Graduate medical education well-being directors in the United States: who are they, and what does the role entail?

BACKGROUND: Institutional Graduate Medical Education (GME) Well-being Director (WBD) roles have recently emerged in the United States to support resident and fellow well-being. However, with a standard position description lacking, the current scope and responsibilities of such roles is unknown. This study describes the scope of work, salary support, and opportunities for role definition for those holding institutional leadership positions for GME well-being. METHODS: In November 2021, 43 members of a national network of GME WBDs in the United States were invited to complete a cross-sectional survey that included questions about job responsibilities, percent effort, and dedicated budget, and a free text response question about unique leadership challenges for GME WBDs. The survey was analyzed using descriptive statistics for quantitative data and thematic analysis for qualitative data. RESULTS: 26 members (60%) responded. Most were physicians, and the majority identified as female and White. Median percent effort salary support was 40%. A small minority reported overseeing an allocated budget. Most respondents worked to improve access to mental health services, oversaw institution-wide well-being programs, designed or delivered well-being content, provided consultations to individual programs, met with trainees, and partnered with diversity, equity, and inclusion (DEI) efforts. GME WBDs described unique challenges that had implications for perceived effectiveness related to resources, culture, institutional structure, and regulatory requirements in GME. DISCUSSION: There was high concordance for several key responsibilities, which may represent a set of core priorities for this role. Other reported responsibilities may reflect institution-specific needs or opportunities for role definition. A wide scope of responsibilities, coupled with limited defined budgetary support described by many GME Well-being Directors, could limit effective role execution. Future efforts to better define the role, optimize organizational reporting structures and provide funding commensurate with the scope of work may allow the GME Well-being Director to more effectively develop and execute strategic interventions.

A multi-residency elective to address well-being as a systems issue.

WHAT WAS THE EDUCATIONAL CHALLENGE?: Burnout is a well-established issue in medical training, but optimal systems approaches for well-being and ways to engage residents in well-being work are unknown. WHAT WAS THE SOLUTION?: The authors developed a multi-residency well-being elective with participants from internal medicine, anesthesiology, and urology residency programs. The elective included an asynchronous learning curriculum, a mentored independent project on system drivers of well-being, and participation in a cross-residency group that set elective priorities. HOW WAS THE SOLUTION IMPLEMENTED?: The authors worked with each residency's leadership to protect time for participation. Concepts from Quality Improvement were used to structure the elective. Project work and resident participation were assessed continually to monitor engagement. WHAT LESSONS WERE LEARNED THAT ARE RELEVANT TO A WIDER GLOBAL AUDIENCE?: Projects led to short- and long-term changes to support well-being in residency programs. Creating opportunities for residents from different specialties to discuss well-being work allowed ideas to spread across residencies. Protecting time to work on well-being issues may enhance a culture of well-being by demonstrating commitment to well-being as a priority equivalent to other educational endeavors. WHAT ARE NEXT STEPS?: Further research is needed to assess the impact on resident participants and to understand how to optimally incorporate resident interventions into broader organizational strategies for well-being.

Evidence of intrauterine device insertion by nurses in Primary Health Care: an integrative review.

OBJECTIVES: to synthesize and analyze evidence on intrauterine device insertion by nurses in Primary Health Care. METHODS: an integrative review, carried out in the BDENF, CINAHL, LILACS, SciELO, Scopus, PubMed and Web of Science databases in June 2022, delimiting the period from 1960 to 2022. RESULTS: 141 articles were identified in the initial search, and 10 studies made up the final sample. Four (40%) were developed in the United States and one (10%) in Brazil, with publications from 1979 to 2021. The findings were grouped into three categories: Nurse training to insert an intrauterine device; Nurses' competency to insert an intrauterine device; and Women's access to intrauterine devices. CONCLUSIONS: nurse theoretical and practical training is a prominent element, consolidated in the favorable outcomes of insertions performed by nurses and satisfaction among women, a practice that has expanded access to the contraceptive method in Primary Health Care.

