Understanding resident wellness: A path analysis of the clinical learning environment at three institutions.

PURPOSE: The clinical learning environment (CLE) affects resident physician well-being. This study assessed how aspects of the learning environment affected the level of resident job stress and burnout. MATERIALS AND METHODS: Three institutions surveyed residents assessing aspects of the CLE and well-being via anonymous survey in fall of 2020 during COVID. Psychological safety (PS) and perceived organizational support (POS) were used to capture the CLE, and the Mini-Z Scale was used to assess resident job stress and burnout. A total of 2,196 residents received a survey link; 889 responded (40% response rate). Path analysis explored both direct and indirect relationships between PS, POS, resident stress, and resident burnout. RESULTS: Both POS and PS had significant negative relationships with experiencing a great deal of job stress; the relationship between PS and stress was noticeably stronger than POS and stress (POS: B= -0.12, p=.025; PS: B= -0.37, p<.001). The relationship between stress and residents' level of burnout was also significant (B = 0.38, p<.001). The overall model explained 25% of the variance in resident burnout. CONCLUSIONS: Organizational support and psychological safety of the learning environment is associated with resident burnout. It is important for educational leaders to recognize and mitigate these factors.

Psychological Safety and Support: Assessing Resident Perceptions of the Clinical Learning Environment.

BACKGROUND: Assessments of the clinical learning environment could allow early interventions to improve graduate medical education. To date, measurement tools for this have not been identified. OBJECTIVE: We established the concurrent validity of 2 instruments that assess cultural facets of the clinical learning environment by correlating them with external program evaluation data. METHODS: In 2017 we surveyed residents across 19 training programs on their perceptions of organizational support by using the Short Survey of Perceived Organizational Support (SPOS), and psychological safety by using the Psychological Safety Scale (PSS). Data were aggregated to the program level and correlated with results from the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey. RESULTS: Of 511 residents, 322 (63%) completed the survey, and 496 of 516 residents (96%) completed the ACGME Resident Survey. Perceived organizational support correlated positively with overall program evaluation score (r = 0.75, P < .001); faculty (r = 0.72, P < .001); evaluation (r = 0.73, P < .001); educational content (r = 0.52, P = .022); and resources domains (r = 0.55, P = .014). Psychological safety had a positive correlation with overall program evaluation (r = 0.57, P = .011); faculty (r = 0.50, P = .028); and evaluation (r = 0.62, P < .005). CONCLUSIONS: The SPOS and PSS correlated with key ACGME Resident Survey domains. Programs showing greater support of residents were likely to show more positive ratings on program evaluation metrics. Teaching institutions may benefit from actively monitoring and improving aspects of their learning environment through internal assessments.

Update in internal medicine residency education: a review of the literature in 2010 and 2011.

BACKGROUND: Evidence-based practice in education requires high-quality evidence, and many in the medical education community have called for an improvement in the methodological quality of education research. OBJECTIVE: Our aim was to use a valid measure of medical education research quality to highlight the methodological quality of research publications and provide an overview of the recent internal medicine (IM) residency literature. METHODS: We searched MEDLINE and PreMEDLINE to identify English-language articles published in the United States and Canada between January 1, 2010, and December 31, 2011, focusing on IM residency education. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), which has demonstrated reliability and validity. Qualitative articles were excluded. Articles were ranked by quality score, and the top 25% were examined for common themes, and 2 articles within each theme were selected for in-depth presentation. RESULTS: The search identified 731 abstracts of which 223 articles met our inclusion criteria. The mean (±SD) MERSQI score of the 223 studies included in the review was 11.07 (±2.48). Quality scores were highest for data analysis (2.70) and lowest for study design (1.41) and validity (1.29). The themes identified included resident well-being, duty hours and resident workload, career decisions and gender, simulation medicine, and patient-centered outcomes. CONCLUSIONS: Our review provides an overview of the IM medical education literature for 2010-2011, highlighting 5 themes of interest to the medical education community. Study design and validity are 2 areas where improvements in methodological quality are needed, and authors should consider these when designing research protocols.

When the patient does not pay: a survey of primary care physicians.

