A National Survey of Burnout and Depression Among Fellows Training in Pulmonary and Critical Care Medicine: A Special Report by the Association of Pulmonary and Critical Care Medicine Program Directors.

BACKGROUND: The prevalence of burnout and depressive symptoms is high among physician trainees. RESEARCH QUESTION: What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? STUDY DESIGN AND METHODS: We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. RESULTS: Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], 0.44; 95% CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95% CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95% CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. INTERPRETATION: Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

Balancing Demands: Determinants of Burnout Reported by Fellows in Pulmonary and Critical Care Medicine.

Background: Burnout is common among physicians who care for critically ill patients and is known to contribute to worse patient outcomes. Fellows training in pulmonary and critical care medicine (PCCM) have risk factors that make them susceptible to burnout; for example, clinical environments that require increased intellectual and emotional demands with long hours. The Accreditation Council for Graduate Medical Education has recognized the increasing importance of trainee burnout and encourages training programs to address burnout. Objective: To assess factors related to training and practice that posed a threat to the well-being among fellows training in PCCM and to obtain suggestions regarding how programs can improve fellow well-being. Methods: We conducted a qualitative content analysis of data collected from a prior cross-sectional electronic survey with free-response questions of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States. Fellows were asked what factors posed a threat to their well-being and what changes their training program could implement. Responses were qualitatively coded and categorized into themes using thematic analysis. Results: A total of 427 fellows (44% of survey respondents) completed at least one free-response question. The majority of respondents (60%) identified as male and white/non-Hispanic (59%). The threats to well-being and burnout were grouped into five themes: clinical burden, individual factors, team culture, limited autonomy, and program resources. Clinical burden was the most common threat discussed by fellows. Fellows highlighted factors contributing to burnout that specifically pertained to trainees including challenging interpersonal relationships with attending physicians and limited protected educational time. Fellows proposed solutions addressing clinical care, changes at the program or institution level, and organizational culture changes to improve well-being. Conclusion: This study provides insight into factors fellows report as contributors to burnout and decreased well-being in addition to investigating fellow-driven solutions toward improving well-being. These solutions may help pulmonary, PCCM, and critical care medicine program directors better address fellow well-being in the future.

Influence of task on interlimb coordination in adults with cerebral palsy.

OBJECTIVE: To examine movement time and kinematic properties of unilateral and bilateral reaching movements in adults with cerebral palsy (CP), focusing on how different types of bilateral movements, simultaneous or sequential, may influence interlimb coordination. DESIGN: Quantitative study using between-group repeated-measures analyses. SETTING: Motor control laboratory at a research university. PARTICIPANTS: Adults with hemiplegic CP (n=11; mean age ± SD, 33±10y; 4 men) and age-matched controls (mean age ± SD, 32±9y; 4 men). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Movement time (MT), maximum deviation from a straight trajectory to the target, and peak speed. RESULTS: Although adults with hemiplegic CP showed strong unilateral deficits, bilateral simultaneous reaching movements were temporally and spatially coupled. Movement of the less affected arm slowed to match the movement of the more affected arm. In contrast, bilateral sequential movements improved MTs of the less affected and more affected arms. CONCLUSIONS: Bilateral sequential movements were conducive to faster MT compared with unilateral or bilateral simultaneous movements. Training that includes bilateral sequential movements may be beneficial to adults with hemiplegic CP. Upper-limb movements are coordinated in a variety of ways to perform routine bilateral tasks. Some bilateral tasks, such as stacking boxes, require more symmetric movements of the upper limbs. Other bilateral tasks, such as opening the refrigerator with 1 hand while placing an item on the shelf with the other hand, emphasize coordinated sequential action between upper limbs. Despite the prevalence of integrative upper-limb use, the control of different forms of bilateral movement is not well understood. A more comprehensive knowledge of upper-limb bilateral movements may hold important implications for developing more effective upper-limb movement therapies.

The effects of Internet-based home training on upper limb function in adults with cerebral palsy.

BACKGROUND: While adults with hemiplegic cerebral palsy (CP) can have significant upper limb dysfunction, the effects of movement-based training has not been investigated. OBJECTIVE: This uncontrolled trial assessed the effects of a home and internet-based upper limb intervention program targeting motor and sensory function. METHODS: Twelve adults, aged 21 to 57 yrs, GMFCS levels I-III with asymmetric upper limb involvement participated in the Upper Limb Training and Assessment (ULTrA) program. Clinical and functional measures included the Motor Activity Log (MAL), the Nine-Hole Peg test, and grip strength. An upper limb training system consisting of a laptop, webcam, target light board, and hand manipulation/ discrimination devices was installed in each participant's home. Training occurred 40 min/day, 5 days/wk for 8 wks and included both unilateral and bilateral reach movements as well as a series of hand sensorimotor tasks such as card turning, stereognosis, and tactile discrimination. Data generated during each session were transmitted to the laboratory via the Internet. MAIN OUTCOME MEASURES: were movement time, interlimb delay time, and performance on hand sensorimotor tasks. RESULTS: Following training, affected limb reach movement time decreased significantly for unilateral and bilateral tasks. Interlimb delay during sequential reaching also decreased. Significant improvement in hand manipulation tasks was also seen. Compliance was excellent and there were no adverse effects. CONCLUSION: The ULTrA program had beneficial effects for adults with CP and is safe and convenient to use. This system contrasts sharply with programs with similar intent that require participant travel and hours of therapist-based intervention.