Qualitative investigation of military surgical resuscitation teams: what are the drivers of success of a rapid response team?

OBJECTIVES: This qualitative study explores the characteristics of a specialised military medical rapid response team (MRRT), the surgical resuscitation team (SRT). Despite mixed evidence of efficacy, civilian MRRTs are widely employed, with significant variation in structure and function. Recent increased use of these teams to mitigate patient risk in challenging healthcare scenarios, such as global pandemics, mass casualty events and resource-constrained health systems, mandates a reconceptualisation of how civilian MRRTs are created, trained and used. Here, we study the core functions and foundational underpinnings of SRTs and discuss how civilian MRRTs might learn from their military counterparts. DESIGN: Semistructured interview-based study using Descriptive Qualitative Research methodology and Thematic Analysis. SETTING: Remote audio interviews conducted via Zoom. PARTICIPANTS: Participants included 15 members of the United States Special Operations Command SRTs, representing all medical specialties of the SRT as well as operational planners. RESULTS: Adaptability was identified as a core function of SRTs and informed by four foundational underpinnings: mission variability, shared values and principles, interpersonal and organisational trust and highly effective teaming. Our findings provide three important insights for civilian MRRTs: (1) team member roles should not be defined by silos of professional specialisation, (2) trust is a key factor in the teaming process and (3) team principles and values result in and are reinforced by organisational trust. CONCLUSION: This study offers the first in-depth investigation of a unique military MRRT. Important insights that may offer benefit to civilian MRRT practices include enabling the breakdown of traditional division of labour, allowing for and promoting deep interpersonal and professional familiarity, and facilitating a cycle of positive reinforcement between teams and organisations. Future investigation of small team limitations, comparability to civilian MRRTs, and the team relationship to the larger organisation are needed to better understand how these teams function in a healthcare system and translate to civilian practice.

Exploring Knowledge, Skills, and Abilities Needed for Army Pharmacist Readiness Using the Nominal Group Technique.

INTRODUCTION: The purpose of this study was to conduct a general educational needs assessment to identify deficiencies in current Army pharmacy education while projecting future educational requirements based on changes in pharmacy practice and evolving demands of military medicine. MATERIALS AND METHODS: Twelve pharmacists participated in a facilitated discussion using the nominal group technique. Data were analyzed using quantitative and qualitative methods to establish consensus. Member checking was used to verify and validate the findings. RESULTS: Participants generated 190 knowledge, skill, and ability (KSA) statements over 3 sessions. Twenty-one statements achieved consensus. Four consensus statements were skills, 7 were knowledge, and 10 were abilities. KSAs were categorized into pharmaceutical care, military, logistics, or legal domain based on a thematic analysis. CONCLUSIONS: With modernized, relevant KSAs, the Army can measure and train a ready pharmacy force. Individual Critical Tasks augmented with KSAs are one potential approach we recommend as a strategy to improve Army pharmacist health profession education.

Physiologic measurements of cognitive load in clinical reasoning.

OBJECTIVES: Cognitive load is postulated to be a significant factor in clinical reasoning performance. Monitoring physiologic measures, such as Heart Rate Variability (HRV) may serve as a way to monitor changes in cognitive load. The pathophysiology of why HRV has a relationship to cognitive load is unclear, but it may be related to blood pressure changes that occur in a response to mental stress. METHODS: Fourteen residents and ten attendings from Internal Medicine wore Holter monitors and watched a video depicting a medical encounter before completing a post encounter form used to evaluate their clinical reasoning and standard psychometric measures of cognitive load. Blood pressure was obtained before and after the encounter. Correlation analysis was used to investigate the relationship between HRV, blood pressure, self-reported cognitive load measures, clinical reasoning performance scores, and experience level. RESULTS: Strong positive correlations were found between increasing HRV and increasing mean arterial pressure (MAP) (p=0.01, Cohen's d=1.41). There was a strong positive correlation with increasing MAP and increasing cognitive load (Pearson correlation 0.763; 95 % CI [; 95 % CI [-0.364, 0.983]). Clinical reasoning performance was negatively correlated with increasing MAP (Pearson correlation -0.446; 95 % CI [-0.720, -0.052]). Subjects with increased HRV, MAP and cognitive load were more likely to be a resident (Pearson correlation -0.845; 95 % CI [-0.990, 0.147]). CONCLUSIONS: Evaluating HRV and MAP can help us to understand cognitive load and its implications on trainee and physician clinical reasoning performance, with the intent to utilize this information to improve patient care.

