Use of an Opt-Out vs Opt-In Strategy Increases Use of Residency Mental Health Services.

Background Residents report high levels of distress but low utilization of mental health services. Prior research has shown several barriers that prevent residents from opting into available mental health services. Objective To determine the impact of a mental health initiative centered around an opt-out versus an opt-in approach to help-seeking, on the use of psychotherapy. Methods Resident use of psychotherapy was compared between 2 time frames. During the first time frame (July 1, 2020 to January 31, 2021), residents were offered access to therapy that they could self-initiate by calling to schedule an appointment (opt-in). The second time frame (February 1, 2021 to April 30, 2021) involved the switch to an opt-out structure, during which the same residents were scheduled for a session but could choose to cancel. Additional changes were implemented to reduce stigma and minimize barriers. The outcome was psychotherapy use by residents. Results Of the 114 residents, 7 (6%) self-initiated therapy during the opt-in period. When these same residents were placed in an opt-out context, 59 of the remaining 107 residents (55%) kept their initial appointment, and 23 (39%) self-initiated additional sessions. Altogether, across both phases, a total of 30 of the 114 residents initiated therapy (ie, 7 during the opt-in and 23 during the opt-out). The differences in therapy use between the 2 phases are statistically significant (P<.001 by McNemar's test). Conclusions There was a substantial increase in residents' use of psychotherapy after the opt-out initiative that included efforts to reduce stigma and encourage mental health services.

A Nation-Wide Survey of Program Directors at a Large Health Care Organization: Prevalence and Perceptions of Resident Wellness Activities.

Background: This study evaluated wellness programs in a large hospital network to determine residency program directors' (PDs) perspectives on their wellness programs' state, including wellness prioritization, frequency of wellness activities, and wellness' influence on decision-making across organizational levels. Methods: In 2021, 211 PDs were sent surveys on program policies, program implementation frequency, perceptions of the administration's ability to prioritize wellness, funding sources, and perceptions of resident wellness' impact on decision-making. Results: Among 211 contacted programs, 148 surveys were completed (70.1%). The majority reported having wellness programs, committees, and funding. Fewer than 25% reported having a chief wellness officer. PDs perceived that fellow colleagues in their institution linked wellness to markers of institutional success to a greater extent than other available options (ie, Accreditation Council for Graduate Medical Education [ACGME] requirements, budgetary concerns, resident input, core faculty priorities, and education quality). Financial well-being was perceived as least connected to wellness. Perceptions of wellness were rated across 3 organizational levels: program, institution, and organization. Across all levels, ACGME requirements (31.0%-32.8%) and budgetary/financial concerns (21.9%-37.0%) were perceived as having the most significant influence on overall decision-making, whereas resident wellness was rated lower in influence (8.0%-12.2%). Most programs allowed residents to attend mental health appointments without using paid time off (87.9%) and while on duty (83.1%). Conclusion: The frequency of wellness activities varied greatly across programs. PDs reported challenges making resident self-care and personal development a priority and perceived resident wellness as having limited importance to decision-making at higher levels.

A Qualitative Follow-Up to a Survey of Program Directors on Wellness Programming at a Large Healthcare Organization: Interviews of High- and Low-Exemplar Programs.

Background: The current research used a qualitative approach to understand which factors facilitate and hinder wellness programming in residency programs. Methods: Program directors identified from a previous quantitative study as having residency programs with notably more or less resident wellness programming than others (ie, high- and low-exemplars, respectively) were contacted. In total, semi-structured interviews were conducted over Zoom with 7 low-exemplars and 9 high-exemplars. Results: The results of this qualitative examination suggest common themes across the 2 exemplar groups, such as wanting more resources for resident wellness with fewer barriers to implementation, viewing wellness as purpose-driven, and seeing wellness as a shared responsibility. There were also critical distinctions between the exemplar groups. Those high in wellness programming expressed more of an emphasis on connections among residents in the program and between the faculty and residents. In contrast, those low in wellness programming described more barriers, such as staffing problems (ie, turnover and lack of faculty wellness) and a lack of integration between the varying levels involved in graduate medical education (GME) operations (ie, between GME programs and sponsoring hospitals, and between GME facilities and the larger health care organization). Conclusion: This study provides insight into program directors' experiences with wellness programming at a large health care organization. The results could point to potential next steps for investigating how the medical education community can improve resident wellness programming.

