Designing and Building a Portfolio of Individual Support Resources for Physicians.

As health care organizations in the United States move toward recovery from the COVID-19 pandemic, physicians and clinical faculty are experiencing occupational burnout and various manifestations of distress. To mitigate these challenges, health care organizations must optimize the work environment and provide support for individual clinicians using a variety of approaches, including mentoring, group-based peer support, individual peer support, coaching, and psychotherapy. While often conflated, each of these approaches offers distinct benefits. Mentoring is a longitudinal 1-on-1 relationship, typically focused on career development, usually with an experienced professional guiding a junior professional. Group-based peer support involves regular, longitudinal meetings of health professionals to discuss meaningful topics, provide mutual support to one another, and foster community. Individual peer support involves training peers to provide timely 1-on-1 support for a distressed colleague dealing with adverse clinical events or other professional challenges. Coaching involves a certified professional helping an individual identify their values and priorities and consider changes that would allow them to adhere to these more fully, and providing longitudinal support that fosters accountability for action. Individual psychotherapy is a longitudinal, short- or long-term professional relationship during which specific therapeutic interventions are delivered by a licensed mental health professional. When distress is severe, this is the best approach. Although some overlap exists, these approaches are distinct and complementary. Individuals may use different methods at different career stages and for different challenges. Organizations seeking to address a specific need should consider which approach is most suitable. Over time, a portfolio of offerings is typically needed to holistically address the diverse needs of clinicians. A stepped care model using a population health approach may be a cost-effective way to promote mental health and prevent occupational distress and general psychiatric symptoms.

The Impact of a Required Longitudinal Stress Management and Resilience Training Course for First-Year Medical Students.

BACKGROUND: Although psychological distress is common among medical students, little remains known about effective interventions. One promising individual-focused approach is mindfulness-based stress management interventions; however, studies to date have relied on volunteers. OBJECTIVE: To determine whether a required longitudinal stress management and resilience course improves well-being among first-year medical students. DESIGN: A quasi-experimental study. PARTICIPANTS: Two cohorts of medical students who participated in a required stress management and resilience course and completed pre and post questionnaires. MAIN MEASURES: Validated instruments were used to examine the effects on burnout, quality of life (QOL), stress, resilience, happiness, and empathy. Paired analysis was conducted to explore changes from baseline. KEY RESULTS: On paired analysis of individual students, mean mental QOL and happiness declined (mental QOL: -5.63 [P < 0.001] and -5.15 [P = 0.015] and happiness: -0.31 [P = 0.02] and -0.4 [P = 0.01], cohorts 1 and 2, respectively) over the course of the year. Similarly, stress scores increased by 4.22 (P < 0.0001) and 3.62 (P = 0.03) in cohorts 1 and 2, respectively. Cognitive and emotive empathy declined in both cohorts but was only statistically significant for cohort 1 (-1.64 and -2.07, P < 0.01). No statistically significant differences in burnout or resilience were seen. CONCLUSIONS: The required longitudinal mindfulness-based stress management course tested in first-year medical students did not lead to measurable improvements in medical student well-being or empathy. These findings contrast with those of studies using volunteer medical students or physicians, which suggested a reduction in burnout and stress using a similar curriculum. Medical schools should consider offering a variety of effective options so that students can select activities they want to engage in.

Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.