Exploring Impostor Phenomenon During Onboarding Into a Military Medical School.

INTRODUCTION: Impostor phenomenon (IP) is an experience where an individual believes that their success was because of chance or luck and was not associated with the mastery of skills. There is a gap in the literature in understanding what role, if any, onboarding (e.g., orientation weeks) into a military medical school plays into student experiences with IP. For many, onboarding serves as the first exposure to the climate, culture, and learning environment of both medical school and the military. Prevention, or early intervention, of IP may reduce potential effects on a medical trainee's confidence and competence in their profession, which may ultimately enhance health care team performance and impact patient outcomes. This study explores if and why military medical students experience IP during a 2-week-long orientation into a military medical school. MATERIALS AND METHODS: The study participants were medical students at a military medical school. Researchers conducted semi-structured interviews in August 2022 to explore if and why students experienced IP and deployed the Clance IP Scale as a measure with validity evidence for ascertaining the presence and magnitude of IP. Researchers calculated total scores from the Clance IP Scale and thematically analyzed interview transcripts. RESULTS: Researchers interviewed 29 matriculating military medical students. Twenty-one (75%) students reported frequent or intense IP experiences on the Clance IP Scale indicating that IP was present in our study sample. Thematic analysis identified six themes that drove one's experience with IP: reevaluation of merit, individualized diversity and inclusion experiences, administrative and financial support, preconceived expectations, building relationships, and new community roles. CONCLUSIONS: Our identified themes provide us with a better understanding of if and why military medical students experience IP during onboarding. Our findings are also consistent with the situated learning theory, which places emphasis on the sense of belonging and may provide a unique and insightful lens through which IP can be further explored and studied, particularly at a military medical school where various identities, dynamics, and aspirations can converge simultaneously. Additionally, our findings suggest that existing practices may benefit from a number of improvements including, but not limited to, tailoring onboarding activities to entail more reflective discussion using small groups, especially for topics related to diversity and inclusion, revisiting areas where students may feel inadequately prepared to transition and perform well in a medical school, reevaluating administrative and financial support that can be roadblocks to a student's transition into the new environment and removing these barriers, and ensuring cultural coherence (organizational alignment of vision and mission) among faculty, staff, and upperclassmen. Future research directions include better understanding how developing single or multiple, identities can impact a medical students' experience with IP during onboarding, pre-clerkship, clerkship, or post-clerkship period, if at all.

Provider Perspectives on Sleep as a Determinant of Health and Housing Outcomes among Veterans Experiencing Homelessness: An Exploratory, Social-Ecological Study.

Sleep problems are common among United States (U.S.) veterans and are associated with poor health, mental health, and functioning. Yet, little is known about insufficient sleep and factors contributing to sleep disparities among veterans experiencing homelessness. We conducted semi-structured interviews to better understand the clinical, environmental, and structural factors contributing to insufficient sleep among veterans and to improve care for this population. Interviews were conducted with 13 providers caring for veterans experiencing homelessness, including physicians, psychologists, nurses, social workers, and peer support specialists. Providers worked at a West Coast VA institution serving a large population of veterans experiencing homelessness. Interviews were analyzed for themes pertaining to sleep using the social-ecological model as a framework. On an individual level, factors influencing sleep included psychiatric disorders and use of substances. On an interpersonal level, factors included safety concerns while sleeping. On an environmental level, factors included noise and proximity to others as barriers to sleep. On the organizational level, logistical issues scheduling sleep clinic appointments and lack of transportation to attend sleep clinic appointments were identified as treatment barriers. These findings can inform future research studying the impact of sleep on health and housing outcomes and interventions addressing sleep among veterans experiencing homelessness.