Perceived Disruption of COVID-19 on Medical Education in Incoming Psychiatric Residents.

Background: In 2020, the global COVID-19 pandemic caused educational disruptions to many medical students nationally. Societal and hospital guidelines, including social distancing protocols, resulted in the cancellation or postponement of many elective procedures. A shortage in personal protective equipment also contributed to restrictions in clinical experiences for trainees. The purpose of this study was to determine resident-perceived preparedness in core clinical competencies and evaluate the disruptions to core clerkships. Methods: A survey was developed to assess self-perceptions of clinical competencies and disruptions to core clerkship experiences. It was distributed to 63 incoming psychiatric residents who matched to training programs in the United States. Results: The survey response rate was 97%. The majority of respondents achieved self-expected levels of proficiency in clinical skills. Deficits were greatest for pelvic/rectal exams and transitions of care. Most students did not experience disruptions to clerkships. Internal medicine, obstetrics, and gynecology clerkships reported the highest rates of virtual completion. Procedures with the lowest reported perceived preparation were arterial puncture, airway management, and IV placement, respectively. Conclusion: Our survey results indicated that most learners did not perceive disruptions to their medical education and incoming psychiatry residents felt well-prepared to start residency. Some specific procedural skills appear to have been affected. Attempts to mitigate these specific inadequacies may help mitigate disruptions due to future events.

The Effects of the COVID-19 Pandemic on Resident Education and Burnout.

Background: The COVID-19 pandemic has impacted the residency experience for physicians across all specialties. There have been studies examining resident perspectives on changes in curriculum and clinical experiences due to the pandemic; however, little research has been conducted on how residents in different specialties interpreted their educational experience and rates of burnout during the pandemic. Methods: We extended surveys to 281 residents across 15 separate residency programs between November 17, 2020, and December 20, 2020. The questions pertained to burnout and the effects of the pandemic on their careers. Differences between general and specialty medicine resident responses were analyzed using descriptive statistics and the Mann-Whitney U test. Results: The final analysis included 105 responses (40% response rate). We received 62 surveys (59%) from general medicine residents and 43 surveys (41%) from specialty medicine residents, with a higher response rate from junior level trainees in both groups. We found no significant differences between general and specialty residents on the level of burnout, impact on clinical experience, or future career due to COVID-19, though there was a significant difference between resident groups on the perceived impact of COVID-19 on learning. Conclusion: Specialty medicine residents reported a negative perception of the pandemic's impact on their learning during residency suggesting a greater impact on training than was perceived by the general medicine residents. Residents from general and specialty medicine programs reported similar levels of burnout and similar perceptions of the pandemic's impact on their clinical experience and future career prospects. Understanding the impacts of the COVID-19 pandemic on resident education and well-being should serve graduate medical education administrators well and prepare them for future interruptions in the traditional learning process.

Creating and Supporting Well-Being in Graduate Medical Education.

Description Graduate medical education strives to create the next generation of skillful and compassionate physicians for our nation. Yet, research shows a high degree of depression, anxiety, workplace burnout, lack of engagement, and general dissatisfaction with the work and learning environment for many of these dedicated individuals. We present this special issue related to creating and supporting well-being in the graduate medical education community.

The paradox of the resident experiencing depression: Higher depression, less favorable help-seeking outcome expectations, and lower help-seeking intentions.

BACKGROUND: Medical residents experiencing depression can cause life-threatening harm to themselves and their patients. Treatment is available, but many do not seek help. METHODS: The current set of three studies investigated whether depressive symptomatology in and of itself served as a help-seeking barrier-and whether expectations of help-seeking benefits provided insight into why this occurred. Nine waves of cross-sectional data were collected from medical residents across several different hospitals in the United States. RESULTS: There was a large negative association between levels of depressive symptomatology and help-seeking intentions (H1) in Studies 1 and 3. In Study 2, this association was significant for one of the two help-seeking measures. For all analyses, studies, and measures, there was a large negative association between residents' levels of depressive symptomatology and agreement that seeking help will lead to positive outcomes (H2). Likewise, there was a moderately large indirect effect for all analyses, studies, and measures such that the association between levels of depressive symptomatology and help-seeking intentions occurred through less favorable expectations of help-seeking benefits (H3). Lower agreement of the benefits associated with help-seeking explained between 43 and 65% of depressive symptomatology's negative association with help-seeking intentions across studies. CONCLUSIONS: The current findings indicate that depressive symptomatology itself represents a help-seeking barrier and underscore the importance of help-seeking expectations in explaining why this occurs. If future studies reveal a causal relationship between the perceived benefits of help-seeking and help-seeking intentions, then increasing such expectations could offer a potential path for increasing resident help-seeking.

