Using nominal group technique among resident physicians to identify key attributes of a burnout prevention program.

PURPOSE: To identify preferred burnout interventions within a resident physician population, utilizing the Nominal Group Technique. The results will be used to design a discrete choice experiment study to inform the development of resident burnout prevention programs. METHODS: Three resident focus groups met (10-14 participants/group) to prioritize a list of 23 factors for burnout prevention programs. The Nominal Group Technique consisted of three steps: an individual, confidential ranking of the 23 factors by importance from 1 to 23, a group discussion of each attribute, including a group review of the rankings, and an opportunity to alter the original ranking across participants. RESULTS: The total number of residents (36) were a representative sample of specialty, year of residency, and sex. There was strong agreement about the most highly rated attributes which grouped naturally into themes of autonomy, meaning, competency and relatedness. There was also disagreement on several of the attributes that is likely due to the differences in residency specialty and subsequently rotation requirements. CONCLUSION: This study identified the need to address multiple organizational factors that may lead to physician burnout. There is a clear need for complex interventions that target systemic and program level factors rather than focus on individual interventions. These results may help residency program directors understand the specific attributes of a burnout prevention program valued by residents. Aligning burnout interventions with resident preferences could improve the efficacy of burnout prevention programs by improving adoption of, and satisfaction with, these programs. Physician burnout is a work-related syndrome characterized by emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment [1]. Burnout is present in epidemic proportions and was estimated to occur in over 50 percent of practicing physicians and in up to 89 percent of resident physicians pre-COVID 19. The burnout epidemic is growing; a recent national survey of US physicians reported an 8.9 percent increase in burnout between 2011 and 2014 [2]. Rates of physician burnout have also increased [3] during the COVID-19 pandemic with a new classification of "pandemic burnout" experienced by over 52 percent of healthcare workers as early as June of 2020 [4]. Physician burnout can lead to depression, suicidal ideation, and relationship problems that may progress to substance abuse, increased interpersonal conflicts, broken relationships, low quality of life, major depression, and suicide [5-7]. The estimated rate of physician suicide is 300-400 annually [8-10].

Holistic processing only? The role of the right fusiform face area in radiological expertise.

Radiologists can visually detect abnormalities on radiographs within 2s, a process that resembles holistic visual processing of faces. Interestingly, there is empirical evidence using functional magnetic resonance imaging (fMRI) for the involvement of the right fusiform face area (FFA) in visual-expertise tasks such as radiological image interpretation. The speed by which stimuli (e.g., faces, abnormalities) are recognized is an important characteristic of holistic processing. However, evidence for the involvement of the right FFA in holistic processing in radiology comes mostly from short or artificial tasks in which the quick, 'holistic' mode of diagnostic processing is not contrasted with the slower 'search-to-find' mode. In our fMRI study, we hypothesized that the right FFA responds selectively to the 'holistic' mode of diagnostic processing and less so to the 'search-to-find' mode. Eleven laypeople and 17 radiologists in training diagnosed 66 radiographs in 2s each (holistic mode) and subsequently checked their diagnosis in an extended (10-s) period (search-to-find mode). During data analysis, we first identified individual regions of interest (ROIs) for the right FFA using a localizer task. Then we employed ROI-based ANOVAs and obtained tentative support for the hypothesis that the right FFA shows more activation for radiologists in training versus laypeople, in particular in the holistic mode (i.e., during 2s trials), and less so in the search-to-find mode (i.e., during 10-s trials). No significant correlation was found between diagnostic performance (diagnostic accuracy) and brain-activation level within the right FFA for both, short-presentation and long-presentation diagnostic trials. Our results provide tentative evidence from a diagnostic-reasoning task that the FFA supports the holistic processing of visual stimuli in participants' expertise domain.

Pediatric Residency Training for Integration of Behavior Health: Indian Perspective.

Behaviour disorders are common in children. Various studies in children and Adolescents in India have found that 6% to 30% of study participants had one or other behaviour This calls for emphasis on integration of behavioral health (IBH) in the training programs for medical undergraduates and postgraduates in paediatrics. This article examines the current medical training programs for IBH of children and adolescents in curriculum of these programs in India. Pediatrics residency programs are described. The impact of Indian culture on IBH issues is also discussed. Ideas for integrating behavioral health in Medical education in India are given.

Incorporating Virtual Reality to Improve Otolaryngology Resident Wellness: One Institution's Experience.

