior residents.

DISCUSSION

Exposure to psychiatry postings before residency, time in learning, and seniority are factors which influence PI development in residents. This has implications for psychiatry residency selection and training, adequate clinical exposure during training rotations, and continual support for new and senior residents to foster PI formation over time.

"Necessary Compromises": A Qualitative Exploration of the Influence of Burnout on Resident Education

OBJECTIVE

Burnout is prevalent among resident physicians and has a negative impact on their well-being and effectiveness at work. How burnout shapes residents' educational experiences, attitudes, habits, and practices is not well understood. There is also a lack of research regarding self-identified mitigation strategies for residents. The authors qualitatively explored burnout's role in the educational experiences of resident physicians.

METHODS

Qualitative data were generated from a sample of 29 emergency medicine residents through four semistructured focus groups across four institutions in January and February 2019. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major and minor themes.

RESULTS

Residents reported that a misalignment of their individual versus institutional priorities and a lack of agency were significant contributors to their burnout. Residents described how burnout affected multiple aspects of their education, including their motivation and curiosity to learn, engagement in scholarly activity, and teaching of others. Residents identified several ways of building a sense of community that they explained was most useful in mitigating their experiences with burnout.

CONCLUSION

Burnout had a negative influence on many facets of residents' educational experiences during training. Program directors and educators can take resident-identified steps to moderate its detrimental role on trainee education.

"I Wish They Had Asked": a Qualitative Study of Emotional Distress and Peer Support During Internship

BACKGROUND

Interns are vulnerable to emotional distress and burnout. Little is known about the extent to which interns' well-being can be influenced by peer support provided by their senior residents.

OBJECTIVE

To elucidate contributors to interns' emotional distress and ways that peer support from senior residents may impact intern well-being.

DESIGN

Qualitative study using semi-structured interviews conducted December 2017-March 2018.

PARTICIPANTS

Second year residents (n = 11) in internal medicine at a major academic medical center during the data collection period.

APPROACH

Constructivist grounded theory approach in which transcripts were analyzed in an iterative fashion using constant comparison to identify themes and to create a conceptual model.

KEY RESULTS

The investigators identified three themes around emotional distress and two themes around resident peer support. Distress was a pervasive experience among participants, caused by a combination of contextual factors that decreased emotional resilience (e.g., sleep deprivation) and acute triggers (e.g., patient death) that led to an abrupt increase in distress. Participants grappled with identity reconciliation throughout internship. Reaching clinical competency reinforced self-efficacy for participants. With regard to peer support, participants recalled that resident support was ad hoc, primarily involving task support and debriefing traumatic events. Participants reflected that their intern experiences shaped their supervisory support style once they became senior residents; they did not perceive any formalized, systematic approach to supporting interns.

CONCLUSIONS

We propose a model illustrating key points at which near-peers can make an impact in reducing interns' distress and suggest strategies they can use. Given the substantial role peer learning plays in intern development, senior residents can impact their interns by normalizing emotions, allowing vulnerability, and highlighting the importance of self-care. A formalized peer support skill-building curriculum for senior residents may empower them to provide more effective support as part of their supervisory efforts.

Higher Grit Scores Associated With Less Burnout in a Cohort of Internal Medicine Residents

BACKGROUND

The association between grit, defined as perseverance and passion for long-term goals, and professional burnout has not been studied in internal medicine residents. Our objective was to examine whether internal medicine residents' scores on a grit scale were associated with various measures of burnout.

METHODS

All residents from a single internal medicine program were invited to participate in a study of grit and burnout. Grit and burnout were measured using the Short Grit Scale and modified Maslach Burnout Inventory, respectively. In addition, demographics, last In-Training Examination (ITE) score, and interest in a subspecialty were captured.

RESULTS

A total of 139 of 168 eligible residents (83%) participated. Emotional exhaustion and depersonalization (i.e., burn out) were identified in 63% and 42% of residents, respectively. Endorsement of emotional exhaustion was higher for residents living with family members, postgraduate year (PGY)1 and PGY2 compared with PGY3 residents, and residents scoring above the 50th percentile on the last ITE. Grit scores were higher for residents not reporting emotional exhaustion. As grit score increases, the odds of reporting emotional exhaustion significantly decreased, after adjustments for demographics, ITE scores, type of medical school, PGY level, and interest in a subspecialty (odds ratio = 0.36, 95% CI 0.15-0.84).

CONCLUSIONS

Grit appeared to be an independent predictor of burnout in internal medicine residents in this sample, with lower grit scores associated with higher burnout scores. By measuring grit early in residency, programs can potentially identify residents at risk for symptoms of burnout, specifically emotional exhaustion, and implement targeted interventions.

