Developing a practical algorithm for a pediatric emergency department's response to radiological dispersal device events.

OBJECTIVE: In the aftermath of the detonation of a radiological dispersal device (RDD), or "dirty bomb," a large influx of children would be expected to present to the emergency department, including many patients not directly affected by the event who present with concerns regarding radiation exposure. Our objective was to develop an algorithm for efficiently and effectively triaging and appropriately treating children based on the likelihood of their having been contaminated or exposed. METHODS: The hospital's disaster preparedness committee with the help of disaster planning experts engaged in an iterative process to develop a triage questionnaire and patient flow algorithm for a pediatric hospital following an RDD event. The questionnaire and algorithm were tested using hypothetical patients to ensure that they resulted in appropriate triage and treatment for the full range of anticipated patient presentations and were then tested in 2 live drills to evaluate their performance in real time. RESULTS: The triage questionnaire reduced triage times and accurately sorted children into groups based on the type of intervention they required. Nonmedical personnel were able to administer the triage questionnaire effectively with minimal training, relieving professional staff. The patient flow algorithm and supporting materials provided direction to staff about how to appropriately treat patients once they had been triaged. CONCLUSIONS: In the event of the detonation of an RDD, the triage questionnaire and patient flow algorithm presented would enable pediatric hospitals to direct limited resources to children requiring intervention due to injury, contamination, or exposure.

Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians.

Importance: Physician turnover interrupts care delivery and creates health care system financial burden. Objective: To describe the prevalence of burnout, professional fulfillment, and intention to leave (ITL) among physicians at academic-affiliated health care systems and identify institutional and individual factors associated with ITL. Design, Setting, and Participants: This cross-sectional study administered a survey to 37 511 attending-level medical specialists at 15 academic medical institutions participating in the Healthcare Professional Well-Being Academic Consortium. Data were collected from October 2019 to July 2021. Statistical analysis was performed from May 2022 to March 2023. Exposures: Hypothesized institutional and individual determinants of occupational well-being. Main Outcomes and Measures: The main outcome was ITL, defined as having at least a moderate intention (a score of 2 on a 0-4 scale) to leave one's institution within the next 2 years. Additional outcomes included burnout and professional fulfillment, defined using published Professional Fulfillment Index cut points. Results: Of 18 719 academic physician survey respondents (8381 [44.8%] male; 2388 [12.8%] Asian, 10 599 [56.6%] White, 1039 [5.6%] other race, 4693 [25.1%] unknown race; 294 [1.6%] Hispanic or Latina/Latino/Latinx), 6903 of 18 217 (37.9%) met criteria for burnout and 7301 of 18 571 (39.3%) for professional fulfillment; 5177 of 15 890 (32.6%) reported moderate or greater ITL. Burnout, professional fulfillment, and ITL varied across specialties. After adjusting for demographics, each 1-point increase (range 0-10) in burnout was directly associated with ITL (odds ratio [OR], 1.52 [95% CI, 1.49-1.55])c, and each 1-point increase in professional fulfillment was inversely associated with ITL (OR, 0.64 [95% CI, 0.63-0.65]). After adjusting for demographics, burnout, and professional fulfillment, each 1-point increase (range 0-10) in supportive leadership behaviors (OR, 0.83 [95% CI, 0.82-0.84]), peer support (OR, 0.93 [95% CI, 0.91-0.95]), personal-organizational values alignment (OR, 0.81 [95% CI, 0.80-0.82]), perceived gratitude (OR, 0.95 [95% CI, 0.92-0.97]), COVID-19 organizational support (OR, 0.88 [95% CI, 0.85-0.91]), and electronic health record helpfulness (OR, 0.95 [95% CI, 0.93-0.97]) were inversely associated with ITL, whereas each 1-point increase (range 0-10) in depression (OR, 1.08 [95% CI, 1.05-1.10]) and negative impact of work on personal relationships (OR, 1.09 [1.07-1.11]) were directly associated with ITL. Conclusions and Relevance: In this cross-sectional study of academic physicians, 32.6% indicated moderate or higher ITL within 2 years. Burnout, lack of professional fulfillment, and other well-being factors were associated with ITL, suggesting the need for a comprehensive approach to reduce physician turnover.

