Benjamin R. Doolittle

Burnout and coping among parish-based clergy

To investigate the correlation between burnout, coping strategies, and spiritual attitudes of religious leaders, parish-based United Methodist clergy were invited to complete a questionnaire booklet that included the Maslach Burnout Inventory, the Hatch Spiritual Involvement and Beliefs Scale, and validated coping scales. Of a total of 358 parish clergy, 222 (62%) completed the survey. Prevalence of high emotional exhaustion was 19%, high depersonalization 10%, and low personal accomplishment 11%. Correlation coefficient analysis revealed that a higher spirituality score correlated with greater personal accomplishment, but also related to greater emotional exhaustion and greater depersonalization. Clergy were more likely to have greater emotional exhaustion and depersonalization if they employed coping strategies of venting, disengagement, and self-blame. Acceptance, active coping, planning and positive reframing were correlated with greater personal accomplishment, but less strongly with emotional exhaustion and depersonalization. A higher spirituality score correlates with greater personal accomplishment but also greater emotional exhaustion and depersonalization. Certain coping strategies, including acceptance, active coping, planning, and positive reframing may also protect against burnout. The implications of these relationships are discussed.

The Impact of Behaviors upon Burnout Among Parish-Based Clergy

Burnout has an important impact upon the professional satisfaction of clergy. Identifying protective behaviors that may prevent against burnout is important for the long-term emotional health of individual clergy as well as the wider church. This research reports findings among 358 parish-based clergy that identifies the prevalence of burnout and correlates this data with demographic risk factors and protective behaviors. Clergy who met criteria for burnout were younger, identified themselves as being depressed and unsatisfied with their spiritual life, and have endured a traumatic church placement. This research also suggests that having a variety of interests and activities outside of one’s vocation may protect against burnout. In particular, behaviors that enhance relationships—such as seeking mentors and attending retreats—as well as pursuing outside activities—such as regular exercise and scholarly reading—protect against burnout. Further implications for the wider church are discussed.

Burnout, Coping, and Spirituality Among Internal Medicine Resident Physicians

BACKGROUND Burnout in physicians is common, and studies show a prevalence of 30% to 78%. Identifying constructive coping strategies and personal characteristics that protect residents against burnout may be helpful for reducing errors and improving physician satisfaction. OBJECTIVE We explored the complex relationships between burnout, behaviors, emotional coping, and spirituality among internal medicine and internal medicine-pediatrics residents. METHODS We anonymously surveyed 173 internal medicine and medicine-pediatrics residents to explore burnout, coping, and spiritual attitudes. We used 3 validated survey instruments: the Maslach Burnout Inventory, the Carver Coping Orientation to Problems Experienced (COPE) Inventory, and the Hatch Spiritual Involvement and Beliefs Scale (SIBS). RESULTS A total of 108 (63%) residents participated, with 31 (28%) reporting burnout. Residents who employed strategies of acceptance, active coping, and positive reframing had lower emotional exhaustion and depersonalization (all, P < .03). Residents who reported denial or disengagement had higher emotional exhaustion and depersonalization scores. Personal accomplishment was positively correlated with the SIBS total score (r  =  +.28, P  =  .003), as well as the internal/fluid domain (r  =  +.32, P  =  .001), existential axes (r  =  +.32, P  =  .001), and humility/personal application domain (r  =  +.23, P  =  .02). The humility/personal application domain also was negatively correlated with emotional exhaustion (r  =  -.20, P  =  .04) and depersonalization (r  =  -.25, P  =  .009). No activity or demographic factor affected any burnout domain. CONCLUSIONS Burnout is a heterogeneous syndrome that affects many residents. We identified a range of emotional and spiritual coping strategies that may have protective benefit.

