Perfectionism as a predictor of physician burnout.

BACKGROUND: Burnout is common among physicians and has detrimental effects on patient care and physician health. Recent editorials call attention to perfectionism in medicine; however, no studies to date have examined the effect of perfectionism on burnout in physicians practicing in the United States. This study examined associations among demographics, perfectionism and personality traits, and burnout among practicing physicians. METHODS: This cross-sectional study included general pediatric and pediatric sub-specialist physicians. Out of the 152 physicians contacted, 69 enrolled (Meanage = 44.16 ± 9.98; 61% female). Emotional exhaustion, depersonalization, and personal accomplishment burnout were assessed via the Maslach Burnout Inventory. Validated instruments were used to measure personality and perfectionism. Data were analyzed using linear regression models. RESULTS: Across physicians assessed, 42% reported either high emotional exhaustion burnout or depersonalization burnout. High self-critical perfectionism uniquely predicted both high emotional exhaustion burnout (B = 0.55, 95%CI 0.25-0.85) and depersonalization burnout (B = 0.18, 95%CI 0.05-0.31). Low conscientiousness (B = -6.12; 95%CI, -10.95- -1.28) predicted higher emotional exhaustion burnout and low agreeableness (B = -3.20, 95%CI -5.93- -0.46) predicted higher depersonalization burnout. CONCLUSIONS: Perfectionism is understudied among physicians and the current findings suggest that addressing system and individual-level factors that encourage perfectionism is warranted and may reduce risk for physician burnout.

Effect of Inadequate Sleep on Clinician Performance.

The negative impacts of sleep deprivation and fatigue have long been recognized. Numerous studies have documented the ill effects of impaired alertness associated with the disruption of the sleep-wake cycle; these include an increased incidence of human error-related accidents, increased morbidity and mortality, and an overall decrement in social, financial, and human productivity. While there are multiple studies on the impact of sleep deprivation and fatigue in resident physicians, far fewer have examined the effects on attending physicians, and only a handful addresses the accumulated effects of chronic sleep disturbances on acute sleep loss during a night call-shift. Moreover, the rapid and unprecedented spread of coronavirus disease 2019 (COVID-19) pandemic significantly increased the level of anxiety and stress on the physical, psychological, and the economic well-being of the entire world, with heightened effect on frontline clinicians. Additional studies are necessary to evaluate the emotional and physical toll of the pandemic in clinicians, and its impact on sleep health, general well-being, and performance.

The Effect of Operating Room Temperature on the Performance of Clinical and Cognitive Tasks.

INTRODUCTION: Operating room (OR) temperature may impact the performance of health care providers. This study assesses whether hot or cold room temperature diminishes the performance of OR personnel measured by psychomotor vigilance testing (PVT) and self-report scales. METHODS: This prospective observational study enrolled surgical/anesthesia trainees, student registered nurse anesthetists, and certified registered nurse anesthetists. Each provider participated in a test of psychomotor function and a questionnaire using a self-report scale of personal comfort and well-being. The PVT and questionnaires were completed after 30 minutes of exposure to 3 different conditions (temperature of 21°C, 23°C, and 26°C). RESULTS: The cohort of 22 personnel included 9 certified registered nurse anesthetists, 7 anesthesia/surgical trainees, and 6 student registered nurse anesthetists. Mean reaction time on the PVT was comparable among baseline (280 ± 47 ms), hot (286 ± 55 ms; P = 0.171), and cold (303 ± 114 ms; P = 0.378) conditions. On the self-report score (range, 1-21), there was no difference in the self-rated subjective performance between baseline and cold conditions. However, the self-rated subjective performance scale was lower (12 ± 6, P = 0.003) during hot conditions. DISCUSSION: No difference was noted in reaction time depending on the temperature; however, excessive heat in the OR environment was associated with worse self-rated subjective performance among health care providers. Particularly, self-rated subjective physical demand and frustration were greater under hot condition.

Wellness interventions for anesthesiologists.

PURPOSE OF REVIEW: The review examines the different preventive measures that have been found to be useful to abolish or decrease the negative effects of burnout and increase resilience in anesthesiologists. RECENT FINDINGS: Studies in anesthesiology cite autonomy, control of the work environment, professional relationships, leadership, and organizational justice as the most important factors in job satisfaction. Factors such as difficulty in balancing personal and professional life, poor attention to wellness, work alcoholism, and genetic factors increase an individual's susceptibility to burnout. Exposure to chronic or repeated stress instigates a spectrum of autonomic, endocrine, immunologic, and behavioral responses that activate the sympathetic-adrenal-medullary and hypothalamic-pituitary-adrenal axis. Investigating the difference in psychobiologic reactivity, as well as defining the psychological symptoms that are characteristic to individuals vulnerable to stress-induced illness, would enable scientists to better look into the modalities to eradicate the negative effects. Recent studies have shown that a combination of individual and structural changes in institutions can increase resilience in physicians. SUMMARY: Burnout is a pathological syndrome that is triggered by constant levels of high stress. A combination of individual efforts as well as structural interventions can help to increase wellbeing in physicians.

