Prevalence of resident burnout at the start of training.

BACKGROUND: Job burnout is characterized by emotional exhaustion, depersonalization, and feelings of decreased personal accomplishment, and it may be linked to depression and suboptimal patient care. Burnout among American internal medicine residents ranges between 55% and 76%. PURPOSE: We aim to further characterize burnout prevalence at the start of residency. METHODS: Between 2006 and 2007, all incoming internal medicine interns at Mount Sinai Hospital and Elmhurst Hospital Center were asked to complete a survey at orientation. The survey included an instrument to measure burnout, a sleep deprivation screen, a personality inventory and demographic information. Comparison tests were conducted to identify statistically significant differences. RESULTS: The response rate was 94% (145/154). Overall burnout prevalence was 34% (50/145). Interns self-identifying as anxious (51% vs. 28%, p= .01) or disorganized (60% vs. 31%, p= .03) were more likely to have burnout. CONCLUSIONS: Our study found higher levels of burnout among beginning medical interns than reported in the literature. Burnout correlated with some self-reported personality features.

The creation and evaluation of a systems-based practice/managed care curriculum in a primary care internal medicine residency program.

BACKGROUND: A systems-based practice (SBP) is defined by the Accreditation Council for Graduate Medical Education as "manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value" (1). We developed a systems-based practice / managed care curriculum in a monthly workshop format, and integrated it into our Mount Sinai School of Medicine (Elmhurst) program in internal medicine. We evaluated the success of this workshop by utilizing both subjective and objective assessments of knowledge obtained by medical residents in attendance. METHODS: We surveyed our medical residents in order to assess their educational experiences in the workshop with regard to their comfort level with the use, application, and discussion with patients of 13 concepts central to current SBP issues, as well as to what extent they believed the workshop improved or enhanced this level of comfort (subjective assessment). Residents then completed 10 true/false questions designed to measure their understanding of key SBP points (objective assessment). Their performance on this section was evaluated based on their individual experiences with the workshop. RESULTS: The mean comfort level for all 13 SBP topics increased via Likert scale from 2.79 before participation in the workshop, to 3.51 after participation. The mean comfort level improved for 11 out of the 13 topics (only "Medicaid" and "Medicare" did not show this improvement). Results of the 10-question test revealed that the mean percent correct score was lowest for those who did not attend the workshop (60% for interns and 67% for residents), intermediate for those who attended once (78%), and highest for those who attended more than once (84%). Of those who attended at least once, senior residents scores slightly lower than interns and junior residents (78% vs. 81%); the difference was not statistically significant. CONCLUSION: The inclusion of an SBP curriculum can increase internal medicine residents' understanding of, and comfort with, important topics in managed care and SBP.

Comprehensive educational performance improvement (CEPI): an innovative competency-based assessment tool.

BACKGROUND: The focus of competency-based training is on outcomes, specifically well-trained residents. Our goal is to help move resident assessment away from content- and process-based factors and towards measures of mastery of practice. Doing so requires reorganizing and reprioritizing elements of the training program. We describe our attempt to shift the priorities of our program (the primary care internal medicine residency of the Mount Sinai School of Medicine [Elmhurst] Program) towards the desired outcomes of the medical resident, faculty, institution, and program as a whole. These outcomes are based on the six core competencies of graduate medical education (medical knowledge, patient care, interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning and improvement). We call this process "comprehensive educational performance improvement" (CEPI). METHODS: We began by identifying each individual learning element of the program and classifying it into a clinical, didactic or evaluative "domain." We thus identified 40 clinical learning elements (specific outpatient and inpatient clinical settings), 25 didactic learning elements (specific lecture formats, workshops, conferences, etc.), and 11 evaluative elements (evaluation formats and contexts). Then we developed a set of questions intended to define and evaluate each element. Finally, we established criteria for prioritizing these questions, by asking relevant faculty, staff, and residents to assign priority scores for each. RESULTS: By this process, we generated 2-6 questions for each learning element, resulting in a total of 301 questions. This constituted a comprehensive plan for the assessment of both the program and the competency of the medical residents who have completed the program. Examples of the application of this process are described. CONCLUSIONS: The CEPI process has a number of strengths. It allows for the concurrent assessment of each learning element with its intended outcomes, enabling us to simultaneously assess its outcome and its programmatic value. It effectively integrates the cognitive aspects of a program element with its clinical aspects, along with the input of evaluators at various levels. Finally, it helps train faculty members in an evidence-based approach to the curriculum.