Reflecting on LTCOS Scholarship and Implications for Educational Practice.

The Long Term Career Outcome Study is a central program of research in the Center for Health Professions Education at the Uniformed Services University. The overarching goal of Long Term Career Outcome Study is to perform evidence-based evaluations before, during, and after medical school, and as such, it represents a form of educational epidemiology. In this essay, we highlighted the findings of the investigations published in this special issue. These investigations span from "before" medical school matriculation to "during" medical school and "after" learners go on to graduate training and practice. Furthermore, we discuss how this scholarship might shed light on improving the educational practices at the Uniformed Services University and potentially elsewhere. We hope that this work demonstrates how research can enhance medical education processes and connect research, policy, and practice.

Supporting the Transition to Distance Education During the Pandemic and Beyond.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic affected almost every country around the world, and various forms of lockdown or quarantine measures were implemented. The lockdowns forced medical educators to step beyond traditional educational approaches and adopt distance education technologies to maintain continuity in the curriculum. This article presents selected strategies implemented by the Distance Learning Lab (DLL) at the Uniformed Services University of Health Sciences (USU), School of Medicine (SOM), in transitioning their instruction to an emergency distance education format during the COVID-19 pandemic. MATERIALS AND METHODS: When moving programs/courses to a distance education format, it is important to recognize that two primary stakeholders are involved in the process: faculty members and students. Therefore, to be successful in transitioning to distance education, strategies must address the needs of both groups and provide support and resources for both.The DLL used two lenses of adult learning and targeted needs assessment to design faculty and student support during the pandemic. The DLL adopted a learner-centered approach to education, focusing on meeting the faculty members and students where they are. This translated into three specific support strategies for faculty: (1) workshops, (2) individualized support, and (3) just-in-time self-paced support. For students, DLL faculty members conducted orientation sessions and provided just-in-time self-paced support. RESULTS: The DLL has conducted 440 consultations and 120 workshops for faculty members since March 2020, serving 626 faculty members (above 70% of SOM faculty members locally) at USU. In addition, the faculty support website has had 633 visitors and 3,455 pageviews. Feedback comments provided by faculty members have specifically highlighted the personalized approach and the active, participatory elements of the workshops and consultations.Evaluations of the student orientation sessions showed that they felt more confident in using the technologies after the orientation. The biggest increase in confidence levels was seen in the topic areas and technology tools unfamiliar to them. However, even for tools that students were familiar with before the orientation, there was an increase in confidence ratings. CONCLUSION: Post-pandemic, the potential to use distance education remains. It is important to have support units that recognize and cater to the singular needs of medical faculty members and students as they continue to use distance technologies to facilitate student learning.

Well-being at a Military Medical School and Implications for Military Retention.