The Utility of the Modified Yale Preoperative Anxiety Scale for Predicting Success in Pediatric Patients Undergoing MRI Without the Use of Anesthesia.

PURPOSE: MRI is a common modality for diagnostic imaging. In children, general anesthesia is often required to complete MRI examinations. Simulation training can reduce the need for anesthesia in some children. Reliable screening tools to select who could benefit from practice MRI sessions are lacking. This study evaluates the use of the modified Yale Preoperative Anxiety Scale (mYPAS) in effectively identifying patients who may benefit from simulation-based training. METHODS: Children aged 5 and older who were originally scheduled for MRI with anesthesia in 2015 to 2016 were prospectively recruited for simulation-based training. The mYPAS assessment was performed by trained certified child life specialists before and after practice MRI sessions. The primary outcome was whether mYPAS could predict completing an MRI examination without anesthesia. RESULTS: Eighty patients (43 boys and 37 girls, age 8.5 ± 3.0 years) were enrolled in the study. Eleven subjects (14%) required general anesthesia to complete the MRI examination despite participating in the simulation. In the overall cohort, mYPAS scores improved after simulation from 31 ± 11 to 27 ± 9 (95% confidence interval of difference, -6, -2; P < .001 by paired t test). Receiver operating characteristic curve analysis found that presimulation mYPAS had good utility for predicting anesthesia requirement for MRI completion (area under the curve = 0.81). A presimulation mYPAS score > 33 predicted need for anesthesia with 82% sensitivity and 78% specificity. CONCLUSIONS: The mYPAS is a quick screening tool to identify pediatric patients who could benefit from simulation training by being able to complete an MRI examination without anesthesia.

Effects of partial sleep deprivation on reaction time in anesthesiologists.

BACKGROUND: Fatigue in anesthesiologists may have implications that extend beyond individual well-being. AIM: The aim of the present study was to evaluate the impact of sleep deprivation on the reaction time in anesthesiologists either after an overnight call or regular working hours. Moderation of this effect by coping strategies was observed. METHODS: Psychomotor vigilance test was used to assess reaction time in 23 anesthesiologists at two time-points: (i) on a regular non-call day and (ii) after a 17-h in-house call. Student's paired t-test was used to compare Psychomotor Vigilance Task data at these two moments. Change score regression was performed to determine the association between coping strategies, assessed using the Coping Strategy Indicator instrument, and decline in reaction time after night call. RESULTS: Twenty-one colleagues completed the psychomotor vigilance test measurements after two decided to end their participation for personal reasons. Post-call psychomotor vigilance test mean reaction time decreased by an average of 31.2 ms (95% CI: 0.5, 61.9; P = 0.047) when compared to regular day. Reliance on specific coping mechanisms, indicated by Coping Strategy Indicator scale scores, included problem-solving (28 ± 4), followed by seeking social support (23 ± 5) and avoidance (19 ± 4). The change score regression model (r2 = 0.48) found that greater reliance on avoidance was associated with greater increase in reaction time after night call. CONCLUSION: Reaction time increased considerably in anesthesiologists after a night call duty. Greater subjective reliance on avoidance as a coping strategy was associated with greater deterioration in performance.

Time to talk about work-hour impact on anesthesiologists: The effects of sleep deprivation on Profile of Mood States and cognitive tasks.

BACKGROUND: A physician's fatigue raises significant concerns regarding personal and patient safety. Effects of sleep deprivation on clinical performance and the quality of patient care are major considerations of today's health care environment. AIM: To evaluate the impact of partial sleep deprivation after a 17-h overnight call (3 pm-7 am) on the mood status and cognitive skills of anesthesiologists in an academic clinical hospital setting, as compared to these parameters during regular working hours. METHODS: Taking circadian rhythm into account, the following measures were assessed in 21 pediatric anesthesiologists at two time points over the course of the study; (i) between 7 and 8 am on a regular non call day, and (ii) between 7 and 8 am after a 17-h in-house call (3 pm-7 am). Six mood states were assessed using the Profile of Mood States. A Total Mood Disturbance (TMD) score was obtained as the sum of all mood scores minus vigor. The total score provides a global estimate of affective state. Simple cognitive tests were similarly administered to assess cognitive skills. A two-tailed paired t-test was used to compare data between regular and post call days. A P < 0.05 was used. RESULTS: The study cohort included 21 pediatric anesthesiologists at a tertiary care children's hospital. Tension, anger, fatigue, confusion, TMD, irritability, feeling jittery, and sleepiness were significantly affected (P < 0.05). A decrease in vigor, energy, and confidence was observed after a night call shift (P < 0.05). There was also a decrease in being "talkative" after the call shift (P < 0.05). CONCLUSION: Partial sleep deprivation affects the total mood status of anesthesiologists and impacts their cognitive skills. These findings are particularly relevant in a context of increased work expectation, particularly on clinical performance in our modern medical system. Such observations suggest that there may be changes that impact the safety of our patients and the quality of health care that is provided.

Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): formative evaluation and randomized controlled trial.

BACKGROUND: The purpose of this 2-phase project was to conduct a formative evaluation and to test the preliminary efficacy of a newly developed Web-based Tailored Intervention for Preparation of parents and children undergoing Surgery (WebTIPS). METHODS: Phase 1 enrolled 13 children 2 to 7 years of age undergoing outpatient elective surgery and their parents for formative evaluation of WebTIPS. Parent participation focus groups are common in qualitative research and are a method of asking research participants about their perceptions and attitudes regarding a product or concept. In phase 2, children 2 to 7 years of age in 2 medical centers were assigned randomly to receive the WebTIPS program (n = 38) compared with children receiving the standard of care (n = 44). The primary outcome of phase II was child and parent preoperative anxiety. RESULTS: In phase 2, parents reported WebTIPS to be both helpful (P < 0.001) and easy to use (P < 0.001). In phase 2, children in the WebTIPS group (36.2 ± 14.1) were less anxious than children in the standard of care group (46.0 ± 19.0) at entrance to the operating room (P = 0.02; Cohen d = 0.59) and introduction of the anesthesia mask (43.5 ± 21.7 vs 57.0 ± 21.2, respectively, P = 0.01; Cohen d = 0.63). Parents in the WebTIPS group (32.1 ± 7.4) also experienced less anxiety compared with parents in the control group (36.8 ± 7.1) in the preoperative holding area (P = 0.004; Cohen d = 0.65). CONCLUSIONS: WebTIPS was well received by parents and children and led to reductions in preoperative anxiety.

Effects of age and emotionality on the effectiveness of midazolam administered preoperatively to children.

BACKGROUND: Multiple studies document the beneficial effect of midazolam on preoperative anxiety in children. Many clinicians report, however, that some children may in fact not benefit from the administration of this drug. METHODS: After screening for relevant exclusion criteria, children undergoing surgery were enrolled in the study (n = 262) and received 0.5 mg/kg oral midazolam at 20-40 min before induction of anesthesia. Personality instruments were administered to all children, and anxiety levels were evaluated before and after administration of midazolam as well as during induction of anesthesia. Blood was drawn during the induction process and later analyzed for midazolam levels. A priori definitions of responders and nonresponders to midazolam were established using a multidisciplinary task force, videotapes of induction, and a validated and reliable anxiety scale, the modified Yale Preoperative Anxiety Scale. RESULTS: While 57% of all children scored at the minimum of the modified Yale Preoperative anxiety scale, 14.1% of children fell in the a priori defined group of midazolam nonresponders. Midazolam blood levels (94 +/- 41 vs. 109 +/- 40 ng/ml) and timing between administration of midazolam and induction (28 +/- 9 vs. 29 +/- 8 min) did not differ between midazolam responders and nonresponders. In contrast, midazolam nonresponders were younger (4.2 +/- 2.3 vs. 5.9 +/- 2.0 yr), more anxious preoperatively (49.7 +/- 22.9 vs. 38.3 +/- 19.1), and higher in emotionality (13.6 +/- 3.6 vs. 11.3 +/- 3.8) as compared with responders (P < 0.05). CONCLUSIONS: Although midazolam is an effective anxiolytic for most children, 14.1% of children still exhibit extreme distress. This subgroup is younger, more emotional, and more anxious at baseline. Future studies are needed to determine the best strategy to treat these children.

Task analysis of the preincision period in a pediatric operating suite: an independent observer-based study of 656 cases.

