A Quality Improvement Initiative to Reduce Pediatrician Burnout Led by the American Academy of Pediatrics Section on Internal Medicine and Pediatrics (Med-Peds).

Physician burnout impacts care (of self and patient), productivity, longevity of career, and overall cost to the system. While burnout rates for pediatricians are lower than average, they have not improved significantly over time. While strategies at the system level have been more successful than those at the individual level, both aspects are vital. This quality improvement study explores physician wellness and burnout trends of a sample population of pediatricians at the 2018 and 2019 AAP National Conference and Exhibition (NCE), using the Physician Health and Wellness Booth (PHWB). A rapid cycle approach with the Plan-Do-Check-Act (PDCA) framework was utilized. The aim was to observe if reported burnout decreased by 20% over six months. Of the pediatricians who interacted with the PHWB, 56 were randomly selected to participate. This included men and women and those in various practice settings, ranging from resident physicians to providers in practice for over 20 years. Baseline surveys included elements from a modified Maslach Burnout Inventory and the Stanford Physician Wellness Survey, focusing on burnout components (emotional exhaustion, depersonalization, and fulfillment) and wellness activities. Individual-based interventions were provided at the PHWB, including adult preventative health guidelines, resources on sleep, stress mitigation, and complementary medicine. Participants received a movie ticket and Starbucks gift card. Follow-up included six monthly newsletters with strategies from seven wellness domains. Post-intervention surveys at six months assessed all baseline questions plus the effectiveness of monthly newsletters. A second PDCA cycle was conducted from the 2019 NCE. All individual-based interventions continued with an added aromatherapy oil station. Additional system-based resources included sample institutional wellness initiatives and burnout cost analyses, all focusing on advocating for cultural change at their respective home organizations. Interactive monthly wellness calendars addressing seven wellness domains were emailed for six months follow-up.  Results from 10 post-intervention surveys (10/56=18% of respondents) from the initial cohort reported an average of 25% decrease in burnout (p=0.09). This was measured on a scale of 1-10 (from "never" burned out to "very often") and improved from 6.68 ("sometimes" to "often" burned out) to 5.0 ("rarely" to "sometimes" burned out). Results from Cohort 2 reflected a decrease in burnout from 4.94 ("rarely" to "sometimes" burned out) to 2.85 ("never" to "rarely" burned out) in return from 20 post-intervention surveys (20/48=42% of respondents, p=0.003). Participants noted a lack of control over work schedules and a disconnect with organizational values as drivers of burnout. Both the PHWB and monthly newsletters were rated as valuable as reminders about wellness practices. Limitations included low response rate, which was notable, and inability to prove causation of improvement from our intervention. Future steps include utilizing subject identification numbers to allow for anonymity in a prospective cohort study with a third PDCA cycle. This would allow anonymous but matched same-subject comparison of pre- and post-survey results despite the small sample size. Follow-up incentives could be beneficial. Lastly, data from both cohorts revealed the highest level of burnout in early career physicians within 10 years of training, paving an opportunity for future study.

Evaluating the Impact of a Pilot Nationwide Webinar Series on National Med-Peds Residents' Association Membership.

BACKGROUND: As the COVID-19 pandemic significantly reduced the ability of medical students to travel and interact directly with combined Internal Medicine-Pediatrics (Med-Peds) residency programs, medical students desiring appropriate guidance and information about Med-Peds residency training needed a national forum for information during an unprecedented virtual recruitment year. OBJECTIVE: To develop a nationally coordinated webinar series for medical students and student advisors to learn about the Med-Peds specialty for residency training to keep applicant numbers and applicant interest from significantly falling. METHODS: A national webinar series focusing on general Med-Peds information, career interests, and tailored advising was created amongst the three national Med-Peds organizations over a three-month period in Spring 2020. RESULTS: There was a 221% increase in medical student membership to the National Med-Peds Residents' Association (NMPRA) compared to the same months in 2017, 2018, and 2019 and no significant reduction in the Electronic Residency Application Service® applications to Med-Peds programs over that same time period. CONCLUSIONS: A national forum for medical students inquiring about the combined Med-Peds specialty can be effective in recruiting members to NMPRA and keeping interest high in Med-Peds.

Perceptions of Resident Autonomy in Internal Medicine, Pediatrics, and Internal Medicine-Pediatrics.