Mistreatment Experiences, Protective Workplace Systems, and Occupational Distress in Physicians.

Importance: Reducing physician occupational distress requires understanding workplace mistreatment, its relationship to occupational well-being, and how mistreatment differentially impacts physicians of diverse identities. Objectives: To assess the prevalence and sources of mistreatment among physicians and associations between mistreatment, occupational well-being, and physicians' perceptions of protective workplace systems. Design, Setting, and Participants: This survey study was administered in September and October 2020 to physicians at a large academic medical center. Statistical analysis was performed from May 2021 to February 2022. Main Outcomes and Measures: Primary measures were the Professional Fulfillment Index, a measure of intent to leave, and the Mistreatment, Protection, and Respect Measure (MPR). Main outcomes were the prevalence and sources of mistreatment. Secondary outcomes were the associations of mistreatment and perceptions of protective workplace systems with occupational well-being. Results: Of 1909 medical staff invited, 1505 (78.8%) completed the survey. Among respondents, 735 (48.8%) were women, 627 (47.1%) were men, and 143 (9.5%) did not share gender identity or chose "other"; 12 (0.8%) identified as African American or Black, 392 (26%) as Asian, 10 (0.7%) as multiracial, 736 (48.9%) as White, 63 (4.2%) as other, and 292 (19.4%) did not share race or ethnicity. Of the 1397 respondents who answered mistreatment questions, 327 (23.4%) reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, reported by 232 physicians (16.6%). Women were more than twice as likely as men to experience mistreatment (31% [224 women] vs 15% [92 men]). On a scale of 0 to 10, mistreatment was associated with a 1.13 point increase in burnout (95% CI, 0.89 to 1.36), a 0.99-point decrease in professional fulfillment (95% CI, -1.24 to -0.73), and 129% higher odds of moderate or greater intent to leave (odds ratio, 2.29; 95% CI, 1.75 to 2.99). When compared with a perception that protective workplace systems are in place "to a very great extent," a perception that there are no protective workplace systems was associated with a 2.41-point increase in burnout (95% CI, 1.80 to 3.02), a 2.81-point lower professional fulfillment score (95% CI, -3.44 to -2.18), and 711% higher odds of intending to leave (odds ratio, 8.11; 95% CI, 3.67 to 18.35). Conclusions and Relevance: This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that health care organizations should prioritize reducing workplace mistreatment.

Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors.

Importance: Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error. Objective: To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout. Design, Setting, and Participants: This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study. Exposures: Sleep-related impairment. Main Outcomes and Measures: Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection. Results: Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r = 0.51; P < .001), work exhaustion (r = 0.58; P < .001), and overall burnout (r = 0.59; P < .001) were large. Sleep-related impairment correlation with professional fulfillment (r = -0.40; P < .001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively. Conclusions and Relevance: In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.

Burning without burning out: A call to protect the calling of medicine.

Physicians enter the field of medicine with a sense of calling to meet the needs of others. This sense of calling is a source of resilience and strength, inspiring physicians to defer their own needs in service to patients' needs. When this trade-off becomes chronic, as it does in dysfunctional work environments, burnout can result and both physicians and patients suffer negative consequences. Some of the sources of physician distress, like exposure to suffering and involvement in medical errors, are inherent to medical practice, while others are the product of workplace inefficiencies and flaws in how the health care system functions. Individual physicians can cultivate strategies to maintain resilience in the face of medicine's inherent challenges, while health care organizations work to reduce the systemic drivers of burnout and build cultures that support physicians to thrive. In this and next month's issues, we offer eight articles on aspects of physician well-being with the goal of inspiring and empowering individuals and organizations to take action to transform the health care system so that it can better meet the needs of physicians and their patients.

Cultivating the joy of medicine: A focus on intrinsic factors and the meaning of our work.