Evidence-Based Interventions that Promote Resident Wellness from the Council of Emergency Residency Directors

Initiatives for addressing resident wellness are a recent requirement of the Accreditation Council for Graduate Medical Education in response to high rates of resident burnout nationally. We review the literature on wellness and burnout in residency education with a focus on assessment, individual-level interventions, and systemic or organizational interventions.

The Correlation of Burnout and Optimism among Medical Residents

Introduction Burnout is common among clinical specialties and has implications on the residents' well-being and mental health. Evidence suggests that optimism and burnout are correlated, but research has not focused on the applicability to medical residents. The objective of the study was to define burnout in residents and correlate it with optimism. Methods The authors conducted a correlational, prospective cross-sectional study using self-reported single item burnout (1-10) and Life Oriented Test-Revised (LOT-R) (0-24) survey instruments among residents of neurosurgery, neurology, internal medicine, family medicine and emergency medicine at a community-based hospital. Residents were asked to fill out the survey once in the 2018 academic year and once again in the 2019 academic year. Burnout and optimism scores were correlated and compared across subgroups for each year. Results There was no statistical significance found amongst any subgroups in burnout in 2018 but significance was found for both internal medicine (t = 3.74, p = 0.001) and neurosurgery (t = -3.07, p = 0.01) in 2019. Mean burnout increased from 2018 to 2019 from 4.39 to 5.1. Optimism remained constant from 2018 to 2019 (16.7 and 16.76, respectively) and there was no difference across subgroups. There was a statistically significant negative correlation between burnout and optimism in both 2018 (r = -0.364, p = 0.006) and 2019 (r = -0.39, p = .001). Conclusion Burnout and optimism are negatively correlated. Although burnout increased over time, optimism remained constant indicating the stability of this trait and implication for future interventions.

Outrunning Burnout in a GI Fellowship Program During the COVID-19 Pandemic

Many GI training programs have needed to adjust to the serious disruption to the training and education of fellows worldwide due to the COVID-19 pandemic. A silent problem that has arisen within programs is the issue of burnout among their trainees. Burnout is common among gastroenterologists, especially in fellows (Keswani et al. in Gastroenterology 147(1):11-14, 2014. https://doi.org/10.1053/j.gastro.2014.05.023 , Am J Gastroenterol 106(10):1734-1740, 2011. https://doi.org/10.1038/ajg.2011.148 ), with negative consequences to patient care and the safety of the trainees if not effectively dealt with. In this article, the author describes several additional factors potentially contributing to the intensifying burnout of the fellows in their home institution during this pandemic. Moreover, he describes specific practical interventions that the hospital and program have taken in order to address these factors.

University of California Technology Wellness Index: A Physician-Centered Framework to Assess Technologies' Impact on Physician Well-Being

Technology is increasingly being incorporated into the everyday workflows of physicians. There are concerns that electronic medical records and other digital technologies will contribute to the growing epidemic of physician burnout. However, some technologies, such as telemedicine, have demonstrated positive effects on physician health by saving time, enhancing work-life balance, improving quality, and restoring more control and flexibility to their practices. Organizations often lack data to evaluate the impact of technologies on physician health. The University of California Technology Wellness Index is a framework that provides a fast, systematic, physician-centered method to assess the impact of technology on physician well-being.

Perceptions of the Learning Environment on the Relationship Between Stress and Burnout for Residents in an ACGME-I Accredited National Psychiatry Residency Program

BACKGROUND

High rates of burnout have been reported in physicians in training, with contributing factors including stress, lack of coping skills, and attributes of the learning environment. The interrelationships among these factors and how they affect versus mitigate burnout in an international cohort of residents have not been studied.

OBJECTIVE

We examined the interrelationships between stress, perceptions of the learning environment, and coping strategies used in a cohort of psychiatry residents in Singapore, using burnout as the dependent variable. We hypothesized that perceptions of the learning environment and coping strategies influence the relationship between residency-related stress and burnout in psychiatry residents.

METHODS

From June 2016 to September 2017, 67 of 75 (89%) psychiatry residents from a single program in Singapore were assessed on their levels of stress and burnout, perceptions of their learning environment (including role autonomy, teaching, and social support), and the coping mechanisms they used.

RESULTS

Psychiatry residents in this Singaporean program perceived their overall learning environment to be positive. Perceptions of the learning environment, not coping strategies, significantly mediated the relationship between stress and burnout.

CONCLUSIONS

Findings from this study suggest that perceptions of the learning environment mediate the relationship between stress and burnout. Approaches to evaluate and improve resident perceptions of aspects of their learning environment may be an effective strategy to manage burnout in psychiatry residency programs.