We designed this cross-sectional investigation to assess anesthesia release time (ART = patient-on-table until release for surgical preparation) and surgical preparation time (start of surgical preparation to incision) of children undergoing anesthesia and surgery (n = 656). Data collected by trained independent observers included variables such as age, ASA physical status, anesthetic technique, and placement of invasive monitoring. We found that mean ART was 11.0 +/- 9.7 min and the mean surgical preparation time was 11.1 +/- 10.0 min. Also, ART ranged from 7 +/- 7 min (for mask anesthesia) to 52 +/- 18 min (general anesthesia/endotracheal tube and invasive hemodynamic monitoring). The percentage of ART of the total case length was 15% +/- 7%, with a wide variability depending on the total case length. We also found that there is a significant variability in ART as a function of the surgical service involved (analysis of variance; P = 0.0001), ASA physical status (P = 0.0001), and age. For example, younger children had a significantly longer ART as compared with older children (P = 0.001). Room coverage ratio by the attending anesthesiologist and training level of the anesthesia resident did not impact ART (P = not significant). We conclude that ART in children undergoing surgery is highly variable and is a function of factors such as the surgical service involved, age of the child, and ASA physical status of the child. These factors should be considered when scheduling a surgical case.

Predicting which children benefit most from parental presence during induction of anesthesia.

BACKGROUND: The purpose of this large-scale prospective cohort study (n = 426) was to identify child and parent characteristics that are associated with low anxiety and good compliance during induction of anesthesia when parents are present. METHODS: Outcome variables included child's anxiety and child's compliance during induction of anesthesia. Predictor variables included demographics, temperament, trait (baseline) anxiety, coping style, and locus of control. RESULTS: Results of a linear regression model (overall proportion of variance accounted for equals 39.5%) showed that significant predictors of anxiety during induction of anesthesia while parents are present included: the child's age (DeltaR(2) = 0.315, P = 0.0001), behavior during previous medical visits (DeltaR(2) = 0.025, P = 0.001), child's activity level (DeltaR(2) = 0.016, P = 0.007), parent's state (contextual) anxiety (DeltaR(2) = 0.022, P = 0.001) and parent's locus of control (DeltaR(2) = 0.009, P = 0.036). A linear regression model that was constructed with compliance of the child as the outcome revealed similar findings. CONCLUSIONS: Children who benefit from parental presence are older, had lower levels of activity in their temperament, and had parents who were calmer and who valued preparation and coping skills for medical situations. The practical implications of these findings are discussed.

Hypnosis reduces preoperative anxiety in adult patients.

In this study we examined the effect of hypnosis on preoperative anxiety. Subjects were randomized into 3 groups, a hypnosis group (n = 26) who received suggestions of well-being; an attention-control group (n = 26) who received attentive listening and support without any specific hypnotic suggestions and a "standard of care" control group (n = 24). Anxiety was measured pre- and postintervention as well as on entrance to the operating rooms. We found that patients in the hypnosis group were significantly less anxious postintervention as compared with patients in the attention-control group and the control group (31 +/- 8 versus 37 +/- 9 versus 41 +/- 11, analysis of variance, P = 0.008). Moreover, on entrance to the operating rooms, the hypnosis group reported a significant decrease of 56% in their anxiety level whereas the attention-control group reported an increase of 10% in anxiety and the control group reported an increase of 47% in their anxiety (P = 0.001). In conclusion, we found that hypnosis significantly alleviates preoperative anxiety. Future studies are indicated to examine the effects of preoperative hypnosis on postoperative outcomes.

Sevoflurane versus halothane: postoperative maladaptive behavioral changes: a randomized, controlled trial.

BACKGROUND: The authors conducted a double-blind, randomized, controlled trial to determine whether the use of sevoflurane in children undergoing anesthesia and surgery results in a higher incidence of postoperative maladaptive behavioral changes as compared with halothane. METHODS: Children and their parents (n = 102) were randomly assigned to either a halothane group (n = 50) or a sevoflurane group (n = 52). The intraoperative anesthetic protocol was strictly controlled, and the postoperative analgesic consumption and pain levels were recorded. The effect of the group assignment on emergence status and maladaptive postoperative behavioral changes was assessed both by validated psychological measures and physiologic instruments (actigraphy) on postoperative days 1-7. Anxiety of the parent and child was also assessed, as was the child's postoperative recovery (Recovery Inventory). RESULTS: There were no group differences in preoperative state anxiety, postoperative analgesic requirements, postoperative pain, or the incidence of emergence delirium (P = not significant). Two-way repeated-measures analysis of variance showed no group differences in the incidence of postoperative maladaptive behaviors (F4,72 = 0.60, P = 0.701) or actigraphic variables such as percent sleep, number of night awakenings, and night awakenings that lasted for more than 5 min (P = not significant). CONCLUSION: The authors found no increased incidence of emergence delirium, maladaptive postoperative behavior changes, or sleep disturbances in children undergoing anesthesia with sevoflurane as compared with halothane.