OBJECTIVE: Despite ethical implications, there are anecdotal reports of health practitioners withholding services from patients who do not pay their bills. We surveyed physicians about their attitudes and experiences regarding nonpaying patients. DESIGN: A cross-sectional mailed survey. PARTICIPANTS: Three hundred seventy-nine of 1000 surveyed primary care physicians participated. MEASUREMENTS AND MAIN RESULTS: We studied how likely participants were to withhold 13 services from hypothetical patients who did not pay the physician's bills based on a 4-point Likert scale. Respondents were asked whether they had actually ever withheld such services from patients. The effects of demographic data on the number of services withheld from hypothetical and actual patients were analyzed by analysis of variance and multiple logistic regression. Most respondents (84%) would have withheld at least 1 item of service from the hypothetical patient, with 41% having ever withheld care from their actual patients. Most services involved administrative actions, but many respondents would be willing to forego other types of medical care. Being younger (P = 0.003), believing that patients are not always entitled to medical care (P = 0.002) and being in an urban practice (P = 0.03) were associated with withholding medical care from patients. CONCLUSIONS: A majority of primary care practitioners responding to our survey would be willing to withhold medical care from patients who do not pay their bills; some have actually done so despite ethical and legal mandates to the contrary. Physicians should be educated about the importance of the patient-physician relationship and their ethical obligations to patients.

Physicians' willingness to report impaired colleagues.

We surveyed physicians to determine what factors were associated with their reporting of impaired colleagues to Physician Health Programs (PHPs). We conducted a cross-sectional mail survey of 1000 randomly selected practicing physicians in the United States. A survey instrument asked the physicians whether they would report 10 hypothetical impaired colleagues to a PHP. The results show that a majority of the physicians would report physicians to PHPs, but were more likely to report hypothetical physicians involved in substance abuse than those who were emotionally or cognitively impaired (p<0.001). Respondents who felt they had a societal obligation as opposed to an obligation to protect the rights of the individual (p=0.006) were more likely to report hypothetical physicians. Those respondents who stated they knew of guidelines on reporting impaired physicians had more frequently reported impaired colleagues (p<0.001). We conclude that physicians should be educated on the availability and functioning of PHPs and the ethical and legal obligations of assisting impaired colleagues.

Physicians' understanding of consent requirements for phase I clinical trials in cognitively impaired or highly vulnerable populations.

We investigated physicians' attitudes about entering patients who cannot give informed consent or who are of a vulnerable population into clinical trials. A survey instrument asked a nationwide sample of practicing physicians about whether ten hypothetical patients could be enrolled in a phase I clinical trials. The impact of demographic variables on the number of scenarios viewed as completely or somewhat acceptable was analyzed via student's T tests or analysis of variance (ANOVA) as applicable. All significant (p<0.01) variables were entered into a multiple logistic regression model. Eighty-four percent of respondents indicated that at least one case scenario was acceptable. A majority of those who conduct clinical trials (62%), who had training in the ethics of clinical research (78%), and who sit on institutional review boards (IRBs) (83%) approved of at least one case scenario. Physicians approved of the entry of some patients who cannot give informed consent or who are of a vulnerable population into clinical trials. More effective education on the guidelines involving clinical research should be available to practicing physicians, residents, and medical students. There should also be assurance that physicians who conduct clinical trials or who sit on IRBs have the requisite knowledge about the ethics of clinical research.

Residents' prescription writing for nonpatients.

CONTEXT: Writing prescriptions is one of the most tangible new responsibilities that residents acquire after graduating from medical school. During their regular duties, house officers' prescription writing is carefully monitored. Little is known, however, about residents' patterns of prescription writing outside of supervision or about residents' knowledge of the ethical and legal guidelines that regulate prescription writing. OBJECTIVE: To study what factors influence residents' decision to write prescriptions for nonpatients. DESIGN, SETTING, AND PARTICIPANTS: Survey distributed in December 1997 to 92 internal medicine and family practice residents at a US community-based teaching hospital. Eighty percent responded. MAIN OUTCOME MEASURES: Self-reported prescribing activities for nonpatients and for individuals in 12 hypothetical vignettes. RESULTS: Eighty-five percent of respondents reported having written prescriptions for nonpatients. Based on their responses to the vignettes, under certain circumstances, up to 95% of residents would write a prescription for an individual who is not their patient (eg, a sibling). Thirteen percent of residents believed that some ethical guidelines on prescription-writing activity existed. Only 4% of residents reported being aware of federal or state laws addressing the appropriateness of physician prescription writing for nonpatients. None of the residents were able to describe the circumstances that make prescription writing for nonpatients illegal or unethical based on legal statutes or ethical guidelines, respectively. CONCLUSIONS: In a sample of community-based internal medicine and family practice residents, unsupervised prescription writing by residents for individuals who are not their patients is a common occurrence. Since residency training is a time when practice habits are established, it is important that all residents learn about the ethical, legal, and liability implications of writing prescriptions for nonpatients.