INTRODUCTION: Physical and psychological well-being play a critical role in the academic and professional development of medical students and can alter the trajectory of a student's quality of personal and professional life. Military medical students, given their dual role as officer and student, experience unique stressors and issues that may play a role in their future intentions to continue military service, as well as practice medicine. As such, this study explores well-being across the 4 years of medical school at Uniformed Services University (USU) and how well-being relates to a student's likelihood to continue serving in the military and practicing medicine. METHODS: In September 2019, 678 USU medical students were invited to complete a survey consisting of three sections-the Medical Student Well-being Index (MSWBI), a single-item burnout measure, and six questions regarding their likelihood of staying in the military and medical practice. Survey responses were analyzed using descriptive statistics, analysis of variance (ANOVA), and contingency table analysis. Additionally, thematic analysis was conducted on open-ended responses included as part of the likelihood questions. RESULTS: Our MSWBI and burnout scores suggest that the overall state of well-being among medical students at USU is comparable to other studies of the medical student population. ANOVA revealed class differences among the four cohorts, highlighted by improved well-being scores as students transitioned from clerkships to their fourth-year curriculum. Fewer clinical students (MS3s and MS4s), compared to pre-clerkship students, indicated a desire to stay in the military. In contrast, a higher percentage of clinical students seemed to "reconsider" their medical career choice compared to their pre-clerkship student counterparts. "Medicine-oriented" likelihood questions were associated with four unique MSWBI items, whereas "military-oriented" likelihood questions were associated with one unique MSWBI item. CONCLUSION: The present study found that the overall state of well-being in USU medical students is satisfactory, but opportunities for improvement exist. Medical student well-being seemed to have a stronger association with medicine-oriented likelihood items than with military-oriented likelihood items. To obtain and refine best practices for strengthening engagement and commitment, future research should examine if and how military and medical contexts converge and diverge throughout training. This may enhance the medical school and training experience and, ultimately, reinforce, or strengthen, the desire and commitment to practice and serve in military medicine.

Breaking Down Grit: Persistency and Flexibility in the Career Plans of Military Medical Students.

INTRODUCTION: The field of medicine is experiencing a crisis as high levels of physician and trainee burnout threaten the pipeline of future physicians. Grit, or passion and perseverance for long-term goals, has been studied in high-performing and elite military units and found to be predictive of successful completion of training in adverse conditions. The Uniformed Services University of the Health Sciences (USU) graduates military medical leaders who make up a significant portion of the Military Health System physician workforce. Taken together, an improved understanding of the relationships between burnout, well-being, grit, and retention among USU graduates is critical to the success of the Military Health System. MATERIALS AND METHODS: The current study was approved by the Institutional Review Board at USU and explored these relations among 519 medical students across three graduating classes. These students participated in two surveys approximately one year apart from October 2018 until November 2019. Participants completed measures on grit, burnout, and likelihood of leaving the military. These data were then merged with demographic and academic data (e.g., Medical College Admission Test scores) from the USU Long Term Career Outcome Study. These variables were then analyzed simultaneously using structural equation modeling to examine the relationships among variables in a single model. RESULTS: Results reaffirmed the 2-factor model of grit as both passion and perseverance (or interest consistency). No significant relationships emerged between burnout and other study variables. Sustained and focused interest was predictive of less likelihood of staying in the military. CONCLUSION: This study offers important insights into the relationship among well-being factors, grit, and long-term career planning in the military. The limitations of using a single-item measure of burnout and measuring behavioral intentions in a short time frame during undergraduate medical education highlight the importance of future longitudinal studies that can examine actual behaviors across a career lifespan. However, this study offers some key insights into potential impacts on the retention of military physicians. The findings suggest that military physicians who are most likely to stay in the military tend to embrace a more fluid and flexible medical specialty path. This is critical in expectation setting for the military to train and retain military physicians across a wide range of critical wartime specialties.

Profiles of Military Medical Students' Well-being, Burnout, and Retention.

BACKGROUND: Well-being concerns among medical students are more prevalent than their age-matched peers in the United States. It remains unknown, however, if individual differences in well-being exist among U.S. medical students serving in the military. In this study, we sought to identify profiles (i.e., subgroups) of well-being in military medical students and examine the associations between these well-being profiles and burnout, depression, and intended retention in military and medical fields. METHODS: Using a cross-sectional research design, we surveyed military medical students and then conducted latent class analysis to explore profiles of well-being, and applied the three-step latent class analysis method to assess predictors and outcomes of well-being profiles. RESULTS: Heterogeneity in well-being was identified among the 336 military medical students surveyed, portraying medical students' falling into three distinct subgroups: High well-being (36%), low well-being (20%), and moderate well-being (44%). Different subgroups were associated with different risks of outcomes. Students in the subgroup of low well-being were at the highest risk of burnout, depression, and leaving medicine. In contrast, students in the moderate well-being group were at the highest risk of leaving military service. CONCLUSIONS: These subgroups may be clinically important as burnout, depression, and intention to leave medical field and/or military service occurred with varying likelihoods among medical students across the different well-being subgroups. Military medical institutions may consider improving recruitment tools to identify the best alignment between students' career goals and the military setting. Besides, it is crucial for the institution to address diversity, equity, and inclusion issues that may lead to alienation, anxiety, and a sense of wanting to leave the military community.

