Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey.

OBJECTIVES: Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN: Cross-sectional survey using four validated instruments. SETTING: Sixty-two sites in Canada and the United States. SUBJECTS: Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS: Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

Effect of race, gender identity, and their intersection on career satisfaction: A cross-sectional survey of academic physicians.

PURPOSE: Ensuring a representative workforce is a matter of equity and social justice and has implications for patient care and population health. We examined the relationship of the binary gender identity and race of physicians who felt comfortable to self-identify, with workplace experiences and career satisfaction in academic medicine. METHODS: The outcome of interest of a cross-sectional survey of full-time clinical faculty members within the Department of Medicine, University of Toronto, was physician's self-reported career satisfaction. Using logistic regression, we examined relationships of binary gender identity (female/male) and race [under-represented minority (URM) versus over-represented in medicine (ORM)] to: workplace experiences (respectful interactions, perception of having to work harder, exclusion from social networks, witnessing/experiencing unprofessionalism, and confidence in taking action to address incivility without reprisal); and career satisfaction, controlling for age, rank, protected time, and workplace experiences. RESULTS: Female gender and URM status were associated with younger age, lower rank, and less positive workplace experiences. 132 respondents (44.4%) strongly agreed they had career satisfaction. Compared with ORM men, career satisfaction was significantly lower for URM and ORM female physicians (OR 0.30, 95% CI 0.14-0.65, and 0.48, 95% CI 0.27-0.85, respectively) and non-significantly lower for URM male physicians (OR 0.62, 95% CI 0.32-1.19). Adjustment for academic rank and workplace experiences fully attenuated these relationships. CONCLUSIONS: URM female academic physicians had lower career satisfaction than their ORM male counterparts, largely explained by systematic differences in workplace experiences, particularly perceptions of exclusion from social networks and having to work harder to be perceived as legitimate scholars. This suggests a role for institutions and leaders to build inclusive, anti-racist, and anti-oppressive cultures to support the flourishing of all faculty.

Types of clinical reasoning in a summative clerkship oral examination.

INTRODUCTION: Dual-process theory characterizes clinical reasoning (CR) as Type 1 (intuitive) and Type 2 (analytical) thinking. This study examined CR on a summative clinical clerkship structured clinical oral examination (SCOE). METHODS AND SUBJECTS: 511 clinical clerks at the University of Toronto underwent SCOEs. Type 1, Type 2, and Global CR performance were compared to other internal medicine clerkship assessments using descriptive statistics and Spearman correlations. RESULTS: Clinical clerks achieved mean marks >75% on the three clinical reasoning stations, on Type 1 and 2 CR tasks, and the overall SCOE. Performance on the SCOE CR stations correlated with each of the other clerkship assessments: written examination, inpatient, and ambulatory clinic assessments. The correlation of performance between Type 1 and Type 2 clinical reasoning tasks was statistically significant but weak (rs = 0.28). This suggests that defined measures of Type 1 and Type 2 reasoning were indeed assessing distinct constructs. CONCLUSION: Clinical clerks used both Type 1 and Type 2 reasoning with success. This study's characterization of Type 1 and Type 2 CR as separate domains, distinct from existing measures on the SCOE as well as the other clerkship assessments, can suggest a further addition to multimodal clerkship assessment.

The impact of organizational culture on professional fulfillment and burnout in an academic department of medicine.

Physician wellness is vital to career satisfaction, provision of high quality patient care, and the successful education of the next generation of physicians. Despite this, the number of physicians experience symptoms of burnout is rising. To assess the impact of organizational culture on physicians' professional fulfillment and burnout, we surveyed full-time Department of Medicine members at the University of Toronto. A cross-sectional survey assessed: physician factors (age, gender, minority status, disability, desire to reduce clinical workload); workplace culture (efforts to create a collegial environment, respectful/civil interactions, confidence to address unprofessionalism without reprisal, witnessed and/or personally experienced unprofessionalism); professional fulfillment and burnout using the Stanford Professional Fulfillment Index. We used multivariable linear regression to examine the relationship of measures of workplace culture on professional fulfillment and burnout (scores 0-10), controlling for physician factors. Of 419 respondents (52.0% response rate), we included 400 with complete professional fulfillment and burnout data in analyses (60% ≤ age 50, 45% female). Mean scores for professional fulfillment and burnout were 6.7±1.9 and 2.8±1.9, respectively. Controlling for physician factors, professional fulfillment was associated with satisfaction with efforts to create a collegial environment (adjusted beta 0.45, 95% CI 0.21 to 0.70) and agreement that colleagues were respectful/civil (adjusted beta 0.85, 95% CI 0.53 to 1.17). Lower professional fulfillment was associated with higher burnout scores. Controlling for professional fulfillment and physician factors, lower confidence in taking action to address unprofessionalism (adjusted beta -0.22, 95% CI -0.40 to -0.03) was associated with burnout. Organizational culture and physician factors had an impact on professional fulfillment and burnout. Professional fulfillment partially mediated the relationship between organizational culture and burnout. Strategies that promote inclusion, respect and civility, and safe ways to report workplace unprofessionalism are needed in academic medicine.

