Burnout and Well-Being Among Cardiology Fellowship Program Directors.

OBJECTIVES: The third annual Cardiovascular Diseases (CV) Fellowship Program Directors (PDs) Survey sought to understand burnout and well-being among CV fellowship PDs. BACKGROUND: Physician burnout is a common phenomenon. Data on burnout among cardiologists, specifically CV PDs, remain limited. METHODS: The survey contained 8 questions examining satisfaction, stress, and burnout among CV fellowship PDs. Burnout was defined based on the self-reported presence of ≥1 symptom of burnout, constant feelings of burnout, or complete burnout. RESULTS: Survey response rate was 57%. Most respondents were men (78%) and 54% represented university-based programs. Eighty percent reported satisfaction with their current job as PD, and 96% identified interactions with fellows as a driver of their satisfaction. Forty-five percent reported feeling a great deal of stress from their job. Stress was higher among women PDs, early-career PDs, and PDs of larger and university-based programs. Twenty-one percent reported some symptoms of burnout, and only 36% reported enjoyment without stress or burnout. Rates of enjoyment without stress or burnout were higher among men and late-career PDs, PDs of smaller programs, and PDs of community-based programs. Seventeen percent of PDs reported a high likelihood of resigning in the next year, of which the most common reason was the tasks of PDs were becoming overwhelming. CONCLUSIONS: Most CV fellowship PDs are satisfied with their position, but stress and burnout remain common. Women PDs, early-career PDs, and PDs of larger, university-based programs demonstrate more adverse markers of well-being. Opportunities exist to support CV fellowship PDs in their critical role.

Race and Gender Bias in Internal Medicine Program Director Letters of Recommendation.

BACKGROUND: While program director (PD) letters of recommendation (LOR) are subject to bias, especially against those underrepresented in medicine, these letters are one of the most important factors in fellowship selection. Bias manifests in LOR in a number of ways, including biased use of agentic and communal terms, doubt raising language, and description of career trajectory. To reduce bias, specialty organizations have recommended standardized PD LOR. OBJECTIVE: This study examined PD LOR for applicants to a cardiology fellowship program to determine the mechanism of how bias is expressed and whether the 2017 Alliance for Academic Internal Medicine (AAIM) guidelines reduce bias. METHODS: Fifty-six LOR from applicants selected to interview at a cardiology fellowship during the 2019 and 2020 application cycles were selected using convenience sampling. LOR for underrepresented (Black, Latinx, women) and non-underrepresented applicants were analyzed using directed qualitative content analysis. Two coders used an iteratively refined codebook to code the transcripts. Data were analyzed using outputs from these codes, analytical memos were maintained, and themes summarized. RESULTS: With AAIM guidelines, there appeared to be reduced use of communal language for underrepresented applicants, which may represent less bias. However, in both LOR adherent and not adherent to the guidelines, underrepresented applicants were still more likely to be described using communal language, doubt raising language, and career trajectory bias. CONCLUSIONS: PDs used language in a biased way to describe underrepresented applicants in LOR. The AAIM guidelines reduced but did not eliminate this bias. We provide recommendations to PDs and the AAIM on how to continue to work to reduce this bias.

A single center evaluation of applicant experiences in virtual interviews across eight internal medicine subspecialty fellowship programs.

Due to the COVID-19 pandemic, most graduate medical education (GME) training programs conducted virtual interviews for prospective trainees during the 2020-2021 application cycle. Many internal medicine (IM) subspecialty fellowship programs hosted virtual interviews for the first time with little published data to guide best practices.To evaluate how IM subspecialty fellowship applicants perceived the virtual interview day experience.We designed a 38-item questionnaire that was sent via email to applicants in eight IM subspecialty programs at a single tertiary academic medical center (University of California, San Francisco) from September-November, 2020.Seventy-five applicants completed the survey (75/244, 30.7%), including applicants from all eight fellowship programs. Most survey respondents agreed that the length of the virtual interview day (mean = 6.4 hours) was long enough to gather the information they needed (n = 65, 86.7%) and short enough to prevent fatigue (n = 55, 73.3%). Almost all survey respondents agreed that they could adequately assess the clinical experience (n = 71, 97.3%), research opportunities (n = 72, 98.6%), and program culture (n = 68, 93.2%). Of the respondents who attended a virtual educational conference, most agreed it helped to provide a sense of the program's educational culture (n = 20, 66.7%). Areas for improvement were identified, with some survey respondents reporting that the virtual interview day was too long (n = 11) or that they would have preferred to meet more fellows (n = 10).Survey respondents indicated that the virtual interview was an adequate format to learn about fellowship programs. These findings can inform future virtual interviews for GME training programs.