Military Medical Students' Coping With Stress to Maintain Well-being.

INTRODUCTION: Previous studies have shown that medical students experience a great level of burnout and poor well-being during their clinical training periods. In this study, we sought to understand how military medical students cope with stress to prevent burnout and support their well-being. We also investigated if these coping strategies are associated with military medical students' self-reported well-being, burnout, and depression levels. The findings could help inform programming, resources, and educational strategies to better support students to thrive in their careers long term. METHODS: Using a cross-sectional research design, we surveyed military medical students and conducted content analysis on participant responses to the open-ended item by trained coders. Coding was based on the existing coping theory frameworks as well as categories that emerged inductively to represent the data. RESULTS: The primary four strategies military medical students utilized included social connection (59.9%), exercise (58.3%), personal relaxation (36%), and work-life balance (15.7%). The use of work-life balance strategy was significantly associated with more positive well-being and lower depression compared to those who did not use this strategy. Three main coping typologies were further extracted, including personal care, connection, and cognitive strategies. Based on the typologies, 62% of students were recognized as multi-type copers (who combined more than two coping typologies), who reported significantly more positive well-being compared to students who relied on a single typology. CONCLUSIONS: The findings demonstrate that certain coping strategies are more positively associated with a good state of well-being and less burnout, and that utilization of multiple types of coping strategies is more supportive. This study amplifies the voice of military medical students concerning the importance of prioritizing self-care and available resources given the unique pressures and demands of their dual military medical curriculum.

Cognitive biases in internal medicine: a scoping review.

BACKGROUND: Medical errors account for up to 440,000 deaths annually, and cognitive errors outpace knowledge deficits as causes of error. Cognitive biases are predispositions to respond in predictable ways, and they don't always result in error. We conducted a scoping review exploring which biases are most prevalent in Internal Medicine (IM), if and how they influence patient outcomes, and what, if any, debiasing strategies are effective. CONTENT: We searched PubMed, OVID, ERIC, SCOPUS, PsychINFO, and CINAHL. Search terms included variations of "bias", "clinical reasoning", and IM subspecialties. Inclusion criteria were: discussing bias, clinical reasoning, and physician participants. SUMMARY: Fifteen of 334 identified papers were included. Two papers looked beyond general IM: one each in Infectious Diseases and Critical Care. Nine papers distinguished bias from error, whereas four referenced error in their definition of bias. The most commonly studied outcomes were diagnosis, treatment, and physician impact in 47 % (7), 33 % (5), and 27 % (4) of studies, respectively. Three studies directly assessed patient outcomes. The most commonly cited biases were availability bias (60 %, 9), confirmation bias (40 %, 6), anchoring (40 %, 6), and premature closure (33 %, 5). Proposed contributing features were years of practice, stressors, and practice setting. One study found that years of practice negatively correlated with susceptibility to bias. Ten studies discussed debiasing; all reported weak or equivocal efficacy. OUTLOOK: We found 41 biases in IM and 22 features that may predispose physicians to bias. We found little evidence directly linking biases to error, which could account for the weak evidence of bias countermeasure efficacy. Future study clearly delineating bias from error and directly assessing clinical outcomes would be insightful.

Clinical Reasoning Curricula in Preclinical Undergraduate Medical Education: A Scoping Review.