BACKGROUND: Physician burnout has reached epidemic levels, as documented in national studies of both physicians in training and practising physicians. The consequences are negative effects on patient care, professionalism, physicians' own care and safety, and the viability of health-care systems. A more complete understanding than at present of the quality and outcomes of the literature on approaches to prevent and reduce burnout is necessary. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Scopus, Web of Science, and the Education Resources Information Center from inception to Jan 15, 2016, for studies of interventions to prevent and reduce physician burnout, including single-arm pre-post comparison studies. We required studies to provide physician-specific burnout data using burnout measures with validity support from commonly accepted sources of evidence. We excluded studies of medical students and non-physician health-care providers. We considered potential eligibility of the abstracts and extracted data from eligible studies using a standardised form. Outcomes were changes in overall burnout, emotional exhaustion score (and high emotional exhaustion), and depersonalisation score (and high depersonalisation). We used random-effects models to calculate pooled mean difference estimates for changes in each outcome. FINDINGS: We identified 2617 articles, of which 15 randomised trials including 716 physicians and 37 cohort studies including 2914 physicians met inclusion criteria. Overall burnout decreased from 54% to 44% (difference 10% [95% CI 5-14]; p<0·0001; I2=15%; 14 studies), emotional exhaustion score decreased from 23·82 points to 21·17 points (2·65 points [1·67-3·64]; p<0·0001; I2=82%; 40 studies), and depersonalisation score decreased from 9·05 to 8·41 (0·64 points [0·15-1·14]; p=0·01; I2=58%; 36 studies). High emotional exhaustion decreased from 38% to 24% (14% [11-18]; p<0·0001; I2=0%; 21 studies) and high depersonalisation decreased from 38% to 34% (4% [0-8]; p=0·04; I2=0%; 16 studies). INTERPRETATION: The literature indicates that both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians. Further research is needed to establish which interventions are most effective in specific populations, as well as how individual and organisational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions. FUNDING: Arnold P Gold Foundation Research Institute.

Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.

IMPORTANCE Despite the documented prevalence and clinical ramifications of physician distress, few rigorous studies have tested interventions to address the problem. OBJECTIVE To test the hypothesis that an intervention involving a facilitated physician small-group curriculum would result in improvement in well-being. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 74 practicing physicians in the Department of Medicine at the Mayo Clinic in Rochester, Minnesota, conducted between September 2010 and June 2012. Additional data were collected on 350 nontrial participants responding to annual surveys timed to coincide with the trial surveys. INTERVENTIONS The intervention involved 19 biweekly facilitated physician discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning for 9 months. Protected time (1 hour of paid time every other week) for participants was provided by the institution. MAIN OUTCOMES AND MEASURES Meaning in work, empowerment and engagement in work, burnout, symptoms of depression, quality of life, and job satisfaction assessed using validated metrics. RESULTS Empowerment and engagement at work increased by 5.3 points in the intervention arm vs a 0.5-point decline in the control arm by 3 months after the study (P = .04), an improvement sustained at 12 months (+5.5 vs +1.3 points; P = .03). Rates of high depersonalization at 3 months had decreased by 15.5% in the intervention arm vs a 0.8% increase in the control arm (P = .004). This difference was also sustained at 12 months (9.6% vs 1.5% decrease; P = .02). No statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction were seen. In additional comparisons including the nontrial physician cohort, the proportion of participants strongly agreeing that their work was meaningful increased 6.3% in the study intervention arm but decreased 6.3% in the study control arm and 13.4% in the nonstudy cohort (P = .04). Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the trial intervention arm, decreased slightly in the trial control arm, and increased in the nontrial cohort (P = .03, .007, and .002 for each outcome, respectively). CONCLUSIONS AND RELEVANCE An intervention for physicians based on a facilitated small-group curriculum improved meaning and engagement in work and reduced depersonalization, with sustained results at 12 months after the study. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01159977.

Predicting patients' expectations of hospital chaplains: a multisite survey.

