Colin P. West

Association of Resident Fatigue and Distress With Perceived Medical Errors

CONTEXT Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown. OBJECTIVE To determine the association of fatigue and distress with self-perceived major medical errors among resident physicians using validated metrics. DESIGN, SETTING, AND PARTICIPANTS Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic, Rochester, Minnesota. Data were provided by 380 of 430 eligible residents (88.3%). Participants began training from 2003 to 2008 and completed surveys quarterly through February 2009. Surveys included self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the PRIME-MD depression screening instrument, and the Epworth Sleepiness Scale. MAIN OUTCOME MEASURES Frequency of self-perceived, self-defined major medical errors was recorded. Associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error were determined using generalized estimating equations for repeated measures. RESULTS The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P < .001). Subsequent error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P < .001; emotional exhaustion OR, 1.06; 95% CI, 1.04-1.08; P < .001; lower personal accomplishment OR, 0.94; 95% CI, 0.92-0.97; P < .001), a positive depression screen (OR, 2.56; 95% CI, 1.76-3.72; P < .001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79-0.91; P < .001). Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression. CONCLUSION Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014.

OBJECTIVE To evaluate the prevalence of burnout and satisfaction with work-life balance in physicians and US workers in 2014 relative to 2011. PATIENTS AND METHODS From August 28, 2014, to October 6, 2014, we surveyed both US physicians and a probability-based sample of the general US population using the methods and measures used in our 2011 study. Burnout was measured using validated metrics, and satisfaction with work-life balance was assessed using standard tools. RESULTS Of the 35,922 physicians who received an invitation to participate, 6880 (19.2%) completed surveys. When assessed using the Maslach Burnout Inventory, 54.4% (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.5% (n=3310) in 2011 (P<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%; P<.001). Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty. In contrast to the trends in physicians, minimal changes in burnout or satisfaction with work-life balance were observed between 2011 and 2014 in probability-based samples of working US adults, resulting in an increasing disparity in burnout and satisfaction with work-life balance in physicians relative to the general US working population. After pooled multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians remained at an increased risk of burnout (odds ratio, 1.97; 95% CI, 1.80-2.16; P<.001) and were less likely to be satisfied with work-life balance (odds ratio, 0.68; 95% CI, 0.62-0.75; P<.001). CONCLUSION Burnout and satisfaction with work-life balance in US physicians worsened from 2011 to 2014. More than half of US physicians are now experiencing professional burnout.

Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population

Purpose To compare the prevalence of burnout and other forms of distress across career stages and the experiences of trainees and early career (EC) physicians versus those of similarly aged college graduates pursuing other careers. Method In 2011 and 2012, the authors conducted a national survey of medical students, residents/fellows, and EC physicians (⩽ 5 years in practice) and of a probability-based sample of the general U.S. population. All surveys assessed burnout, symptoms of depression and suicidal ideation, quality of life, and fatigue. Results Response rates were 35.2% (4,402/12,500) for medical students, 22.5% (1,701/7,560) for residents/fellows, and 26.7% (7,288/27,276) for EC physicians. In multivariate models that controlled for relationship status, sex, age, and career stage, being a resident/fellow was associated with increased odds of burnout and being a medical student with increased odds of depressive symptoms, whereas EC physicians had the lowest odds of high fatigue. Compared with the population control samples, medical students, residents/fellows, and EC physicians were more likely to be burned out (all P < .0001). Medical students and residents/fellows were more likely to exhibit symptoms of depression than the population control samples (both P < .0001) but not more likely to have experienced recent suicidal ideation. Conclusions Training appears to be the peak time for distress among physicians, but differences in the prevalence of burnout, depressive symptoms, and recent suicidal ideation are relatively small. At each stage, burnout is more prevalent among physicians than among their peers in the U.S. population.

Career Fit and Burnout Among Academic Faculty

BACKGROUND Extensive literature documents personal distress among physicians and a decrease in their satisfaction with the practice of medicine over recent years. We hypothesized that physicians who spent more of their time in the aspect of work that they found most meaningful would have a lower risk of burnout. METHODS Faculty physicians in the Department of Internal Medicine at a large academic medical center were surveyed in the fall of 2007. The survey evaluated demographic variables, work characteristics, and career satisfaction. Burnout was measured using the Maslach Burnout Inventory. Additional questions evaluated which professional activity (eg, research, education, patient care, or administration) was most personally meaningful and the percentage of effort that was devoted to each activity. RESULTS Of 556 physicians sampled, 465 (84%) returned surveys. A majority (68%) reported that patient care was the aspect of work that they found most meaningful, with smaller percentages reporting research (19%), education (9%), or administration (3%) as being most meaningful. Overall, 34% of faculty members met the criteria for burnout. The amount of time spent working on the most meaningful activity was strongly related to the risk of burnout. Those spending less than 20% of their time (approximately 1 d/wk) on the activity that is most meaningful to them had higher rates of burnout (53.8% vs 29.9%; P<.001). Time spent on the most meaningful activity was the largest predictor of burnout on multivariate analysis (odds ratio, 2.75; P = .001). CONCLUSIONS The extent to which faculty physicians are able to focus on the aspect of work that is most meaningful to them has a strong inverse relationship to their risk of burnout. Efforts to optimize career fit may promote physician satisfaction and help to reduce attrition among academic faculty physicians.

Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism: A Randomized Clinical Trial

IMPORTANCE Despite the documented prevalence and clinical ramifications of physician distress, few rigorous studies have tested interventions to address the problem. OBJECTIVE To test the hypothesis that an intervention involving a facilitated physician small-group curriculum would result in improvement in well-being. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 74 practicing physicians in the Department of Medicine at the Mayo Clinic in Rochester, Minnesota, conducted between September 2010 and June 2012. Additional data were collected on 350 nontrial participants responding to annual surveys timed to coincide with the trial surveys. INTERVENTIONS The intervention involved 19 biweekly facilitated physician discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning for 9 months. Protected time (1 hour of paid time every other week) for participants was provided by the institution. MAIN OUTCOMES AND MEASURES Meaning in work, empowerment and engagement in work, burnout, symptoms of depression, quality of life, and job satisfaction assessed using validated metrics. RESULTS Empowerment and engagement at work increased by 5.3 points in the intervention arm vs a 0.5-point decline in the control arm by 3 months after the study (P = .04), an improvement sustained at 12 months (+5.5 vs +1.3 points; P = .03). Rates of high depersonalization at 3 months had decreased by 15.5% in the intervention arm vs a 0.8% increase in the control arm (P = .004). This difference was also sustained at 12 months (9.6% vs 1.5% decrease; P = .02). No statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction were seen. In additional comparisons including the nontrial physician cohort, the proportion of participants strongly agreeing that their work was meaningful increased 6.3% in the study intervention arm but decreased 6.3% in the study control arm and 13.4% in the nonstudy cohort (P = .04). Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the trial intervention arm, decreased slightly in the trial control arm, and increased in the nontrial cohort (P = .03, .007, and .002 for each outcome, respectively). CONCLUSIONS AND RELEVANCE An intervention for physicians based on a facilitated small-group curriculum improved meaning and engagement in work and reduced depersonalization, with sustained results at 12 months after the study. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01159977.

Relationship between increased personal well-being and enhanced empathy among

BACKGROUND: While resident distress and its potential to negatively effect patient care have been well documented, little is known about resident well-being or its potential to enhance care.OBJECTIVE: We measured resident well-being and explored its relationship with empathy.DESIGN: Anonymous, cross-sectional survey.PARTICIPANTS: Internal medicine residents at Mayo Clinic Rochester (n=165, summer 2003).MEASUREMENTS: Well-being was measured using the previously validated Medical Outcomes Study 8-item Short Form (SF-8). Empathy was measured using the previously validated Perspective Taking (PT) and Empathetic Concerns (EC) Sub-scales of the Interpersonal Reactivity Index (IRI).RESULTS: Eighty-three (50%) residents responded to the survey. Mean scores for well-being as measured by the SF-8 were comparable to the general population, and empathy scores on the IRI were similar to other resident samples. Resident empathy on both the cognitive (PT) and emotive (EC) sub-scales of the IRI was higher for residents with higher mental well-being on the SF-8; however, this difference was statistically significant only for the cognitive sub-scale. The importance of a number of personal wellness promotion strategies differed for residents with higher mental well-being on the SF-8.CONCLUSIONS: High mental well-being was associated with enhanced resident empathy in this cross-sectional survey. Future studies need to explore the potential for high resident well-being to enhance medical care and competency in addition to exploring the negative consequences of resident distress. Studies investigating how to promote resident well-being are needed.