OBJECTIVE: Burnout is defined as work-related emotional exhaustion, depersonalization, and decreased sense of accomplishment. Virtual reality (VR) has emerged as an effective treatment modality for various conditions related to anxiety, however, few studies have assessed its role for stress management in residents. We hypothesize that VR-based mindfulness meditation can reduce resident burnout in real-world settings. STUDY DESIGN: Prospective randomized crossover trial. METHODS: Resident participants completed the validated Maslach Burnout Inventory (MBI). One group used a VR-based meditation app; the second group received no intervention. After a 2-month rotation, all subjects completed an MBI and crossed over to the other arm. Wilcoxon rank-sum tests were used to compare MBI scores before and after intervention, and to compare results by gender and postgraduate year. Mann-Whitney U tests were used to assess qualitative differences between participants. RESULTS: Eighteen residents completed the study. Five participants were female and 13 were male. Weekly use of VR-guided meditation and paced breathing was associated with a significant decrease in emotional exhaustion (P = .009), and on subgroup analysis, male gender specifically was associated with a decrease in emotional exhaustion (P = .027). In the post-intervention survey, 42.9% subjects reported that VR encouraged them to employ paced breathing techniques, 71.4% reported that they would use the technology if regularly available, and 21.4% reported they would use paced breathing in the future. CONCLUSION: VR-based therapy may serve as a successful tool in stress management and reduce the rate of burnout among otolaryngology residents. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1972-1976, 2021.

The SARS-CoV-2 Pandemic: Real-Time Training and Service for Preventive Medicine Residents.

The 2020 SARS-CoV-2 pandemic created a unique opportunity for Public Health/General Preventive Medicine (PH/GPM) and Occupational and Environmental Medicine (OM) residents to contribute to pandemic public health response activities. We surveyed all 18 Health Resources and Services Administration (HRSA)-funded PH/GPM and OM residency program directors to evaluate program and resident involvement in pandemic response activities from January 1 through June 30, 2020. Of 116 residents, 110 (95%) participated at some level in the response activities including screening/testing, contact tracing, surveillance, data analysis, incident command, provider support, reopening, direct patient care, education, and risk communication. Residents' response activities were in multiple settings, such as state, local, and federal health agencies; hospital systems; long-term care facilities; academic centers; local businesses and labor unions; Federally Qualified Health Centers; homeless shelters; and clinics. Residents' participation was facilitated by their training in public health, epidemiology, the care of patients and populations, and emergency preparedness. Programs should continue to promote these experiences and key roles that PH/GPM and OM residents can play, as this leadership is a necessity for the successful navigation of future major public health events. As the pandemic continues, evaluation of residents' experiences will help guide longer-term changes to program curriculum and partnerships. Many trainees' contributions and expertise met both educational and service goals and therefore should be integrated into ongoing pandemic response work in PH/GPM and OM programs.

Promoting Access of Osteopathic Medical Students to Surgical Residency Training Programs.

The COVID-19 pandemic has uncovered disparities for allopathic and osteopathic surgical applicants for the upcoming 2021 residency application cycle. It has provided an opportunity for change to the current paradigm in surgical resident selection. This study seeks to quantify the disproportionality of opportunities between allopathic and osteopathic students and provides solutions to level the playing field for all applicants.

Admissions Is Not Enough: The Racial Achievement Gap in Medical Education.

The achievement gap is a disparity in academic and standardized test performance that exists between White and underrepresented minority (URM) students that begins as early as preschool and worsens as students progress through the educational system. Medical education is not immune to this inequality. URM medical students are more likely to experience delayed graduation and course failure, even after accounting for science grade point average and Medical College Admission Test performance. Moreover, URM students are more likely to earn lower scores on licensing examinations, which can have a significant impact on their career trajectory, including specialty choice and residency competitiveness. After the release of preliminary recommendations from the Invitational Conference on USMLE Scoring (InCUS) and public commentary on these recommendations, the National Board of Medical Examiners and Federation of State Medical Boards announced that the United States Medical Licensing Examination (USMLE) Step 1 would transition from a 3-digit numeric score to pass/fail scoring. Given that another of InCUS's recommendations was to "minimize racial demographic differences that exist in USMLE performance," it is paramount to consider the impact of this scoring change on URM medical students specifically. Holistic admissions are a step in the right direction of acknowledging that URM students often travel a further distance to reach medical school. However, when residency programs emphasize USMLE performance (or any standardized test score) despite persistent test score gaps, medical education contributes to the disproportionate harm URM students face and bolsters segregation across medical specialties. This Perspective provides a brief explanation of the achievement gap, its psychological consequences, and its consequences in medical education; discusses the potential effect of the Step 1 scoring change on URM medical students; and provides a review of strategies to redress this disparity.