Learning Echocardiography in the Workplace: A Cognitive Load Perspective.

PURPOSE: Although workplace learning environments provide authentic tasks to promote learning, elements of clinical settings may distract trainees and impede learning. The characteristics of workplace learning environments that require optimization are ill-defined. Applying principles of cognitive load theory (CLT) to optimize learning environments by managing intrinsic load (complexity of the task matched to learner knowledge and skill), minimizing extraneous load (any aspect that is not part of task completion), and increasing germane load (processing for storage in long-term memory) could be advantageous. The authors explored trainee perceptions of characteristics that helped or impaired learning from a cognitive load perspective. Echocardiography interpretation was used as a model. METHOD: The authors conducted semistructured interviews between December 2018 and March 2019 with a purposeful sample of 10 cardiology trainees at the University of California, San Francisco, School of Medicine until thematic sufficiency was achieved. Participants represented a range of training levels (3 fourth-year trainees, 2 fifth-year trainees, 3 sixth-year trainees, and 2 advanced echocardiography fellows) and career aspirations (4 desired careers in imaging). Two independent coders analyzed interview transcripts using template analysis. Codes were mapped to CLT subcomponents. RESULTS: Trainees selected their own echocardiograms to interpret; if trainees' skill levels and the complexity of the selected echocardiograms were mismatched, excess intrinsic load could result. Needing to look up information essential for task completion, interruptions, reporting software, and time pressures were characteristics that contributed to extraneous load. Characteristics that related to increasing germane load included the shared physical space (facilitating reading echocardiograms with attendings and just-in-time guidance from near peers) and the availability of final reports to obtain feedback independent of teachers. CONCLUSIONS: As interpreted from a cognitive load perspective, findings highlight characteristics of workplace learning environments that could be optimized to improve learning. The findings have direct application to redesigning these learning environments.

Cardiovascular events and hospital resource utilization pre- and post-transcatheter mitral valve repair in high-surgical risk patients.

MitraClip is an approved therapy for mitral regurgitation (MR); however, health care resource utilization pre- and post-MitraClip remains understudied. METHODS: Patients with functional and degenerative MR at high surgical risk in the EVEREST II High-Risk Registry and REALISM Continued-Access Study were linked to Medicare data. Pre- and post-MitraClip all-cause death, stroke, myocardial infarction, heart failure (HF), and bleeding hospitalizations were identified. Inpatient costs, adjusted to 2010 US dollars, were calculated, and event rate ratios and cost ratios were estimated with multivariable modeling. RESULTS: Among 403 linked patients, the mean age was 80 years, 60% were male, mean baseline left ventricular ejection fraction was 49.6%, 83.3% were New York Heart Association class III/IV, 78.2% were MR grade 3+/4+, and 63.3% had functional MR. All-cause hospitalization decreased from 1,854 to 1,435/1,000 person-years (P<.001). HF hospitalization decreased following MitraClip (749 vs 332/1000 person-years, P<.001), but bleeding increased (199 vs 298/1000 person-years, P<.001). Changes in stroke and myocardial infarction were not statistically significant. Overall mean Medicare costs per patient were similar pre- and post-MitraClip, although there was a significant decrease in mean costs among those that survived a full year after MitraClip ($18,131 [SD $25,130] vs $11,679 [SD $22,486], P=.02). CONCLUSIONS: MitraClip was associated with a reduced rate of all-cause and HF hospitalizations and an increased rate of bleeding hospitalizations. One-year Medicare costs were reduced in those who survived a full year after the MitraClip procedure. Payors and providers seeking to reduce HF hospitalizations and associated Medicare costs may consider MitraClip among appropriate patients likely to survive 1 year.