OBJECTIVE: To identify patient expectations regarding chaplain visitation, characteristics of patients who want to be visited by a chaplain, and what patients deem important when a chaplain visits. PARTICIPANTS AND METHODS: Three weeks after discharge, 4500 eligible medical and surgical patients from hospitals in Minnesota, Arizona, and Florida were surveyed by mail to collect demographic information and expectations regarding chaplain visitation. The survey was conducted during the following time periods: Minnesota participants, April 6 until April 25, 2006; Arizona participants, October 16, 2008, until January 13, 2009; Florida participants, October 16, 2008, until January 20, 2009. Categorical variables were summarized with frequencies or percentages. Associations between responses and site were examined using χ(2) tests. Multivariate logistic regression was used to assess the likelihood of wanting chaplain visitation on the basis of patient demographics and perceived importance of reasons for chaplain visitation. RESULTS: About one-third of those surveyed responded from each site. Most were male, married, aged 56 years or older, and Protestant or Catholic. Of the respondents, nearly 70% reported wanting chaplain visitation, 43% were visited, and 81% indicated that visitation was important. The strongest predictor of wanting chaplain visitation was denomination vs no indicated religious affiliation (Catholic: odds ratio [OR], 8.11; 95% confidence interval [CI], 4.49-14.64; P<.001; evangelical Protestant: OR, 4.95; 95% CI, 2.74-8.91; P<.001; mainline Protestant: OR, 4.34; 95% CI, 2.58-7.29; P<.001). Being female was a weak predictor (OR, 1.48; 95% CI, 1.05-2.09; P=.03), as was site. Among the reasons given by respondents for wanting chaplain visitation, the most important were that chaplains served as reminders of God's care and presence (OR, 4.37; 95% CI, 2.58-7.40; P<.001) and that they provided prayer or scripture reading (OR, 2.54; 95% CI, 1.53-4.20; P<.001). CONCLUSION: The results of this study suggest the importance medical and surgical patients place on being visited by a chaplain while they are hospitalized. Those who valued chaplains because they reminded them of God's care and presence and/or because they prayed or read scripture with them were more likely to desire a visit. Our results also suggest that being religiously affiliated is a very strong predictor of wanting chaplain visitation.

Phase I trial of daily oral Polyphenon E in patients with asymptomatic Rai stage 0 to II chronic lymphocytic leukemia.

PURPOSE: To define the optimal dose of Polyphenon E for chronic daily administration and tolerability in patients with chronic lymphocytic leukemia (CLL). PATIENTS AND METHODS: Previously untreated patients with asymptomatic Rai stage 0 to II CLL were eligible for participation. Polyphenon E with a standardized dose of epigallocatechin-3-gallate (EGCG) was administered using the standard phase I design with three to six patients per dose level (range, 400 to 2,000 mg by mouth twice a day). Trough plasma EGCG levels were measured 1 month after initiation of therapy. Response was classified using the National Cancer Institute (NCI) Working Group (WG) Criteria. RESULTS: Thirty-three eligible patients were accrued to dose levels 1 to 8. The maximum-tolerated dose was not reached. The most common adverse effects included transaminitis (33%, all grade 1), abdominal pain (30% grade 1, 0% grade 2, and 3% grade 3), and nausea (39% grade 1 and 9% grade 2). One patient experienced an NCI WG partial remission. Other signs of clinical activity were also observed, with 11 patients (33%) having a sustained > or = 20% reduction in absolute lymphocyte count (ALC) and 11 (92%) of 12 patients with palpable adenopathy experiencing at least a 50% reduction in the sum of the products of all nodal areas during treatment. Trough plasma EGCG levels after 1 month of treatment ranged from 2.9 to 3,974 ng/mL (median, 40.4 ng/mL). CONCLUSION: Daily oral EGCG in the Polyphenon E preparation was well tolerated by CLL patients in this phase I trial. Declines in ALC and/or lymphadenopathy were observed in the majority of patients. A phase II trial to evaluate efficacy using 2,000 mg twice a day began in November 2007.

Curcumin inhibits prosurvival pathways in chronic lymphocytic leukemia B cells and may overcome their stromal protection in combination with EGCG.

PURPOSE: Chronic lymphocytic leukemia (CLL) is incurable with current chemotherapy treatments. Curcumin (diferuloylmethane), an active ingredient in the spice turmeric, inhibits tumor metastasis, invasion, and angiogenesis in tumor cell lines. We evaluated the effects of curcumin on the viability of primary CLL B cells and its ability to overcome stromal mediated protection. EXPERIMENTAL DESIGN: The in vitro effect of curcumin on primary CLL B cells was evaluated using fluorescence activated cell sorter analysis and Western blotting. For some experiments, CLL B cells were cocultured with human stromal cells to evaluate the effects of curcumin on leukemia cells cultured in their microenvironment. Finally, the effect of curcumin in combination with the green tea extract epigallocatechin-3 gallate (EGCG) was evaluated. RESULTS: Curcumin induced apoptosis in CLL B cells in a dose-dependent (5-20 micromol/L) manner and inhibited constitutively active prosurvival pathways, including signal transducers and activators of transcription 3 (STAT3), AKT, and nuclear factor kappaB. Moreover, curcumin suppressed expression of the anti-apoptotic proteins Mcl-1 and X-linked inhibitor of apoptosis protein (XIAP), and up-regulated the pro-apoptotic protein BIM. Coculture of CLL B cells with stromal cells resulted in elevated levels of STAT3, increased expression of Mcl-1 and XIAP, and decreased sensitivity to curcumin. When curcumin was administered simultaneously with EGCG, antagonism was observed for most patient samples. In contrast, sequential administration of these agents led to substantial increases in CLL B-cell death and could overcome stromal protection. CONCLUSIONS: Curcumin treatment was able to overcome stromal protection of CLL B cells on in vitro testing and to synergize with EGCG when administered in a sequential fashion. Additional evaluation of curcumin as a potential therapeutic agent for treatment of CLL seems warranted.