Uniformed Services University Occupational and Environmental Medicine Residency Program.

In 2019, the Uniformed Services University of the Health Sciences (USU) F. Edward Hébert School of Medicine celebrated the 30th anniversary of its Occupational and Environmental Medicine (OEM) Residency program. This unique program is among the largest preventive medicine residency programs in the United States. Residents from the US Army, Navy, Air Force, other federal institutions, and the Canadian Forces come to Bethesda, Maryland, to become OEM specialists in a unique training program encompassing both military and civilian OEM settings. This publication describes the historical development and practice of OEM in the military leading to the development of the USU OEM Residency Program, along with the program's past accomplishments and current operation. Finally, the publication explores potential future directions for this relatively small but important preventive medicine specialty in the practice of military medicine, considering the impacts of reorganization of the Military Health System along with the opportunities this reorganization presents for the USU OEM Residency program.

Characteristics of ACGME Residency Programs That Select Osteopathic Medical Graduates.

BACKGROUND: The transition from American Osteopathic Association (AOA) and Accreditation Council for Graduate Medical Education (ACGME) residency matches to a single graduate medical education accreditation system culminated in a single match in 2020. Without AOA-accredited residency programs, which were open only to osteopathic medical (DO) graduates, it is not clear how desirable DO candidates will be in the unified match. To avoid increased costs and inefficiencies from overapplying to programs, DO applicants could benefit from knowing which specialties and ACGME-accredited programs have historically trained DO graduates. OBJECTIVE: This study explores the characteristics of residency programs that report accepting DO students. METHODS: Data from the American Medical Association's Fellowship and Residency Electronic Interactive Database Access were analyzed for percentage of DO residents in each program. Descriptive statistics and a logit link generalized linear model for a gamma distribution were performed. RESULTS: Characteristics associated with graduate medical education programs that reported a lower percentage of DO graduates as residents were surgical subspecialties, longer training, and higher US Medical Licensing Examination Step 1 scores of their residents compared with specialty average. Characteristics associated with a higher percentage of DO graduates included interviewing more candidates for first-year positions and reporting a higher percentage of female residents. CONCLUSIONS: Wide variation exists in the percentage of DO graduates accepted as residents among specialties and programs. This study provides valuable information about the single Match for DO graduates and their advisers and outlines education opportunities for the osteopathic profession among the specialties with low percentages of DO students as residents.

Assessing Adverse Events After Chiropractic Care at a Chiropractic Teaching Clinic: An Active-Surveillance Pilot Study.

OBJECTIVE: This study aimed to assess the feasibility of implementing an active-surveillance reporting system within a chiropractic teaching clinic and subsequently determining the frequency of adverse events (AEs) after treatment administered by chiropractic interns. METHODS: Interns were invited to collect data from patients using 3 questionnaires that recorded patient symptom change: 2 completed by the patient (before and 7 days after treatment) and 1 completed by the intern (immediately after treatment). Worsened and new symptoms were considered AEs. Qualitative interviews were conducted with clinicians and interns to assess the feasibility of implementing the reporting system, with resulting data categorized under 4 domains: acceptability, implementation, practicality, and integration. RESULTS: Of the 174 eligible interns, 80 (46.0%) collected data from 364 patient encounters, with 119 (32.7%) returning their posttreatment form. Of the 89 unique patients (mean age = 39.5 years; 58.4% female, 41.6% male), 40.1% presented with low back pain and 31.1% with neck pain. After treatment, 25 symptoms (8.9%) were identified as AEs, mostly reported by patients as worsening discomfort or pain. Data from qualitative interviews suggest that the AE reporting system was well accepted; however, proposed specific modifications include use of longitudinal electronic surveys. CONCLUSION: Our findings suggest that it is feasible to conduct an active-surveillance reporting system at a chiropractic teaching clinic. Important barriers and facilitators were identified and will be used to inform future work regarding patient safety education and research.

Spirituality, Religion, and Medicine Education for Internal Medicine Residents.