Wellness and Work: Mixed Messages in Residency Training

Resident physicians are at higher risk for depression, anxiety, and burnout when compared with same-age peers, resulting in substantive personal and professional consequences. Training programs across the country have acknowledged the gravity of this situation and many have implemented programs and curricula that address wellness and resilience, yet the benefits of such initiatives are still largely unknown. While the development of wellness programming is well intentioned, it is often incongruent with the residency training environment. The mixed messaging that occurs when wellness programs are implemented in environments that do not support self-care may unintentionally cause resident distress. Indeed, outside of the time dedicated to wellness curricula, residents are often rewarded for self-sacrifice. In this commentary, we describe how the complexities of the medical system and culture contribute to mixed messaging and we explore the potential impact on residents. We offer recommendations to strengthen wellness programs through efforts to promote structural change in the training environment.

Assessing the Workplace Culture and Learning Climate in the Inpatient Operating Room Suite at an Academic Medical Center

OBJECTIVE

The purpose of this study was to elicit perspectives from operating room (OR) personnel on the workplace culture and learning climate in the surgical suite, and to identify behaviors associated with a positive culture and learning climate.

DESIGN

Qualitative analyses using survey methodology.

SETTING

Main hospital OR suite at a large academic medical center.

PARTICIPANTS

Nurses, faculty, and residents who work in the OR suite.

RESULTS

To improve the OR environment, survey respondents (n = 60) recommended: (1) promoting a respectful "no blame" culture; (2) promoting social cohesion and cross-collaboration; (3) improving communication regarding performance feedback and patient safety; (4) building small interdisciplinary teams working toward common goals; and (5) improving learning opportunities that support professional growth.

CONCLUSIONS

Opportunities exist to improve the OR workplace culture and thereby the learning environment.

Development of the Resident Wellness Scale for Measuring Resident Wellness

Purpose

Graduate medical education programs have a responsibility to monitor resident wellness. Residents are at risk of burnout, depression, and suicide. Burnout and depression are associated with poor patient care. Many existing tools measure burnout, depression, and general human well-being, but resident wellness is a distinct construct. We aimed to develop an instrument to measure resident wellness directly.

Methods

An expert panel from two purposefully different graduate medical education institutions generated a behavior- and experience-based model of resident wellness. The panel and resident leaders from both institutions generated 92 items, which were tested alongside anchor scales measuring burnout, depression, personality, optimism, life satisfaction, and social desirability in a convenience sample of 62 residents. Ten items were selected using a combination of factor analysis, a genetic algorithm, and purposeful selection. The 10-item scale was distributed to 5 institutions at which 376 residents completed it anonymously. Exploratory factor analysis was used to examine the factor structure of the scale.

Results

The model of resident wellness aligned with an accepted framework of well-being in the literature. The 10-item Resident Wellness Scale broadly covered the model and correlated meaningfully with anchor scales. The factor structure of the scale suggested sensitivity to meaningful work, life security, institutional support, and social support.

Conclusions

This novel Resident Wellness Scale is designed to track residents' wellness longitudinally. It is sensitive to aspects of resident wellness that have been shown to reduce burnout and depression and appears to be a psychometrically strong measure of resident wellness.

Does Implementation of a Corporate Wellness Initiative Improve Burnout?

Introduction

Burnout affects over 50% of all physicians. Nearly 70% of emergency physicians are affected, and it has been found to be as high as 76% in resident physicians overall. Previous wellness initiatives have yielded variable results; therefore, we looked for interventions that could potentially be effective at reversing this trend. We explored effective wellness programs originating from other industries. Our objective was to implement a corporate wellness program with previous evidence of success in other healthcare provider populations. We aimed to investigate whether this program would be effective in decreasing burnout in emergency medicine (EM) residents.

Methods

This program was conducted during required EM resident conference hours from 2016–2017. The Maslach Burnout Inventory was completed before and after the series of sessions, and we collected reactions-level data following completion of the six sessions.

Results

Post-intervention scores revealed a small trend toward increased emotional exhaustion and depersonalization scores, and with increased personal accomplishment scores. The overall satisfaction rating for this program was low, at 1.5 on a 5-point scale. Forty-three percent of residents stated that this intervention subjectively worsened their overall burnout, with another 39% stating it did not improve their burnout at all. A similar trend was seen for effects on wellness.

Conclusion

We found that a corporate wellness intervention that had previously been shown to be successful with other types of healthcare providers did not objectively improve burnout and was subjectively perceived as paradoxically worsening burnout for many residents. This result may be related to the type of intervention chosen (individual vs. systems-focused), the design of the intervention itself, or the unique stressors faced by the resident population. [West J Emerg Med.2019;20(1)138–144.]