Physician burnout is at epidemic levels. In our role as healers, the concepts of humanism and relief of suffering are central themes in our work, yet burnout and depersonalization can threaten these values. While working to mitigate burnout, we need to move towards a focus on health and well-being and develop preventive strategies to cultivate resilience. This manuscript discusses the intrinsic factors that motivate us to be physicians: medicine as a calling, finding meaning in our work, and seeking joy in practice. Some strategies that enhance our resilience will be discussed including individual reflective practices, in addition to organizational strategies such as creating team mission statements, and participating in debriefing, Balint groups, and Schwartz Rounds. All of these practices provide opportunities to acknowledge the emotional impact of our care of patients and to focus on our values and the meaning of our work. Strategies to cultivate joy in practice are presented alongside a framework from the Institute for Healthcare Improvement to guide organizations.

Conceptual models for understanding physician burnout, professional fulfillment, and well-being.

Physician burnout is a highly complex phenomenon whose origins are multifactorial. As the medical profession works to better understand and reduce physician burnout, conceptual models can offer a framework to guide research and practice in the field of physician well-being. Conceptual models represent complex systems in a simplified fashion that facilitates understanding of and communication about those systems. This paper reviews seven conceptual models of physician well-being and discusses their strengths and limitations.

Self-valuation: Attending to the Most Important Instrument in the Practice of Medicine.

OBJECTIVE: To measure self-valuation, involving constructive prioritization of personal well-being and a growth mindset perspective that seeks to learn and improve as the primary response to errors, in physicians and evaluate its relationship with burnout and sleep-related impairment. METHODS: We analyzed cross-sectional survey data collected between July 1, 2016, and October 31, 2017, from 5 academic medical centers in the United States. All faculty and medical-staff physicians at participating organizations were invited to participate. The self-valuation scale included 4 items measured on a 5-point (0-4) Likert scale (summative score range, 0-16). The self-valuation scale was developed and pilot tested in a sample of 250 physicians before inclusion in the multisite wellness survey, which also included validated measures of burnout and sleep-related impairment. RESULTS: Of the 6189 physicians invited to participate, 3899 responded (response rate, 63.0%). Each 1-point score increase in self-valuation was associated with -1.10 point lower burnout score (95% CI, -1.16 to -1.05; standardized ß=-0.53; P<.001) and 0.81 point lower sleep-related impairment score (95% CI, -0.85 to -0.76; standardized ß=-0.47; P<.001), adjusting for sex and medical specialty. Women had lower self-valuation (Cohen d=0.30) and higher burnout (Cohen d=0.22) than men. Lower self-valuation scores in women accounted for most of the sex difference in burnout. CONCLUSION: Low self-valuation among physicians is associated with burnout and sleep-related impairment. Further research is warranted to develop and test interventions that increase self-valuation as a mechanism to improve physician well-being.

Organizational strategies to reduce physician burnout and improve professional fulfillment.

Burnout is highly prevalent among physicians and has been associated with negative outcomes for physicians, patients, staff, and health-care organizations. Reducing physician burnout and increasing physician well-being is a priority. Systematic reviews suggest that organization-based interventions are more effective in reducing physician burnout than interventions targeted at individual physicians. This consensus review by leaders in the field across multiple institutions presents emerging trends and exemplary evidence-based strategies to improve professional fulfillment and reduce physician burnout using Stanford's tripartite model of physician professional fulfillment as an organizing framework: practice efficiency, culture, and personal resilience to support physician well-being. These strategies include leadership traits, latitude of control and autonomy, collegiality, diversity, teamwork, top-of-license workflows, electronic health record (EHR) usability, peer support, confidential mental health services, work-life integration and reducing barriers to practicing a healthy lifestyle. The review concludes with evidence-based recommendations on establishing an effective physician wellness program.

Providing Palliative Care in Rare Pediatric Diseases: A Case Series of Three Children with Congenital Disorder of Glycosylation.

Pediatric palliative care providers often care for children with rare, poorly understood diseases. In addition to grappling with a life-limiting diagnosis, families face complexity in decision making stemming from the prognostic uncertainty surrounding their child's rare condition. We discuss several unique challenges, illustrated through case studies of three children who shared the rare diagnosis of congenital disorder of glycosylation.