COVID-19 related disruptions to medical education and perceived clinical capability of new resident physicians: a nationwide study of over 1200 first-year residents.

The COVID-19 pandemic transformed the final year of undergraduate medical education for thousands of medical students across the globe. Out of concern for spreading SARS-CoV-2 and conserving personal protective equipment, many students experienced declines in bedside clinical exposures. The perceived competency of this class within the context of the pandemic is unclear. We designed and distributed a survey to measure the degree to which recent medical school graduates from the USA felt clinically prepared on 13 core clinical skills. Of the 1283 graduates who matched at HCA Healthcare facilities, 90% (1156) completed the survey. In this national survey, most participants felt they were competent in their clinical skills. However, approximately one out of four soon-to-be residents felt they were clinically below where they should be with regard to calling consultations, performing procedures, and performing pelvic and rectal exams. One in five felt they were below where they should be with regard to safely transitioning care. These perceived deficits in important skill sets suggest the need for evaluation and revised educational approaches in these areas, especially when traditional in-person practical skills teaching and practice are disrupted.

Impact of the Las Vegas Mass Shooting Event on the Graduate Medical Education Mission: Can There Be Growth from Tragedy?

INTRODUCTION: Our aim was to determine the psychological and educational impact of the 2017 Las Vegas mass shooting on the graduate medical education (GME) mission within two cohorts of resident physicians and attending faculty at two nearby academic trauma centers. METHODS: A cross-sectional survey assessed 55 resident physicians and attending faculty involved in the acute care of the patients from the mass shooting. We measured the psychological impact of the event, post-traumatic growth, team cohesion, social support, and known risk factors for post-traumatic stress disorder (PTSD). Additionally, we assessed the impact of the event on GME-specific tasks. RESULTS: Attending faculty and physicians in training in GME residencies evaluated over 300 penetrating trauma patients in less than 24 hours, and approximately 1 in 3 physicians had a patient die under their care. Despite this potential for psychological trauma, the majority of clinicians reported minimal distress and minimal impact on GME activities. However, 1 in 10 physicians screened positive for possible PTSD. Paradoxically, the minority of physicians who sought psychological counseling after the event (20%) were not those who reported the highest levels of distress. Residents generally assessed the event as having an overall negative impact on their educational goals, while attendings reported a positive impact. Psychological impact correlated inversely with social support and the amount of prior education relating to mass casualty incidents (MCI) but correlated directly with the degree of stress prior to the event. CONCLUSION: Despite the substantial level of exposure, most resident physicians did not report significant psychological trauma or an impact on their GME mission. Some reported post-traumatic growth. However, a minority reported a significant negative impact; institutions should consider broad screening efforts to detect and assist these individuals after a MCI. Social support, stress reduction, and education on MCIs may buffer the effects of future psychologically traumatic events on physicians in training.

A Two-Year Longitudinal, Cross-Sectional Evaluation of Resident Physician Burnout: An Exploration of the Effects of Stress, Satisfaction, Exercise and EMR.

Background: There is a need for better understanding of trajectory of burnout in clinical training and what factors are associated with resident well-being and burnout overtime. This study examined medical resident burnout and physical activity throughout different times of the academic year, across several different medical specialties and postgraduate years (PGY), over two years. Methods: A resident wellness survey was administered throughout five different waves from summer 2018 to winter 2020. A total of 493 survey responses from seven subspecialties completed the survey. We used 474 responses for quantitative statistical analysis and 138 for qualitative thematic analysis. Results: The average response rate was 47%, and ranged between 40% (Wave 3) and 56% (Wave 1). Three analyses were conducted: the first demonstrated significantly higher Satisfaction in Wave 1 as opposed to Wave 2. The second analysis showed significant correlations between Overall, Satisfaction, and Stress scores and exercise-based questions for female, male, and primary care cohorts of residents. The third analysis showed that in 2018, interns and non-interns differed on Stress but did not differ on Satisfaction or Overall scores. Conclusions: Similar levels of satisfaction, stress, and overall well-being were reported at different times in the academic year and from year to year. Exercise was not consistently related to resident well-being outcomes. These findings suggest a need for targeted interventions based on post-graduate year, time in the academic year and well-being drivers.