Use of Telepsychiatry in Pediatric Emergency Room to Decrease Length of Stay for Psychiatric Patients, Improve Resident On-Call Burden, and Reduce Factors Related to Physician Burnout

Background: Our study aims to demonstrate through implementation of telepsychiatry for child psychiatry patients evaluated in the pediatric emergency room (PedsER); we can reduce length of stay (LOS) and reduce factors contributing to physician burnout through reduction of on-call travel burden. Introduction: Telepsychiatry has increased access to health care using real-time interactive videoconferencing, allowing clinicians and patients in separate locations to have a meaningful clinical encounter. Use has increased over the past several years given cost reduction and need for psychiatric specialty services in under-resourced systems. Materials and Methods: We evaluated data regarding child psychiatry fellow use of telepsychiatry through a prospective real-time questionnaire filled out by the on-call clinician from July 1, 2017 to December 23, 2017 (study period). LOS was measured from the patient's registration time through time of discharge. Results: Telepsychiatry significantly reduced the total monthly LOS for nonhospitalized patients in the PedsER during the study period compared to all prior months (285-193 h; p = 0.032) and compared to a similar prior seasonal time frame (329-193 h; p = 0.017). Telepsychiatry use reduced travel for face-to-face evaluations by 75% and saved 2.22 h per call day. Discussion: Unique in this study is enhancing on-site psychiatric consultation in the emergency room, rather than solving a systems issue of referring out for psychiatric consultation. Moreover, this study uniquely demonstrated a noted improvement in on-call physician travel burden by reducing travel time with telepsychiatry. Physician burnout is notably high during residency training. Factors such as telepsychiatry can improve work efficiency and lend time to activities outside of work, mitigating the onset of this challenging issue. Conclusions: Telepsychiatry was shown to be effective in reducing dwell time and improving on-call burden. This study also showed promise in our system for improving access to other forms of specialized care consultation in PedsER settings.

Emergency Medicine Resident Shift Work Preferences: A Comparison of Resident Scheduling Preferences and Recommended Schedule Design for Shift Workers

BACKGROUND

Shift work can negatively impact an individual's health, wellness, and quality of work. Optimal schedule design can mitigate some of these effects. The American College of Emergency Physicians has published schedule design guidelines to increase wellness and longevity in the field, but these guidelines are difficult to apply to emergency medicine (EM) residents given their high shift burdens and other scheduling constraints. Little is known is known about EM resident scheduling preferences or ideal schedule design in the context of residency training.

OBJECTIVES

The objectives were to determine whether EM resident schedule design preferences are consistent with current scheduling guidelines for shift workers and to gather information on scheduling practices that are important to residents.

METHODS

We surveyed residents at four allopathic EM residency programs and assessed residents' preferences on various schedule design features including shift length, circadian scheduling, night shift scheduling, and impact of schedule design on personal wellness.

RESULTS

Of the 144 residents surveyed, 98% of residents felt that their shift schedule was a key factor in their overall wellness. Residents agreed with shift work guidelines regarding the importance of circadian scheduling (65% favorable), although rated the ability to request a day off and have a full weekend off as more important (84 and 78% favorable responses, respectively). Recommended guidelines promote shorter shifts, but only 24% of residents preferred 8-hour shifts compared to 57, 71, and 43% of residents preferring 9-, 10-, and 12-hour shifts, respectively. Sixty-seven percent of residents preferred their nights to be scheduled in one sequence per 4-week period, a night scheduling strategy most at odds with recommended guidelines.

CONCLUSIONS

Emergency medicine resident scheduling preferences are not universally consistent with shift work guidelines, likely due to the distinct circumstances of residency training. Residents identify schedule design as a significant factor in their overall wellness.

Are medical students in prehospital care at risk of moral injury?

Background

The term ‘moral injury’ may be useful in conceptualising the negative psychological effects of delivering emergency and prehospital medicine as it provides a non-pathological framework for understanding these effects. This is in contrast to concepts such as burnout and post-traumatic stress disorder which suggest practitioners have reached a crisis point. We conducted an exploratory, pilot study to determine whether the concept of moral injury resonated with medical students working in emergency medicine and what might mitigate that injury for them.

Methods

Structured interviews and focus groups were carried out with medical students involved in the delivery of prehospital and emergency medicine. The study was carried out at Barts and the London School of Medicine and Dentistry in May and June 2017. The data were analysed using theoretically driven thematic analysis.

Results

Concepts of moral injury such as witnessing events which contravene one’s moral code, especially those involving children, or acts of violence, resonated with the experiences of medical students in this study. Participants stated that having more medical knowledge and a clear sense of a job to do on scene helped reduce their distress at the time. While social support was a protective factor, not all students found the process of debrief easy to access or undergo, those with more established relationships with colleagues fared better in this regard.

Conclusions

The term moral injury is useful in exploring the experience of medical students in emergency medicine. More effort should be made to ensure that students effectively access debrief and other support opportunities. It is hoped that future work will be undertaken with different professional groups and explore the potential psychological and neuropsychological impact of witnessing trauma.