BACKGROUND: Although graduated autonomy is an essential component of residency training, we have an incomplete understanding of resident and attending faculty perceptions of autonomy. OBJECTIVE: In this study, we assessed differences in perceived autonomy among residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics. METHODS: We surveyed senior-level (PGY-2-5) residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics in three large, urban training centers in November 2014. The survey included domain items such as general perceptions of autonomy, case management, rounding structure, and individual resident and faculty factors that may interplay with the granting or receiving of autonomy. RESULTS: Of 489 eligible respondents, 215 (44%) responded. Internal medicine-pediatrics residents were more likely than categorical pediatrics residents and pediatrics faculty to disagree that they received an appropriate level of autonomy while on inpatient pediatrics general wards (mean = 2.7 relative to 4.0 and 4.3, categorical residents and faculty; 5-point Likert scale; P < .001). On a 5-point Likert scale, the internal medicine-pediatrics residents were more likely to agree that they received too much oversight on pediatrics general ward rotations (mean, 3.9) compared to internal medicine general ward rotations (mean, 1.9) with a P-value between rotations of <.001. Combined internal medicine-pediatrics perceptions of too much oversight while on pediatric general ward rotations were significantly different from their categorical pediatrics peers (pediatrics mean 2.0, P < .001). CONCLUSIONS: Internal medicine-pediatrics residents have differing perceptions of autonomy from their categorical peers as well as categorical supervising faculty. Combined Internal medicine-pediatrics residents' perceived oversight on pediatrics rotations differently from their categorical pediatrics peers and also differently from their experiences on internal medicine wards. A better understanding of combined internal medicine-pediatrics residents' perceptions of autonomy and supervision can help inform future work regarding autonomy-supportive strategies to optimize learning.

Virtual Med-Peds: Description of the First Virtual Med-Peds Student Elective During COVID-19.

BACKGROUND: For medical students seeking additional specialty experience in Med-Peds, in-person electives have often been a source of mentorship and guidance. The COVID-19 pandemic has impacted the ability for the completion of in-person clerkships for medical students across the nation. Virtual opportunities to increase exposure to Med-Peds programs and didactics are lacking at this time.  Objective: To develop a virtual Med-Peds student elective that serves to increase awareness of the Med-Peds specialty, exposure to Med-Peds topics and relevant didactics, and exposure to Med-Peds specific mentorship when on-site clerkships are not available due to the COVID-19 pandemic.  Methods: Fifteen medical students participated in a virtual Med-Peds student elective utilizing Zoom (Zoom Inc, San Jose, CA). Three separate cohorts of five students each completed two-week elective experiences. The virtual elective curriculum was created using asynchronous and synchronous learning modalities. Sessions were composed of self-directed learning topics, peer-to-peer interactive case discussions, resident-led didactics, and attending physician-led didactics and mentorship sessions. A pre-survey was administered at the beginning of the elective and a post-survey was administered at the end of the elective to assess the effectiveness of the elective, student experiences with Med-Peds mentors, and students' general perceptions of Med-Peds as a residency application choice.  Results: All students (100%), rated the Med-Peds elective to have exceeded their expectations. All students indicated this elective had been extremely (100%) valuable to increase their understanding and interest in Med-Peds (top rating on a five-point Likert scale). Compared to prior to the elective, most were very likely (87%) or likely (7%) to apply to Med-Peds as their top (preferred) specialty. Similar to pre-survey data, one-third (33%) of the students were still likely to apply to an alternate specialty in addition to Med-Peds. Hundred percent of students indicated that the mentorship component of the elective exceeded their original expectations. While most students indicated that they are much more strongly considering applying to Med-Peds as a top (preferred) specialty, the number of students who continue to consider dual-application to include either categorical Internal Medicine, categorical Pediatrics, or Family Medicine did not differ before and after completion of the virtual elective.  Conclusions: Implementation of a virtual medical student elective focusing on exposure to Med-Peds can strengthen medical students' interest in the combined specialty despite a paucity of previous experiences or an affiliated Med-Peds program. This new type of rotation can positively impact a student's view of a hospital system and a residency program when in-person clinical rotations are not available.

BRIEF REPORT: health care provided by program directors to their resident physicians and families.

BACKGROUND: Who provides health care to resident physicians is not well studied. OBJECTIVE: To determine whether residency program directors (PDs)provide health care to their own residents and residents' families. DESIGN: An anonymous survey mailed to 1,345 PDs in Emergency Medicine, Family Medicine, Internal Medicine, Medicine-Pediatrics,and Obstetrics-Gynecology in the United States in 2003. RESULTS: Six hundred nineteen PDs (46%) responded. Half had taken care of their own residents for acute conditions. Less commonly, directors had written prescriptions for acute (40%) or chronic needs (15%}or provided ongoing care (22%). Only 3% believed this conflicted with their ability to be effective directors. Responders more likely to provide future care to residents considered this kind of care generally appropriate(P< .001), or appropriate under certain circumstances {P< .001).Most of these spent > 31% of their time seeing patients. There was no difference among types of programs, gender of the director, or the years as director. Twenty-five percent of directors provided care to their residents' families. CONCLUSIONS: Substantial numbers of directors provided healthcare to their own residents. Few believed this conflicted with their director role. We believe organizations of PDs should develop positions about this practice.