PURPOSE: Clinical reasoning is the process of observing, collecting, analyzing, and interpreting patient information to arrive at a diagnosis and management plan. Although clinical reasoning is foundational in undergraduate medical education (UME), the current literature lacks a clear picture of the clinical reasoning curriculum in preclinical phase of UME. This scoping review explores the mechanisms of clinical reasoning education in preclinical UME. METHOD: A scoping review was performed in accordance with the Arksey and O'Malley framework methodology for scoping reviews and is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews. RESULTS: The initial database search identified 3,062 articles. Of these, 241 articles were selected for a full-text review. Twenty-one articles, each reporting a single clinical reasoning curriculum, were selected for inclusion. Six of the reports included a definition of clinical reasoning, and 7 explicitly reported the theory underlying the curriculum. Reports varied in the identification of clinical reasoning content domains and teaching strategies. Only 4 curricula reported assessment validity evidence. CONCLUSIONS: Based on this scoping review, we recommend 5 key principles for educators to consider when reporting clinical reasoning curricula in preclinical UME: (1) explicitly define clinical reasoning within the report, (2) report clinical reasoning theory(ies) used in the development of the curriculum, (3) clearly identify which clinical reasoning domains are addressed in the curriculum, (4) report validity evidence for assessments when available, and (5) describe how the reported curriculum fits into the larger clinical reasoning education at the institution.

Team Stress and Its Impact on Interprofessional Teams: A Narrative Review.

Phenomenon: Interprofessional healthcare team (IHT) collaboration can produce powerful clinical benefits for patients; however, these benefits are difficult to harness when IHTs work in stressful contexts. Research about stress in healthcare typically examines stress as an individual psychological phenomenon, but stress is not only a person-centered experience. Team stress also affects the team's performance. Unfortunately, research into team stress is limited and scattered across many disciplines. We cannot prepare future healthcare professionals to work as part of IHTs in high-stress environments (e.g., emergency medicine, disaster response) unless we review how this dispersed literature is relevant to medical education. Approach: The authors conducted a narrative review of the literature on team stress experienced by interprofessional teams. The team searched five databases between 1 Jan 1990 and 16 August 2021 using the search terms: teams AND stress AND performance. Guided by four research questions, the authors reviewed and abstracted data from the 22 relevant manuscripts. Findings: Challenging problems, time pressure, life threats, environmental distractors, and communication issues are the stressors that the literature reports that teams faced. Teams reacted to team stress with engagement/cohesion and communication/coordination. Stressors impact team stress by either hindering or improving team performance. Critical thinking/decision-making, team behaviors, and time for task completion were the areas of performance affected by team stress. High-quality communication, non-technical skills training, and shared mental models were identified as performance safeguards for teams experiencing team stress. Insights: The review findings adjust current models explaining drivers of efficient and effective teams within the context of interprofessional teams. By understanding how team stress impacts teams, we can better prepare healthcare professionals to work in IHTs to meet the demands placed on them by the ever-increasing rate of high-stress medical situations.

Promoting an interdisciplinary food literacy framework to cultivate critical citizenship.

The goal of this viewpoint is to promote an integrated and holistic framework for food literacy on college campuses. We propose that a framework to promote an effective understanding of food should encompass social, political, scientific, and personal dimensions; integrating these elements into university curricula and campus culture can empower students to become more engaged food citizens, with implications for their own food choices, and also for the broader food system. Emerging findings show that curricular interventions designed to educate about food system-environment connections can motivate students to reduce red meat and increase vegetable consumption. This viewpoint also lays the foundation for future studies to quantify the impact of increased knowledge on food choices, which can ultimately impact the health and wellbeing of both people and the planet.

Examining the patterns of uncertainty across clinical reasoning tasks: effects of contextual factors on the clinical reasoning process.

