"I Have Nothing Else to Give": A Qualitative Exploration of Emergency Medicine Residents' Perceptions of Burnout.

PHENOMENON:: Resident physicians experience high degrees of burnout. Medical educators are tasked with implementing burnout interventions, however they possess an incomplete understanding of residents' lived experiences with this phenomenon. Attempts to understand burnout using quantitative methods may insufficiently capture the complexities of resident burnout and limit our ability to implement meaningful specialty-specific interventions. Qualitative studies examining how residents conceptualize burnout have been briefly examined in other specialties, however the specific stressors that characterize emergency medicine training may lead residents to experience burnout differently. This study used qualitative methodology to explore emergency medicine trainees' perceptions of the complex phenomenon of burnout during their residency training years. Approach: In order to evaluate a novel wellness intervention at their emergency medicine residency program, the authors conducted four semi-structured focus groups with residents and recent alumni from May 2018 to August 2018. After the focus groups concluded, the authors noted that they lacked an insightful understanding of their residents' own experiences with physician burnout. Thus, they performed a secondary analysis of data initially gathered for the curricular evaluation. They followed a reflexive thematic analysis approach, analyzing all focus group transcripts in an iterative manner, discussing and refining codes, and developing thematic categories. Findings: Residents described individual-level manifestations of burnout in their day-to-day lives, a calloused view of patient suffering in the clinical environment, and a fatalistic view toward burnout during their training. They experienced a pervasive negativity, emotional fragility, and neglect of self that bled into their social environments. Clinically, burnout contributed to the erosion of the therapeutic physician-patient relationship. Residents perceived burnout as an inevitable and necessary element of their residency training years. Insights: Residents' lived experiences with burnout include nonclinical manifestations that challenge existing frameworks suggesting that burnout is restricted to the work domain. Burnout interventions in emergency medicine training programs may be more effective if educators inculcate habitual practices of self-monitoring in trainees and explicitly set resident expectations of patient acuity in the clinical environment.Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1875833.

How a Team Effectiveness Approach to Health Systems Science Can Illuminate Undergraduate Medical Education Outcomes.

ABSTRACT: Health care delivery requires physicians to operate in teams to successfully navigate complexity in caring for patients and communities. The importance of training physicians early in core concepts of working in teams (i.e., "teaming") has long been established. Over the past decade, however, little evidence of team effectiveness training for medical students has been available. The recent introduction of health systems science as a third pillar of medical education provides an opportunity to teach and prepare students to work in teams and achieve related core competencies across the medical education continuum and health care delivery settings. Although educators and health care system leaders have emphasized the teaching and learning of team-based care, conceptual models and evidence that inform effective teaming within all aspects of undergraduate medical education (including classroom, clinical, and community settings) are needed to advance the science regarding learning and working in teams. Anchoring teaming through the core foundational theory of team effectiveness and its operational components could catalyze the empirical study of medical student teams, uncover modifiable factors that lead to the evidence for improved student learning, and improve the link among competency-based assessments between undergraduate medical education and graduate medical education. In this article, authors articulate several implications for medical schools through 5 conceptual areas: admissions, the design and teaching of team effectiveness in health systems science curricula, the related competency-based assessments, and course and program evaluations. The authors then discuss the relevance of the measurable components and intended outcomes to team effectiveness in undergraduate medical education as critical to successfully prepare students for teaming in clerkships and eventually residency and clinical practice.

"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.

Patient Co-Participation in Narrative Medicine Curricula as a Means of Engaging Patients as Partners in Healthcare: A Pilot Study Involving Medical Students and Patients Living with HIV.

This paper describes a pilot study of a new model for narrative medicine training, "community-based participatory narrative medicine" (CBPNM), which centers on shared narrative work between healthcare trainees and patients. Nine medical students and eight patients participated in one of two, five-week-long pilot workshop series. A case study of participants' experiences of the workshop series identified three major themes: (1) the reciprocal and collaborative nature of participants' relationships; (2) the interplay between self-reflection and receiving feedback from others; and (3) the clinical and pedagogical implications of the CBPNM model. Principles and proposed outcomes of the CBPNM model are presented.

A Value-Added Health Systems Science Intervention Based on My Life, My Story for Patients Living with HIV and Medical Students: Translating Narrative Medicine from Classroom to Clinic.

In 2018-2019, at the Keck School of Medicine of the University of Southern California (KSOM), we developed and piloted a narrative-based health systems science intervention for patients living with HIV and medical students in which medical students co-wrote patients' life narratives for inclusion in the electronic health record. The pilot study aimed to assess the acceptability of the "life narrative protocol" (LNP) from multiple stakeholder positions and characterize participants' experiences of the clinical and pedagogical implications of the LNP. Students were recruited from KSOM. Patients and staff were recruited from the Maternal, Child, and Adolescent/Adult Center for Infectious Disease and Virology (MCA) at Los Angeles County+USC Medical Center. Ten patients, seventeen students, and ten MCA staff participated in the pilot study. Qualitative methods were used to gather data from students', patients', and staff's perspectives. Three themes emerged from the thematic analysis: (1) patients' life narratives conveyed their unique life experiences and voices; (2) the protocol could result in wide-ranging effects on HIV care; (3) the LNP enabled students to contribute value to patients' healthcare. Across groups, participants considered the LNP an acceptable intervention. The LNP, its limitations, and implications for HIV care, narrative medicine, and health information technology are presented.

Visualizing context through theory deconstruction: a content analysis of three bodies of evaluation theory literature.

While the evaluation field collectively agrees that contextual factors bear on evaluation practice and related scholarly endeavors, the discipline does not yet have an explicit framework for understanding evaluation context. To address this gap in the knowledge base, this paper explores the ways in which evaluation context has been addressed in the practical-participatory, values-engaged, and emergent realist evaluation literatures. Five primary dimensions that constitute evaluation context were identified for this purpose: (1) stakeholder; (2) program; (3) organization; (4) historical/political; and (5) evaluator. Journal articles, book chapters, and conference papers rooted in the selected evaluation approaches were compared along these dimensions in order to explore points of convergence and divergence in the theories. Study results suggest that the selected prescriptive theories most clearly explicate stakeholder and evaluator contexts. Programmatic, organizational, and historical/political contexts, on the other hand, require further clarification.