A Case Series of Buprenorphine/Naloxone Treatment in a Primary Care Practice

ABSTRACT Physicians’ adoption of buprenorphine/naloxone treatment is hindered by concerns over feasibility, cost, and lack of comfort treating patients with addiction. We examined the use of buprenorphine/naloxone in a community practice by two generalist physicians without addiction training, employing a retrospective chart review. From 2006–2010, 228 patients with opiate abuse/dependence were treated with buprenorphine/naloxone using a home-induction protocol. Multiple co-morbidities including diabetes (23% of patients), hypertension (36%), Hepatitis C (43%), and depression (74%) were concurrently managed. In this diverse sample, 1/228 experienced precipitated withdrawal during induction. Of the convenience subsample analyzed (n = 28), 82% (+/−10%) had negative urine drug tests for opioids; 92% (+/−11%) were negative for cocaine; 88% (+/−12%) were positive for buprenorphine. This case series demonstrated feasibility and safety of a low-cost buprenorphine/naloxone home induction protocol employed by generalists. Concurrent treatment of multiple comorbidities conforms with the patient-centered medical home ideal. Randomized trials of this promising approach are needed.

Correlation of burnout syndrome with specific coping strategies, behaviors, and spiritual attitudes among interns at Yale University, New Haven, USA

Purpose: This study aimed to determine the correlation of burnout syndrome with specific coping strategies, behaviors, and spiritual attitudes among interns in internal medicine, primary care, and internal medicine/pediatrics residency programs at two institutions. Methods: Intern physicians completed anonymous voluntary surveys prior to starting the internship in June 2009 and in the middle of the internship in February 2010. Three validated survey instruments were used to explore burnout, coping, and spiritual attitudes: the Maslach Burnout Inventory, the COPE Inventory, and the Hatch Spiritual Involvement and Beliefs Scale. The interns were in programs at the Yale University School of Medicine and a Yale-affiliated community hospital, New Haven, Connecticut, USA. Results: The prevalence of self-identified burnout prior to starting the internship was 1/66 (1.5%) in June 2009, increasing to 10/53 (18.9%) in February 2010 (P<0.0001). From June 2009 to February 2010, the prevalence of high emotional exhaustion increased from 30/66 (45.5%) to 45/53 (84.9%) (P<0.0001), and that of high depersonalization increased from 42/66 (63.6%) to 45/53 (84.9%) (P=0.01). Interns who employed the strategies of acceptance and active coping were less likely to experience emotional exhaustion and depersonalization (P<0.05). Perceptions of high personal accomplishment was 75.5% and was positively correlated with total scores on the Hatch Spiritual Involvement and Beliefs Scale, as well as the internal/fluid and existential/meditative domains of that instrument. Specific behaviors did not impact burnout. Conclusion: Burnout increased during the intern year. Acceptance, active coping, and spirituality were correlated with less burnout. Specific behaviors were not correlated with burnout domains.

Continuity of Care as an Educational Goal but Failed Reality in Resident Training: Time to Innovate

C ontinuity of care between a patient and a physician is a core aspiration. However, we rarely achieve it in residency training, even though benefits of care continuity accrue in several realms, including preventive services, clinical outcomes in chronic disease, patient trust and satisfaction, and economic efficiencies. For trainees, benefits include participatory learning about the clinical courses of diseases and their patients’ experience of illness, understanding the value of a continuous relationships with patients, and developing professional responsibility. In the 1990s, threats to continuity of care included closed managed care programs with restrictive physician panels, exacerbated by frequent changes in employee insurance. Contemporary factors pose new disruptions to care continuity, including the hospitalist movement, resident duty hour limits, team coverage in the patient-centered medical home, and retail clinics. In this article, we explore the impact of these disruptions in continuity on resident education, and we propose strategies for improvement in the ambulatory, hospital, and transitional and alternate care settings.

Application of a prediction rule to discriminate between aseptic and bacterial meningitis in adults.