PURPOSE: Spirituality and religion affect patient health. This topic is often not included in medical resident education. We aimed to evaluate resident knowledge, attitudes, and skill regarding spirituality, religion, and medicine and to develop, implement, and evaluate a curriculum to improve these measures. METHODS: Internal medicine residents at a large, urban academic center were surveyed to determine their baseline knowledge, attitudes, and skill regarding spirituality and religion (37.4% response rate, n = 46/123). A lecture and discussion-based curriculum was implemented over 1 year, followed by another survey (41.4% response rate, n = 51/123); χ2 statistic was used to compare pre- and postsurveys to evaluate the curriculum. RESULTS: Baseline resident attitudes toward spirituality, religion, and medicine were high with most agreeing chaplains are valuable in patient care (93.5%) and that patient spiritual and religious beliefs can affect health (93.5%). Resident self-reported knowledge and skill were low with few knowing the training chaplains receive (4.3%) or reporting competence taking a spiritual history (15.2%). After the curriculum, resident self-reported knowledge increased regarding the role of chaplains (56.5%-80.4%, P = .011) and the training chaplains receive (4.3%-27.5%, P = .002). No significant postcurriculum change was seen in attitudes or skill. CONCLUSIONS: Most internal medicine residents have positive attitudes toward spirituality, religion, and medicine. They do not have adequate knowledge or skill to care for patients in this area, however. Implementation of a curriculum in spirituality, religion, and medicine improved resident self-reported knowledge. Future work should focus on revising the curriculum to better improve resident knowledge and skill.

Burnout in Pediatric Residents: Three Years of National Survey Data.

BACKGROUND: We aimed to describe the national epidemiology of burnout in pediatric residents. METHODS: We conducted surveys of residents at 34 programs in 2016, 43 programs in 2017, and 49 programs in 2018. Survey items included the Maslach Burnout Inventory, demographics, program characteristics, personal qualities, experiences, and satisfaction with support, work-life balance, and learning environment. Analyses included cross-sectional comparisons and cross-sectional and longitudinal regression. RESULTS: More than 60% of eligible residents participated; burnout rates were >50% in all years and not consistently associated with any demographic or residency characteristics. Cross-sectional associations were significant between burnout and stress, sleepiness, quality of life, mindfulness, self-compassion, empathy, confidence in providing compassionate care (CCC), being on a high-acuity rotation, recent major medical error, recent time off, satisfaction with support and career choice, and attitudes about residency. In cross-sectional logistic regression analyses, 4 factors were associated with an increased risk of burnout: stress, sleepiness, dissatisfaction with work-life balance, and recent medical error; 4 factors were associated with lower risk: empathy, self-compassion, quality of life, and CCC. Longitudinally, after controlling for 2017 burnout and 2018 risk factors (eg, recent error, sleepiness, rotation, and time off), 2017 quality of life was associated with 2018 burnout; 2017 self-compassion was associated with lower 2018 stress; and 2017 mindfulness, empathy, and satisfaction with learning environment and career choice were associated with 2018 CCC. CONCLUSIONS: A majority of residents met burnout criteria. Several identified factors (eg, stress, sleepiness, medical errors, empathy, CCC, and self-compassion) suggest targets for interventions to reduce burnout in future studies.

Preparing Physicians for Rural Practice: Availability of Rural Training in Rural-Centric Residency Programs.

BACKGROUND: Exposing residents to rural training encourages future rural practice, but unified accreditation of allopathic and osteopathic graduate medical education under one system by 2020 has uncertain implications for rural residency programs. OBJECTIVE: We describe training locations and rural-specific content of rural-centric residency programs (requiring at least 8 weeks of rurally located training) before this transition. METHODS: In 2015, we surveyed residency programs that were rurally located or had rural tracks in 7 specialties and classified training locations as rural or urban using Rural-Urban Commuting Area (RUCA) codes. RESULTS: Of 1849 residencies in anesthesiology, emergency medicine, general surgery, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry, 119 (6%) were rurally located or offered a rural track. Ninety-seven programs (82%) responded to the survey. Thirty-six programs required at least 8 weeks of rural training for some or all residents, and 69% of these rural-centric residencies were urban-based and 53% were osteopathic. Locations were rural for 26% of hospital rotations and 28% of continuity clinics. Many rural-centric programs (35%) reported only urban ZIP codes for required rural block rotations; 54% reported only urban ZIP codes for required rural clinic sessions, and 31% listed only urban ZIP codes in reporting rural full-time training locations. Programs varied widely in coverage of rural-specific training in 6 core competencies. CONCLUSIONS: In multiple specialties important for rural health care systems, little rurally located residency training and rural-specific content was available. Substantial proportions of training locations reported to be rural were actually urban according to a common rural definition.

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice.