Comprehensive management of the CLL patient: a holistic approach.

The current management of B-chronic lymphocytic leukemia (CLL) is no longer straightforward for the practicing hematologist. Rapid advances in diagnostic precision, methods of predicting prognosis, understanding of natural history of CLL, recognition of clinical complications, clarification of the quality of life (QOL) issues facing the CLL patient, and the exciting array of novel treatment approaches have made the care of the CLL patient more demanding. This review is focused on summarizing these advances in order to provide a framework for integrating this knowledge into routine hematologic practice.

The well-being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group.

PURPOSE: The well-being of oncologists is important to the well-being of their patients. While much is known about oncologist distress, little is known about oncologist well-being. We set out to evaluate oncologist well-being and the personal wellness promotion strategies used by oncologists. PATIENTS AND METHODS: We performed a cross-sectional survey of medical oncologists in the North Central Cancer Treatment Group using a validated instrument to measure quality of life. Study-specific questions explored stressors, wellness promotion strategies and career satisfaction. RESULTS: Of 241 responding oncologists (response rate 61%), 121 (50%) reported high overall well-being. Being age 50 or younger (57 vs. 41%; p = 0.01), male (53 vs. 31%; p = 0.01) and working 60 h or less per week (50 vs. 33%; p = 0.005) were associated with increased overall well-being on bivariate analysis. Ratings of the importance of a number of personal wellness promotion strategies differed for oncologists with high well-being compared with those without high well-being. Developing an approach/philosophy to dealing with death and end-of-life care, using recreation/hobbies/exercise, taking a positive outlook and incorporating a philosophy of balance between personal and professional life were all rated as substantially more important wellness strategies by oncologists with high well-being (p values <0.001). Oncologists with high overall well-being also reported greater career satisfaction. CONCLUSION: Half of medical oncologists experience high overall well-being. Use of specific personal wellness promotion strategies appears to be associated with oncologist well-being. Further investigations of the prevalence, promotion, causes, inequities and clinical impact of physician well-being are needed. .

Pathophysiology and treatment of hot flashes.

Hot flashes affect about three fourths of postmenopausal women and are one of the most common health problems in this demographic group. Dysfunction of central thermoregulatory centers caused by changes in estrogen levels at the time of menopause has long been postulated to be the cause of hot flashes. Treatment should begin with a careful patient history, with specific attention to the frequency and severity of hot flashes and their effect on the individual's function. For mild symptoms that do not interfere with sleep or daily function, behavioral changes in conjunction with vitamin E (800 IU/d) use is a reasonable initial approach. For more severe symptoms, the next step is to determine whether there is a contraindication or a personal reservation to estrogen replacement therapy. For women who are able and willing to use estrogen, it will successfully relieve symptoms by about 80% to 90%. In patients with a history of breast or uterine cancer, treatment with the progestational agent megesterol acetate appears to be a safe alternative that also decreases hot flashes by approximately 80%. For women unwilling or unable to use hormone therapy, one of the newer antidepressant agents can be prescribed. Venlafaxine decreases hot flashes by about 60%. Gabapentin is another drug that appears promising as therapy for women unable or unwilling to use estrogen, and the results of ongoing trials to determine its efficacy are eagerly awaited. The use of clonidine, methyldopa, and belladonna should be discouraged because of their modest efficacy and adverse effects.