Gender differences in career satisfaction, moral distress, and incivility: a national, cross-sectional survey of Canadian critical care physicians.

PURPOSE: In a national cross-sectional survey, we aimed to i) characterize work profile, workload, and income, ii) evaluate work satisfaction, work-life integration, burnout, incivility, mentorship, and promotion, iii) gauge future physician resource requirements, and iv) assess for differences by gender and specialty (adult vs pediatric). METHODS: We developed, tested, and administered an electronic questionnaire. RESULTS: We analyzed 265 fully and 18 partially completed questionnaires. Respondents were predominantly men (192; 72.5%) and adult intensivists (229; 87.7%). Most intensivists (226/272; 83.1%) were somewhat satisfied or strongly satisfied with their career. Over one third of respondents felt that their daily intensive care unit (ICU) clinical work (113/270; 41.9%), yearly non-ICU clinical work (86/248; 34.7%), administrative work (101/264; 38.3%), and in-house call coverage (78/198; 39.4%) were somewhat high or very high. Nearly half (129/273; 47.3%) felt that their work schedule did not leave enough time for personal/family life. Twenty-seven percent (74/272) of respondents were experiencing at least one symptom of burnout when surveyed and 171/272 (63%) experienced burnout symptoms more than once a month. Ten percent planned to retire in the next five years and 17-20% retired each five-year interval thereafter. Compared with men, women felt that their work schedule left significantly less time for personal/family life (χ2 [4] = 11.36, P < 0.05, odds ratio [OR] = 0.55), experienced more frequent and severe burnout symptoms (F [1,120.91] = 8.04, P < 0.01, OR = 2.0; F [1,112.80] = 4.91, P < 0.05, OR = 1.9), and more incivility in their division (χ2 [1] = 13.73, P < 0.001, OR = 2.8), hospital (χ2 [1] = 8.11, P < 0.01, OR = 2.2), and university (χ2 [1] = 4.91, P < 0.05, OR = 2.3). CONCLUSIONS: Although most intensivists were satisfied with their careers, many were dissatisfied with their workload, experienced work-life integration challenges, and acknowledged burnout symptoms. Women intensivists were significantly less satisfied with their careers, experienced greater work-life integration challenges, more frequent and severe burnout symptoms, and greater incivility.

RéSUMé: OBJECTIF: Nous avons créé un sondage transversal national qui avait pour objectif de i) caractériser le profil professionnel, la charge de travail et le revenu; ii) évaluer la satisfaction professionnelle, l'intégration travail ­ vie privée, l'épuisement professionnel, l'incivilité, le mentorat et les opportunités d'avancement professionnel, iii) évaluer les besoins futurs en ressources humaines, et iv) évaluer les différences hommes/femmes et entre spécialités (population adulte vs pédiatrique). MéTHODE: Nous avons mis au point, testé et administré un questionnaire électronique. RéSULTATS: Au total, 265 questionnaires intégralement complétés et 18 questionnaires partiellement complétés nous ont été retournés pour analyse. Les répondants étaient principalement des hommes intensivistes (192; 72,5 %) spécialisés en populations adultes (229; 87,7 %). La plupart des intensivistes (226/272; 83,1 %) se considéraient plutôt satisfaits ou très satisfaits de leur carrière. Plus d'un tiers des répondants étaient d'avis que leur travail clinique quotidien à l'unité des soins intensifs (USI) (113/270; 41,9 %), leur travail clinique annuel non lié à l'USI (86/248; 34,7 %), leur travail administratif (101/264; 38,3 %) et la couverture des gardes sur place (78/198; 39,4 %) étaient plutôt élevés ou très élevés. Près de la moitié (129/273; 47,3 %) des répondants étaient d'avis que leur horaire de travail ne laissait pas suffisamment de temps pour leur vie personnelle/de famille. Vingt-sept pour cent (74/272) des répondants présentaient au moins un symptôme d'épuisement professionnel au moment du sondage et 171/272 (63 %) souffraient de symptômes d'épuisement professionnel plus d'une fois par mois. Dix pour cent planifiaient prendre leur retraite au cours des cinq prochaines années, et 17­20 % planifiaient de le faire dans le courant de chaque intervalle de cinq ans subséquent. Par rapport à leurs collègues masculins, les femmes étaient d'avis que leur horaire de travail laissait significativement moins de temps pour leur vie personnelle/de famille (χ2 [4] = 11,36, P < 0,05, rapport de cotes [RC] = 0,55), souffraient de symptômes d'épuisement professionnel plus fréquents et plus graves (F [1120,91] = 8,04, P < 0,01, RC = 2,0; F [1112,80] = 4,91, P < 0,05, RC = 1,9), et de plus d'incivilité dans leur département (χ2 [1] = 13,73, P < 0,001, RC = 2,8), leur hôpital (χ2 [1] = 8,11, P < 0,01, RC = 2,2) et dans leur université (χ2 [1] = 4,91, P < 0,05, RC = 2,3). CONCLUSION: Bien que la plupart des intensivistes s'estiment satisfaits de leur carrière, bon nombre s'avouent mécontents de leur charge de travail, des défis d'intégration travail / vie de famille et reconnaissent souffrir de symptômes d'épuisement professionnel. Les femmes intensivistes sont significativement moins satisfaites de leur carrière, font face à des défis plus importants en matière d'intégration vie professionnelle / vie privée, souffrent de symptômes d'épuisement professionnel plus fréquents et plus prononcés ainsi que d'une plus grande incivilité.