PURPOSE: A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP). METHOD: The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics. RESULTS: The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC). CONCLUSIONS: Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.

Factors affecting cataract surgery operating time among trainees and consultants.

PURPOSE: To define factors affecting cataract surgery operating time for operating room planning, optimizing throughput, enhancing patient experiences, minimizing costs, and allocating training time. SETTING: Epsom and St. Helier University National Health Service Trust, London, United Kingdom. DESIGN: Retrospective case series. METHODS: All patients who had primary manual phacoemulsification cataract surgery from January 1, 2012, to December 30, 2016, were included. Combined anterior and posterior segment procedures and surgeons with fewer than 50 cases were excluded. Anonymized data collected were demographics, anesthesia, operating time, surgeon grade, case complexity, pupil size, pupil expander or capsular tension ring (CTR) use, intraocular lens type, posterior capsule or zonular fiber rupture or dialysis, vitreous loss, and automated anterior vitrectomy. RESULTS: From 11 067 cases, 9552 (86.3%) had a recorded operating time. The mean ± SD operating times in minutes were as follows: consultants 19 ± 10, junior 30 ± 11, intermediate 27 ± 12, senior trainees 24 ± 10, and fellows 31 ± 11. Operating time was significantly shorter for topical than for sub-Tenon or general anesthesia, especially among trainees. Consultant operating time remained unchanged with increasing case complexity, except for high-complexity cases. Small pupils, pupil expander or CTR use, posterior capsule or zonular fiber rupture or dialysis with or without vitreous loss (mean 45 ± 23) were associated with increased operating times. Iris hooks were associated with greater increases in operating time than Malyugin rings (16 minutes versus 6 minutes; P < .001). There was a modest 3-minute decrease in operating time among consultants over 5 years. CONCLUSION: Cataract surgery operating time was significantly influenced by anesthesia type, surgeon grade, high case complexity, pupil size, pupil expander use/type, CTR use, and intraoperative complications.

Trends in US Medical School Contributions to the Family Physician Workforce: 2018 Update From the American Academy of Family Physicians.

BACKGROUND AND OBJECTIVES: The United States needs more family physicians. Projections based on current trends show a deficit of 52,000 primary care physicians by 2025. Eight national family medicine (FM) organizations have set an ambitious goal of increasing the proportion of US medical school graduates who enter FM residencies to 25% by 2030. This paper describes the most recent number and percentage of students from each US medical school entering Accreditation Council for Graduate Medical Education (ACGME)-accredited FM residency programs, long-term trends in the contribution of allopathic and osteopathic medical schools to the FM workforce, and medical school characteristics associated with higher proportions of FM graduates. METHODS: Data about graduates entering US ACGME-accredited FM residency programs were collected using an annual program census and supplemental sources. Longitudinal census data from allopathic and osteopathic schools were combined to examine trends over time. ANOVA analyses were conducted to compare schools by percent of graduates entering FM, public/private ownership, allopathic/osteopathic, size, and presence of FM department. Medical school length of operation was correlated with percentage of students entering FM. RESULTS: The overall proportion of US students entering ACGME-accredited FM programs has increased modestly over the past decade. Currently, only 12.6% of US allopathic and osteopathic seniors enter ACGME-accredited FM programs. Individual medical schools' contributions to the FM workforce are described. CONCLUSIONS: The proportion of US medical students beginning ACGME-accredited FM residency programs has increased slightly over the last decade. However, significant changes to undergraduate medical education are needed to meet the nation's primary care needs.

Recommendations from the Council of Emergency Medicine Residency Directors: Osteopathic Applicants.

The Council of Emergency Medicine Residency Directors (CORD) Advising Students Committee (ASC-EM) has previously published student advising recommendations for general emergency medicine (EM) applicants in an effort to disseminate standardized information to students and potential advisors. As the shift to a single graduate medical education system occurs by 2020, osteopathic students will continue to represent a larger portion of matched EM applicants, but data shows that their match rate lags that of their allopathic peers, with many citing a lack of access to knowledge EM advisors as a major barrier. Based on available data and experiential information, a sub-group of ASC-EM committee sought to provide quality, evidence-based advising resources for students, their advisors, and medical leadership. The recommendations advise osteopathic students to seek early mentorship and get involved in EM-specific organizations. Students should take Step 1 of the United States Medical Licensing Exam and complete two EM rotations at academic institutions to secure two Standardized Letters of Evaluation and consider regional and program-specific data on percentage of active osteopathic residents.