Abstract Introduction: Differentiating between aseptic and bacterial meningitis presents a difficult diagnostic challenge. Accurately ruling out bacterial meningitis may reduce unnecessary hospitalization, patient morbidity, and utilization of resources. This study applies a prediction rule previously developed in the pediatric population to an adult cohort. Methods: We performed a retrospective chart review of all patients admitted to an urban community hospital in the United States between 1994 and 2007. Results: One hundred eleven patients met the inclusion criteria. Twenty-two (20%) had bacterial meningitis and 89 (80%) had aseptic meningitis. The prediction rule generated a negative predictive value of 100% and a sensitivity of 100%, successfully ruling out all patients with aseptic meningitis. Conclusions: The prediction rule, previously validated in a pediatric population, was accurate in ruling out bacterial meningitis in an adult cohort. Prospective validation in an adult population is warranted.

Implementing the patient-centered medical home in residency education.

Background: In recent years, physician groups, government agencies and third party payers in the United States of America have promoted a Patient-centered Medical Home (PCMH) model that fosters a team-based approach to primary care. Advocates highlight the model′s collaborative approach where physicians, mid-level providers, nurses and other health care personnel coordinate their efforts with an aim for high-quality, efficient care. Early studies show improvement in quality measures, reduction in emergency room visits and cost savings. However, implementing the PCMH presents particular challenges to physician training programs, including institutional commitment, infrastructure expenditures and faculty training. Discussion: Teaching programs must consider how the objectives of the PCMH model align with recent innovations in resident evaluation now required by the Accreditation Council of Graduate Medical Education (ACGME) in the US. This article addresses these challenges, assesses the preliminary success of a pilot project, and proposes a viable, realistic model for implementation at other institutions.

Factors Affecting Resident Satisfaction in Continuity Clinic—a Systematic Review

PurposeIn recent years, with an increasing emphasis on time spent in ambulatory training, educators have focused attention on improving the residents’ experience in continuity clinic. The authors sought to review the factors associated with physician trainee satisfaction with outpatient ambulatory training.MethodsA systematic literature review was conducted for all English language articles published between January 1980 and December 2016 in relevant databases, including Medline (medicine), CINAHL (nursing), PSYCHinfo (psychology), and the Cochrane Central Register of Controlled Clinical Trials. Search terms included internship and residency, satisfaction, quality of life, continuity of care, ambulatory care, and medical education. We included studies that directly addressed resident satisfaction in the ambulatory setting through interventions that we considered reproducible.ResultsThree hundred fifty-seven studies were reviewed; 346 studies were removed based on exclusion criteria with 11 papers included in the final review. Seven studies emphasized aspects of organizational structure such as block schedules, working in teams, and impact on resident-patient continuity (continuity between resident provider and patient as viewed from the provider’s perspective). Four studies emphasized the importance of a dedicated faculty for satisfaction. The heterogeneity of the studies precluded aggregate analysis.ConclusionsClinic structures that limit inpatient and outpatient conflict and enhance continuity, along with a dedicated outpatient faculty, are associated with greater resident satisfaction. Implications for further research are discussed.

Modifying the Primary Care Exception Rule to Require Competency-Based Assessment.

Teaching residents to practice independently is a core objective of graduate medical education (GME). However, billing rules established by the Centers for Medicare and Medicaid Services (CMS) require that teaching physicians physically be present in the examination room for the care they bill, unless the training program qualifies for the Primary Care Exception Rule (PCER). Teaching physicians in programs that use this exception can bill for indirectly supervised ambulatory care once the resident who provides that care has completed six months of training. However, CMS does not mandate that programs assess or attest to residents’ clinical competence before using this rule. By requiring this six-month probationary period, the implication is that residents are adequately prepared for indirectly supervised practice by this time. As residents’ skill development varies, this may or may not be true. The PCER makes no attempt to delineate how residents’ competence should be assessed, nor does the GME community have a standard for how and when to make this assessment specifically for the purpose of determining residents’ readiness for indirectly supervised primary care practice. In this Perspective, the authors review the history and current requirements of the PCER, explore its limitations, and offer suggestions for how to modify the teaching physician billing requirements to mandate the evaluation of residents’ competence using the existing milestones framework. They also recommend strategies to standardize this process of evaluation and to develop benchmarks across training programs.