The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer.

BACKGROUND: Previous literature demonstrates increased mortality for traumatic brain injury (TBI) with transfer to a Level II versus Level I trauma center. Our objective was to determine the effect of the most recent American College of Surgeons-Committee on Trauma (ACS-COT) "Resources for the Optimal Care of the Injured Patient" resources manual ("The Orange Book") on outcomes after severe TBI after interfacility transfer to Level I versus Level II center. METHODS: Utilizing the Trauma Quality Program Participant Use File of the American College of Surgeons admission year 2017, we identified patients with isolated TBI undergoing interfacility transfer to either Level I or Level II trauma center. Logistic regression was performed to determine independent associations with mortality. RESULTS: There were 10,268 (71.6%) transferred to a Level I center and 4,025 (28.4%) were transferred to a Level II center. They were mostly male (61.4%) with a mean ± SD age of 61 ± 20.8 years. Mean Injury Severity Score was 16.3 ± 6.3 and most were injured in a single-level fall (51.5%). Patients transferred to a Level I center were less likely to be White (82.3% vs. 84.7%, 0.002) and more likely to have sustained penetrating trauma (2.7% vs. 1.6%, <0.001). The incidence of severe TBI (Glasgow Coma Scale [GCS] = 3-8) was similar (9.3% vs. 8.3%, 0.068). On logistic regression, severity of TBI predicted death; however, there was no difference in adjusted mortality outcome with admission to a Level II versus a Level I center (0.998 [0.836-1.192], 0.985). CONCLUSIONS: There is no mortality discrepancy in patients with isolated TBI transferred to a Level II versus Level I center despite previous contrary evidence and thus no reason to bypass a Level II in favor of a Level I. This relative improvement potentially relates to the new requirements as defined in the latest version of the ACS-COT's resources manual.

Residents' self-perceived errors in transitions of care in the emergency department.

BACKGROUND: The Accreditation Council for Graduate Medical Education requirements for systems-based practice state residents are expected to participate in identifying system errors and implementing potential systems solutions. The objective of this study was to determine the numbers of perceived errors occurring from patient pass offs between resident physicians in our emergency department. METHODS: Using a prospective observational study, we queried emergency medicine residents about perceived errors in the transition of care using trained research assistants and a standardized protocol. Transition of care was defined as the transfer of responsibility to evaluate and treat and disposition of a patient in the emergency department from 1 resident physician to a second oncoming emergency department resident physician. Mean resident-perceived errors per shift and per patient transfer of care were calculated. Additionally, the mean number of perceived errors impacting patients was calculated. RESULTS: Emergency medicine residents on 107 shifts reported receiving 713 patients in pass off with a mean of 7 patients per physician per shift, with 40% of patients passed off needing some intervention (mean of 2.8 patients per provider per shift). Nineteen of the 107 shifts (17.8%) during which a resident took patients from a prior provider had a perceived error in at least 1 patient signed off. Of the 713 patients transitioned, the receiving physician perceived an error related to the transition of care for 23. Two of the 23 errors were determined by reviewing emergency medicine attendings to not be errors, and for 9 the receiving physician perceived an impact on the patient. All were delays in care or disposition. CONCLUSION: Our data suggest emergency medicine residents were able to perceive errors related to transitions of care, describe the types of pass-off errors, and, to a lesser degree, describe the impact these errors have on patients.

Ketamine for procedural sedation and analgesia by nonanesthesiologists in the field: a review for military health care providers.

Military health care providers located in field environments frequently face situations in which procedural sedation and analgesia are necessary, without the advantage of sophisticated monitoring equipment. Ketamine is a unique agent that can be administered either intravenously or intramuscularly to produce predictable and profound analgesia, with an exceptional safety profile. We review the issues unique to ketamine and provide a practical guide for the use of ketamine for adult and pediatric patients in a field environment.

The sensitivity and specificity of the digital rectal examination for detecting spinal cord injury in adult patients with blunt trauma.