Objectives Uncertainty is common in clinical reasoning given the dynamic processes required to come to a diagnosis. Though some uncertainty is expected during clinical encounters, it can have detrimental effects on clinical reasoning. Likewise, evidence has established the potentially detrimental effects of the presence of distracting contextual factors (i.e., factors other than case content needed to establish a diagnosis) in a clinical encounter on clinical reasoning. The purpose of this study was to examine how linguistic markers of uncertainty overlap with different clinical reasoning tasks and how distracting contextual factors might affect physicians' clinical reasoning process. Methods In this descriptive exploratory study, physicians participated in a live or video recorded simulated clinical encounter depicting a patient with unstable angina with and without contextual factors. Transcribed think-aloud reflections were coded using Goldszmidt's clinical reasoning task typology (26 tasks encompassing the domains of framing, diagnosis, management, and reflection) and then those coded categories were examined using linguistic markers of uncertainty (e.g., probably, possibly, etc.). Results Thirty physicians with varying levels of experience participated. Consistent with expectations, descriptive analysis revealed that physicians expressed more uncertainty in cases with distracting contextual factors compared to those without. Across the four domains of reasoning tasks, physicians expressed the most uncertainty in diagnosis and least in reflection. Conclusions These results highlight how linguistic markers of uncertainty can shed light on the role contextual factors might play in uncertainty which can lead to error and why it is essential to find ways of managing it.

Sequence matters: patterns in task-based clinical reasoning.

Background The cognitive pathways that lead to an accurate diagnosis and efficient management plan can touch on various clinical reasoning tasks (1). These tasks can be employed at any point during the clinical reasoning process and though the four distinct categories of framing, diagnosis, management, and reflection provide some insight into how these tasks map onto clinical reasoning, much is still unknown about the task-based clinical reasoning process. For example, when and how are these tasks typically used? And more importantly, do these clinical reasoning task processes evolve when patient encounters become complex and/or challenging (i.e. with contextual factors)? Methods We examine these questions through the lens of situated cognition, context specificity, and cognitive load theory. Sixty think-aloud transcripts from 30 physicians who participated in two separate cases - one with a contextual factor and one without - were coded for 26 clinical reasoning tasks (1). These tasks were organized temporally, i.e. when they emerged in their think-aloud process. Frequencies of each of the 26 tasks were aggregated, categorized, and visualized in order to analyze task category sequences. Results We found that (a) as expected, clinical tasks follow a general sequence, (b) contextual factors can distort this emerging sequence, and (c) the presence of contextual factors prompts more experienced physicians to clinically reason similar to that of less experienced physicians. Conclusions These findings add to the existing literature on context specificity in clinical reasoning and can be used to strengthen teaching and assessment of clinical reasoning.

Well-being for trainees caring for homeless veterans.

BACKGROUND: Health care trainees caring for homeless patients may experience stress and burnout. Reasons for this include high rates of medical and psychiatric illness and complex social needs within this patient population. This can lead to feelings of inadequacy and exhaustion among health care trainees. To address this, we developed a toolkit for trainees from multiple professions caring for homeless veterans and examined its impact on trainee well-being. METHODS: Fifteen trainees and six faculty members participated in a half-day workshop given by a national expert that demonstrated a variety of well-being practices. Trainees and faculty members then identified 14 evidence-based practices relevant to the clinic for inclusion in the well-being toolkit. Half of the tools were for personal use and half were intended for teams. We developed simple graphics demonstrating each tool, and these were displayed as posters throughout the clinic. Tools were reviewed through workshops and handouts. To assess the trainee response to the toolkit, we used validated measures of burnout, stress, resilience and mindfulness at the beginning and at the end of the academic year. Trainees also rated the value of each tool. RESULTS: Trainees did not experience burnout during the year, and nor did the stress levels change. Both resilience and mindfulness trended towards improvement. Trainees rated the team-based tools as more important than the personal tools; they were also more confident in using the team-based tools. Burnout among physicians caring for marginalised patients can originate from a sense of futility and from witnessing needless suffering DISCUSSION: Team-based well-being tools may represent a better avenue for residency programmes and training sites to pursue well-being programmes, especially for trainees caring for marginalised populations.