Contextualizing Work-Based Assessments of Faculty and Residents: Is There a Relationship Between the Clinical Practice Environment and Assessments of Learners and Teachers?

PURPOSE: Competence is bound to context, yet seldom is environment explicitly considered in work-based assessments. This study explored faculty and residents' perspectives of the environment during internal medicine clinical teaching unit (CTU) rotations, the extent that each group accounts for environmental factors in assessments, and relationships between environmental factors and assessments. METHOD: From July 2014 to June 2015, 212 residents and 54 faculty across 5 teaching hospitals at University of Toronto rated their CTU environment using a novel Practice Environment Rating Scale (PERS) matched by block and hospital. Faculty-PERS data were paired to In-Training Evaluation Reports (ITERs) of residents supervised during each block, and Resident-PERS data to Resident Assessment of Teaching Effectiveness (RATE) scores of the same faculty. Differences between perceptions and assessments were tested using repeated-measures MANOVAs, ANOVAs, and correlations. RESULTS: One-hundred sixty-four residents completed the PERS; residents rated the CTU environment more positively than faculty (3.91/5 vs. 3.29, P < .001). Residents were less likely to report considering environmental factors when assessing faculty (2.70/5) compared with faculty assessing residents (3.40, P < .0001), d = 1.2. Whereas Faculty-PERS ratings did not correlate with ITER scores, Resident-PERS ratings had weak to moderate correlations with RATE scores (overall r = 0.27, P = .001). CONCLUSIONS: Residents' perceptions of the environment had small but significant correlations with assessments of faculty. Faculty's perceptions did not affect assessments of residents, potentially because they reported accounting for environmental factors. Understanding the interplay between environment and assessment is essential to developing valid competency judgments.

Does Making the Numerical Values of Verbal Anchors on a Rating Scale Available to Examiners Inflate Scores on a Long Case Examination?

PURPOSE: Rating scales are frequently used for scoring assessments in medical education. The effect of changing the structural elements of a rating scale on students' examination scores has received little attention in the medical education literature. This study assessed the impact of making the numerical values of verbal anchors on a rating scale available to examiners in a long case examination (LCE). METHOD: During the 2011-2012 academic year, the numerical values of verbal anchors on a rating scale for an internal medicine clerkship LCE were made available to faculty examiners. Historically, and specifically in the control year of 2010-2011, examiners only saw the scale's verbal anchors and were blinded to the associated numerical values. To assess the impact of this change, the authors compared students' LCE scores between the two cohort years. To assess for differences between the two cohorts, they compared students' scores on other clerkship assessments, which remained the same between the two cohorts. RESULTS: From 2010-2011 (n = 226) to 2011-2012 (n = 218), the median LCE score increased significantly from 82.11% to 85.02% (P < .01). Students' performance on the other clerkship assessments was similar between cohorts. CONCLUSIONS: Providing examiners with the numerical values of verbal anchors on a rating scale, in addition to the verbal anchors themselves, led to a significant increase in students' scores on an internal medicine clerkship LCE. When constructing or changing rating scales, educators must consider the potential impact of the rating scale structure on students' scores.

Impact of a formal mentoring program on academic promotion of Department of Medicine faculty: a comparative study.

PURPOSE: To evaluate the impact of a formal mentoring program on time to academic promotion and differences in gender-based outcomes. METHODS: Comparisons of time to promotion (i) before and after implementation of a formal mentoring program and (ii) between mentored and non-mentored faculty matched for covariates. Using paired-samples t-testing and mixed repeated measures ANCOVA, we explored the effect of mentor assignment and influence of gender on time to promotion. RESULTS: Promotional data from 1988 to 2010 for 382 faculty members appointed before 2003 were compared with 229 faculty members appointed in 2003 or later. Faculty appointed in 2003 or later were promoted 1.2 years (mean) sooner versus those appointed before 2003 (3.7 [SD = 1.7] vs. 2.5 [SD = 2], p < 0.0001). Regardless of year of appointment, mentor assignment appears to be significantly associated with a reduction in time to promotion versus non-mentored (3.4 [SD = 2.4] vs. 4.4 [SD = 2.6], p = 0.011). Gender effects were statistically insignificant. Post hoc analyses of time to promotion suggested that observed differences are not attributable to temporal effects, but rather assignment to a mentor. CONCLUSIONS: Mentoring was a powerful predictor of promotion, regardless of the year of appointment and likely benefited both genders equally. University resource allocation in support of mentoring appears to accelerate faculty advancement.