Evidence of intrauterine device insertion by nurses in Primary Health Care: an integrative review / Evidencias de inserción de dispositivos intrauterinos por parte de enfermeros en Atención Primaria de Salud: revisión integradora / Evidências da inserção de dispositivo intrauterino por enfermeiros na Atenção Primária à Saúde: revisão integrativa

ABSTRACT Objectives: to synthesize and analyze evidence on intrauterine device insertion by nurses in Primary Health Care. Methods: an integrative review, carried out in the BDENF, CINAHL, LILACS, SciELO, Scopus, PubMed and Web of Science databases in June 2022, delimiting the period from 1960 to 2022. Results: 141 articles were identified in the initial search, and 10 studies made up the final sample. Four (40%) were developed in the United States and one (10%) in Brazil, with publications from 1979 to 2021. The findings were grouped into three categories: Nurse training to insert an intrauterine device; Nurses' competency to insert an intrauterine device; and Women's access to intrauterine devices. Conclusions: nurse theoretical and practical training is a prominent element, consolidated in the favorable outcomes of insertions performed by nurses and satisfaction among women, a practice that has expanded access to the contraceptive method in Primary Health Care.

RESUMEN Objetivos: sintetizar y analizar la evidencia sobre la inserción de dispositivos intrauterinos por parte de enfermeras en la Atención Primaria de Salud. Métodos: revisión integrativa, realizada en las bases de datos BDENF, CINAHL, LILACS, SciELO, Scopus, PubMed y Web of Science en junio de 2022, delimitando el período de 1960 a 2022. Resultados: se identificaron 141 artículos en la búsqueda inicial y 10 publicaciones conformaron la muestra final. Cuatro (40%) fueron desarrollados en Estados Unidos y uno (10%) en Brasil, con publicaciones de 1979 a 2021. Los hallazgos se agruparon en tres categorías: Capacitación de enfermeras para insertar un dispositivo intrauterino; Competencia de las enfermeras para insertar un dispositivo intrauterino; y Acceso de las mujeres a los dispositivos intrauterinos. Conclusiones: la formación teórica y práctica de los enfermeros es un elemento destacado, consolidado en los resultados favorables de las inserciones realizadas por los enfermeros y la satisfacción de las mujeres, práctica que ha ampliado el acceso al método anticonceptivo en la Atención Primaria de Salud.

RESUMO Objetivos: sintetizar e analisar as evidências da inserção de dispositivo intrauterino por enfermeiros na Atenção Primária à Saúde. Métodos: revisão integrativa, realizada nas bases de dados BDENF, CINAHL, LILACS, SciELO, Scopus, PubMed e Web of Science em junho de 2022, delimitando-se o período de 1960 a 2022. Resultados: identificaram-se 141 artigos na busca inicial, e 10 publicações compuseram a amostra final. Quatro (40%) foram desenvolvidos nos Estados Unidos e um (10%) no Brasil, sendo publicações de 1979 a 2021. Os achados foram agrupados em três categorias: Treinamento dos enfermeiros para inserção de dispositivo intrauterino; Competência dos enfermeiros para inserção de dispositivo intrauterino; e Acesso das mulheres aos dispositivos intrauterinos. Conclusões: o treinamento teórico e prático dos enfermeiros é um elemento de destaque, consolidado nos desfechos favoráveis das inserções realizadas por enfermeiros e satisfação entre as mulheres, prática que tem ampliado o acesso ao método contraceptivo na Atenção Primária à Saúde.

"I Wish They Had Asked": a Qualitative Study of Emotional Distress and Peer Support During Internship.

BACKGROUND: Interns are vulnerable to emotional distress and burnout. Little is known about the extent to which interns' well-being can be influenced by peer support provided by their senior residents. OBJECTIVE: To elucidate contributors to interns' emotional distress and ways that peer support from senior residents may impact intern well-being. DESIGN: Qualitative study using semi-structured interviews conducted December 2017-March 2018. PARTICIPANTS: Second year residents (n = 11) in internal medicine at a major academic medical center during the data collection period. APPROACH: Constructivist grounded theory approach in which transcripts were analyzed in an iterative fashion using constant comparison to identify themes and to create a conceptual model. KEY RESULTS: The investigators identified three themes around emotional distress and two themes around resident peer support. Distress was a pervasive experience among participants, caused by a combination of contextual factors that decreased emotional resilience (e.g., sleep deprivation) and acute triggers (e.g., patient death) that led to an abrupt increase in distress. Participants grappled with identity reconciliation throughout internship. Reaching clinical competency reinforced self-efficacy for participants. With regard to peer support, participants recalled that resident support was ad hoc, primarily involving task support and debriefing traumatic events. Participants reflected that their intern experiences shaped their supervisory support style once they became senior residents; they did not perceive any formalized, systematic approach to supporting interns. CONCLUSIONS: We propose a model illustrating key points at which near-peers can make an impact in reducing interns' distress and suggest strategies they can use. Given the substantial role peer learning plays in intern development, senior residents can impact their interns by normalizing emotions, allowing vulnerability, and highlighting the importance of self-care. A formalized peer support skill-building curriculum for senior residents may empower them to provide more effective support as part of their supervisory efforts.