Single Item Measures of Emotional Exhaustion and Depersonalization Are Useful for Assessing Burnout in Medical Professionals

ABSTRACTBACKGROUNDBurnout has negative effects on work performance and patient care. The current standard for burnout assessment is the Maslach Burnout Inventory (MBI), a well-validated instrument consisting of 22 items answered on a 7-point Likert scale. However, the length of the MBI can limit its utility in physician surveys.OBJECTIVETo evaluate the performance of two questions relative to the full MBI for measuring burnout.DESIGN AND PARTICIPANTSCross-sectional data from 2,248 medical students, 333 internal medicine residents, 465 internal medicine faculty, and 7,905 practicing surgeons.MEASUREMENTS AND MAIN RESULTSThe single questions with the highest factor loading on the emotional exhaustion (EE) (“I feel burned out from my work”) and depersonalization (DP) (“I have become more callous toward people since I took this job”) domains of burnout were evaluated in four large samples of medical students, internal medicine residents, internal medicine faculty, and practicing surgeons. Spearman correlations between the single EE question and the full EE domain score minus that question ranged from 0.76–0.83. Spearman correlations between the single DP question and the full DP domain score minus that question ranged from 0.61–0.72. Responses to the single item measures of emotional exhaustion and depersonalization stratified risk of high burnout in the relevant domain on the full MBI, with consistent patterns across the four sampled groups.CONCLUSIONSSingle item measures of emotional exhaustion and depersonalization provide meaningful information on burnout in medical professionals.

Effects of 5-Hydroxytryptamine (Serotonin) Type 3 Antagonists on Symptom Relief and Constipation in Nonconstipated Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND & AIMS We performed a systematic review and meta-analyses to estimate treatment efficacy and constipation rate of 5-hydroxytryptamine (serotonin) (5-HT(3)) antagonists in patients with nonconstipated (NC) or diarrhea-predominant (D)-irritable bowel syndrome (IBS). METHODS Two reviewers independently searched MEDLINE, EMBASE, and Web of Science (January 1, 1966 to December 15, 2006) for randomized controlled trials of 5-HT(3) antagonists in IBS reporting clinical end points of the IBS symptom complex and safety parameters. Study characteristics, markers of methodologic quality, and outcomes for the intention-to-treat population for each randomized controlled trial were extracted independently. RESULTS We found 14 eligible randomized controlled trials of alosetron (n = 3024) or cilansetron (n = 1116) versus placebo (n = 3043) or mebeverine (n = 304). Random-effects meta-analyses found 5-HT(3) antagonists more effective than the comparators in achieving global improvement in IBS symptoms (pooled relative risk, 1.60; 95% confidence interval [CI], 1.49-1.72; I(2) = 0%) and relief of abdominal pain and discomfort (pooled relative risk, 1.30; 95% CI, 1.22-1.39; I(2) = 22%). Benefit was apparent for both agents, in patients of either sex. These agents were more likely to cause constipation (pooled relative risk, 4.28; 95% CI, 3.28-5.60, I(2) = 65%); there was less constipation with 5-HT(3) antagonists in D-IBS patients than in mixed populations (NC-IBS and D-IBS; relative risk ratio, 0.65; 95% CI, 0.41-0.99). Nine patients (0.2%) using 5-HT(3) antagonists had possible ischemic colitis versus none in control groups. CONCLUSIONS 5-HT(3) antagonists significantly improve symptoms of NC-IBS or D-IBS in men and women. There is an increased risk of constipation with 5-HT(3) antagonists, although the risk is lower in those with D-IBS.

Effects of cyclophosphamide on pulmonary function in patients with scleroderma and interstitial lung disease: a systematic review and meta-analysis of randomized controlled trials and observational prospective cohort studies

IntroductionThe purpose of the present study was to systematically review the effect of cyclophosphamide treatment on pulmonary function in patients with systemic sclerosis and interstitial lung disease.MethodsThe primary outcomes were the mean change in forced vital capacity and in diffusing capacity for carbon monoxide after 12 months of therapy in patients treated with cyclophosphamide.ResultsThree randomized clinical trials and six prospective observational studies were included for analysis. In the pooled analysis, the forced vital capacity and the diffusing capacity for carbon monoxide predicted values after 12 months of therapy were essentially unchanged, with mean changes of 2.83% (95% confidence interval = 0.35 to 5.31) and 4.56% (95% confidence interval = -0.21 to 9.33), respectively.ConclusionsCyclophosphamide treatment in patients with systemic sclerosis-related interstitial lung disease does not result in clinically significant improvement of pulmonary function.

The influence of personal and environmental factors on professionalism in medical education

BackgroundProfessionalism is a critical quality for physicians to possess. Physician professionalism has received increased attention in recent years, with many authorities suggesting that professionalism is in decline. An understanding of the factors contributing to professionalism may allow the development of more effective approaches to promoting this quality in medical education.DiscussionWe propose a model of personal and environmental factors that contribute to physician professionalism. Personal factors include distress/well-being, individual characteristics, and interpersonal qualities. Environmental factors include institutional culture, formal and informal curricula, and practice characteristics. Promotion of professionalism requires efforts directed at each of these elements.SummaryOne responsibility of medical education is to foster the development of professionalism among its learners. Both personal and environmental factors play a role in physician professionalism. Accordingly, institutions should consider these factors as efforts to promote physician professionalism evolve.