STUDY OBJECTIVES: The digital rectal examination (DRE) may assist physicians in detecting spinal cord injury in patients with blunt trauma. However, the test characteristics of the DRE for detecting spinal cord injury are unknown. METHODS: We conducted a retrospective review of consecutive adult patients with blunt trauma over a 2-year period. The DRE result was compared with the presence or absence of spinal cord injury at discharge. RESULTS: A total of 1032 adult patients with blunt trauma had a DRE. Of these, 54 (5.2%) had diagnoses consistent with spinal cord injury. Ninety-nine patients had decreased rectal tone, 27 of whom also had spinal cord injuries. The sensitivity, specificity, positive predictive value, and negative predictive values were 50%, 93%, 27%, and 97%, respectively. CONCLUSION: The DRE is insensitive to spinal cord injury and has a poor positive predictive value. The high specificity must be balanced against the large number of false-positive results.

Coronary artery occlusion following blunt chest trauma: a case report and review of the literature.

Blunt chest trauma causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a healthy 29-year-old man who developed a myocardial infarction due to complete occlusion of the proximal right coronary artery following blunt chest trauma. A review of the literature found 63 cases of previously healthy patients under 40 years of age who developed coronary artery occlusion following blunt chest trauma; diagnosis in all cases had been proven by angiography or during autopsy. The presentation, results of electrocardiography and echocardiography and laboratory findings of these patients are described.

Deferral of the rectal examination in blunt trauma patients: a clinical decision rule.

OBJECTIVES: To develop a clinical decision rule that would allow for the safe deferral of the digital rectal examination (DRE) in blunt trauma patients. METHODS: The authors reviewed the medical records of all adult blunt trauma patients meeting trauma team activation criteria over a 14-month period. The results of the DRE and six predictor variables-abnormal neurologic examination, abdominal tenderness, pelvic stability, blood at the urethral meatus, blood pressure < 90 mm Hg, and age over 65 years-were recorded. Patients with abnormal DREs had their discharge summaries reviewed for specific criteria to determine if the abnormal DRE was a true- or false-positive examination. Predictor variables were entered into a classification and regression tree (CART) analysis designed to predict true-positive abnormal DREs. RESULTS: Of the 579 patients, 53 had abnormal DREs, 34 of which were true positives. CART analysis retained three predictors, abnormal neurologic examination, blood at the urethral meatus, and age over 65 years, and accurately classified all patients with a true-positive abnormal DRE. The probability of a true-positive abnormal DRE in a patient with a normal neurologic examination, no blood at the urethral meatus, and age less than 65 years is between 0% and 0.8%. CONCLUSIONS: Adult patients with blunt trauma and a normal neurologic examination, with no blood at the urethral meatus, and who are less than 65 years old have an exceedingly low likelihood of a true-positive abnormal DRE. If validated, patients who meet these three criteria may have the DRE safely deferred.

Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events.

OBJECTIVES: Physicians commonly use etomidate for adult rapid-sequence intubation (RSI), but the manufacturer does not recommend its use for children under 10 years of age due to a lack of data. The authors present their experience with etomidate for pediatric RSI in order to further develop its risk-benefit profile in this age group. METHODS: Trained abstractors reviewed the medical records for all children under 10 years old who received etomidate for RSI between July 1996 and April 2001. RESULTS: 105 children, with an average age of 3 (+/-2.9) years, received a median dose of 0.32 (+/-0.12) mg/kg of etomidate. The systolic blood pressure increased an average of 4 mm Hg (95% CI = -3.3 to 9.2); the diastolic blood pressure increased 7 mm Hg (95% CI = -3.1 to 11) within 10 minutes of receiving etomidate. The heart rate increased an average of 10 beats/min (95% CI = 4.0 to 17.4). Complications included three patients who vomited within 10 minutes of etomidate administration. There were no cases of documented myoclonus, status epilepticus, or new-onset seizures. Thirty-eight patients received corticosteroids during the hospital course, none for suspected adrenal insufficiency. Three patients died, all from severe brain injury. CONCLUSIONS: In children less than 10 years old, etomidate seems to produce minimal hemodynamic changes, and appears to have a low risk of clinically important adrenal insufficiency, myoclonus, and status epilepticus. The association between etomidate and emesis (observed in less than 3% of enrolled patients) remains unclear. For clinical situations in which minimal blood pressure changes during RSI are critical, etomidate appears to have a favorable risk-benefit profile for children under 10 years old.