Designing Well-Being: Using Design Thinking to Engage Residents in Developing Well-Being Interventions.

PROBLEM: Improving well-being in residency requires solutions that focus on organizational factors and the individual needs of residents, yet there are few examples of successful strategies to address this challenge. Design thinking (DT), or human-centered design, is an approach to problem-solving that focuses on understanding emotions and human dynamics and may be ideally suited to tackling well-being as a complex problem. The authors taught residents to use DT techniques to identify, analyze, and address organizational well-being challenges. APPROACH: Internal medicine residents at the University of California, San Francisco completed an 8-month DT program in 2016-2017. The program consisted of four 2-hour workshops with small group project work between sessions. In each session, resident teams shared their progress and analyzed emerging themes to solve well-being problems. At the conclusion of the program, they summarized the final design principles and recommendations that emerged from their work and were interviewed about DT as a strategy for developing well-being interventions for residents. OUTCOMES: Eighteen residents worked in teams to design solutions to improve: community and connection, space for reflection, peer support, and availability of individualized wellness. The resulting recommendations led to new interventions to improve well-being through near-peer communities. Residents emphasized how DT enhanced their creative thinking and trust in the residency program. They reported that not having enough time to work on projects between sessions and losing momentum during their clinical rotations were their biggest challenges. NEXT STEPS: Residents found DT useful for completing needs assessments, piloting interventions, and outlining essential design principles to improve well-being in residency. DT's focus on human values may be particularly suited to developing well-being interventions to enhance institutional community and culture. One outcome-that DT promoted creativity and trust for participants-may have applications in other spheres of medical education.

Becoming outstanding educators: What do they say contributed to success?

Aspiring medical educators and their advisors often lack clarity about career paths. To provide guidance to faculty pursuing careers as educators, we sought to explore perceived factors that contributed to the career development of outstanding medical educators. Using a thematic analysis, investigators at two institutions interviewed 39 full or associate professor physician faculty with prominent roles as medical educators in 2016. The social cognitive career theory (SCCT) informed the interview guide. Investigators developed the codebook and performed iterative analysis using qualitative methods. Extensive team discussion generated the final themes. Eight themes emerged related to preparation, early successes, mentors, networks, faculty development, balance, work environment, and multiple identities. Preparation led to early successes, which served as "launch points," while mentors, networks, and faculty development programs served as career accelerators to open more opportunities, and a supportive work environment was an additional enabler of this pathway. Educators who reported balance between work and outside interests described boundary setting as well as selectively choosing new opportunities to establish boundaries in mid-career. Participants described multiple professional identities, and clinician and educator identities tended to merge and reinforce each other as careers progressed. This study revealed common themes describing trajectories of success among medical educators. These themes aligned with the SCCT, and typically replayed and spiraled over the course of the educators' careers. These findings resonate with other studies, lending credence to an approach to career development that can be shared with junior faculty who are exploring careers in medical education.

Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients.

Background: Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective: To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design: Prospective cohort study. Setting: 10 academic medical centers in the United States. Patients: 822 adults readmitted to a general medicine service. Measurements: For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results: Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation: Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion: Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source: Association of American Medical Colleges.

Physician Perspectives on Factors Contributing to Readmissions and Potential Prevention Strategies: A Multicenter Survey.

BACKGROUND: The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts. OBJECTIVE: To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission. DESIGN: Cross-sectional multicenter study. PARTICIPANTS: We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies. MAIN MEASURES: We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician). KEY RESULTS: We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30). CONCLUSIONS: Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.

Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients.

IMPORTANCE: Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement. OBJECTIVES: To determine preventability of readmissions and to use these estimates to prioritize areas for improvement. DESIGN, SETTING, AND PARTICIPANTS: An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors. MAIN OUTCOME AND MEASURE: Likelihood that a readmission could have been prevented. RESULTS: The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%). CONCLUSIONS AND RELEVANCE: Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.