The Med-Peds Hospitalist Workforce: Results From the American Academy of Pediatrics Workforce Survey.

OBJECTIVE: There is no published literature about the med-peds hospitalist workforce, physicians dually trained in internal medicine and pediatrics. Our objective was to analyze this subset of physicians by using data from the American Academy of Pediatrics (AAP) workforce survey to assess practice patterns and workforce demographics. We hypothesized that demographic differences exist between hospitalists and nonhospitalists. METHODS: The AAP surveyed med-peds physicians from the Society of Hospital Medicine and the AAP to define workforce demographics and patterns of practice. We compared self-identified hospitalists with nonhospitalist physicians on multiple characteristics. Almost one-half of the hospitalists self-identified as being both primary care physicians and hospitalists; we therefore also compared the physicians self-identifying as being both primary care physicians and hospitalists with those who identified themselves solely as hospitalists. RESULTS: Of 1321 respondents, 297 physicians (22.4%) self-reported practicing as hospitalists. Hospitalists were more likely than nonhospitalists to have been practicing<10 years (P<.001), be employed by a health care organization (P<.001), work>50 hours per week (P<.001), and see only adults (P<.001) or children (P=.03) in their practice rather than a mix of both groups. Most, 191/229 (83.4%), see both adults and children in practice, and 250/277 (90.3%) stated that their training left them well prepared to practice both adult and pediatric medicine. CONCLUSIONS: Med-peds hospitalists are more likely to be newer to practice and be employed by a health care organization than nonhospitalists and to report satisfaction that their training sufficiently prepared them to see adults and children in practice.

The practice patterns of recently graduated internal medicine-pediatric hospitalists.

OBJECTIVES: To identify the current practice patterns and professional activities of internal medicine-pediatrics (med-peds) hospitalists who have graduated in the past 5 years (June 2009-June 2013). METHODS: The national Medicine-Pediatrics Program Directors Association (MPPDA) conducted a cross-sectional survey study of the 79 residency program directors who are members of the MPPDA regarding the practice patterns of recent graduates (from 2009-2013) currently practicing as hospitalists. The survey was distributed in the spring of 2014 on the MPPDA listserv. The survey inquired about time spent caring for hospitalized adults and children, medical school appointments, practice in freestanding children's hospitals, and completion of hospital medicine (HM) fellowships. RESULTS: Forty-nine program directors (62%) completed the survey and provided data on 1042 graduates from 46 programs. Of those graduates, 26.4% (n=275) practice as hospitalists, and none had completed an HM fellowship. Approximately two-thirds (65%) of med-peds hospitalists provide care to hospitalized children and adults, with one-third providing care solely to hospitalized adults. Approximately one-half (53.5%) have an appointment with a medical school and roughly one-quarter (28%) practice in a freestanding children's hospital. CONCLUSIONS: An increasing percentage of recent med-peds graduates are pursuing careers in HM, and two-thirds are providing care to hospitalized children. As consideration for an accredited pediatric HM fellowship continues, certifying and accrediting bodies should consider how this will impact the med-peds workforce and allow med-peds graduates flexibility in their training requirements that will permit them to acquire the necessary skills to care for hospitalized children and adults.

Field trips as a novel means of experiential learning in ambulatory pediatrics.

BACKGROUND: Parents and caregivers look to pediatric health care providers for guidance on feeding, safety issues, and child-care products for children, but trainees have infrequent first-hand exposure to child products marketed to parents. OBJECTIVE: To conduct a pilot study to assess an experiential field trip as a novel method of enhancing medical knowledge in ambulatory pediatric feeding and safety. METHODS: Resident physicians and medical students visited a local children's store, where they took part in an interactive store tour, product discussions, and product demonstrations led by a physician educator. Participants also completed a 20-question pretest and a 20-question posttest related to common ambulatory pediatric feeding and safety issues, based on recent American Academy of Pediatrics (AAP) policy statements and practice guidelines. RESULTS: Sixty-seven medical students and resident physicians participated in the study. Overall, participants' short-term knowledge significantly increased from 9.9 ± 2.6 to 15.4 ± 2.2 questions correct (P  =  .001), with statistically significant gains (P < .001) on both the feeding and safety sections of the test. There were no differences in improvement based on participant's student or resident status, residency program type, program year, sex, or parental status. Ninety-five percent of the participants believed that their knowledge was enhanced by this approach, and participants uniformly agreed that this field trip was valuable to their pediatric training and that such field trip sessions should continue. CONCLUSIONS: The inclusion of experiential learning through an interactive field trip in the curriculum of medical training was acceptable and feasible and showed short-term improvements in knowledge of AAP safety and feeding concepts.