Deborah Seltzer

This is just too awful; I just can't believe I experienced that...: medical students' reactions to their "most memorable" patient death.

Purpose To examine medical students’ emotional reactions to their ”most memorable” patient death and the support they receive. Method In 2000–01, 65 third-year medical students at two Northeastern U.S. medical schools were randomly selected to participate in 60–90-minute interviews of open-ended and structured questions and a written questionnaire (using a ten-point scale) about their “most memorable” patient death. Independent reviewers coded each interview to identify the analytical categories. Descriptive data were generated from the written questionnaire. Results A total of 32 interviews were used in the analysis. Twelve (38%) students were in contact with the patient for less than 24 hours and 23 (73%) were not at all or minimally close to the patient (0–3 on ten-point scale). Sixteen of 28 students (57%) rated the impact of the death as highly emotionally powerful (7–10 on ten-point scale). The finality of deaths, particularly sudden deaths, evoked strong emotions. Four of 16 (25%) students who found the death highly emotionally powerful rated the amount of support from supervisors as extremely inadequate (0–3 on ten-point scale). There was no discussion of the death in 17 (63%) of the 27 cases in which the patient was cared for by the student’s team. Students perceived from supervising physicians that death and emotions are negative aspects of medicine. Conclusions Medical students experienced patient deaths as emotionally powerful even when they were not close to the patients. Debriefing sessions with students were rare, and many students felt inadequately supported. Thus, a unique opportunity to teach about death, emotions and coping with stress is often lost.

It was haunting...: physicians' descriptions of emotionally powerful patient deaths.

Purpose To understand the emotional experiences of physicians who care for dying patients and to identify educational opportunities for improving patient care and physician well-being. Method Between 1999–2001, physicians at two quaternary care medical centers in Boston, Massachusetts, and Pittsburgh, Pennsylvania, participated in 90-minute, semistructured personal interviews on their most emotionally powerful patient death. Quantitative data was obtained through face-to-face surveys rated on ten-point scales that asked physicians about emotional characteristics of and emotional responses to the death. In the qualitative portion of the survey, physicians were asked to describe the details of the most emotionally powerful patient death, the types and sequence of their emotional reactions, their methods of coping, and subsequent changes in behavior. Results Physicians had powerful experiences with death during all stages of their careers. Experiences with patient death generally fit into one of three types: “good,” “overtreated,” or “shocking/unexpected.” Housestaff often described coping in isolation with the disturbing emotions generated in the care of dying patients. Physicians learned how to care for and cope with dying patients from their experiences with patients whose deaths were most emotionally powerful and reported changes in their clinical behavior and career paths as a result. Conclusions Physicians’ emotional reactions to patient death can affect patient care and the personal lives of physicians. Supervising physicians have an opportunity to improve both the care of dying patients and house-staff coping with these deaths by using the “teachable moments” that are present for trainees as they care for the dying.

A Comprehensive Career-Success Model for Physician-Scientists

With todays focus on the translation of basic science discoveries into clinical practice, the demand for physician-scientists is growing. Yet, physicians have always found it challenging to juggle the demands of clinical care with the time required to perform research. The Research on Careers Workgroup of the Institute for Clinical Research Education at the University of Pittsburgh developed a comprehensive model for career success that would address, and allow for the evaluation of, the personal factors, organizational factors, and their interplay that contribute to career success. With this model, leaders of training programs could identify early opportunities for intervening with potential physician-scientists to ensure career success. Through an iterative process described in this article, the authors identified and examined potential models for career success from the literature, added other elements determined to be significant, and developed a comprehensive model to assess factors associated with career success for physician-scientists. The authors also present examples of ways in which this model can be adapted and applied to specific situations to assess the effects of different factors on career success.

Urban homelessness and poverty during economic prosperity and welfare reform: changes in self-reported comorbidities, insurance, and sources for usual care, 1995-1997.

Little is known of how homeless and other urban poor populations have fared during the robust economy and within structural changes in health care delivery and entitlement programs of the 1990s. This is important in determining the need for population-specific services during a vigorous economy with low unemployment and increasing Medicaid managed-care penetration. This study compared health insurance status and availability of a source for usual medical care, psychiatric and substance abuse comorbidities, and perceived causes of homelessness in homeless adults surveyed in 1995 and 1997. Cross-sectional, community-based surveys were conducted in 1995 and 1997 at sites frequented by urban homeless adults residing in Pittsburgh, Pennsylvania. Self-reported medical, mental health, and substance abuse comorbidities, health insurance, and source for usual care were measured. Compared to the 388 individuals surveyed in 1995, the 267 homeless adults surveyed in 1997 had more medical comorbidity (56.6% vs. 30.2%, P<.001) and mental health comorbidity (44.9% vs. 36.9%, P=.04) and required more chronic medication (52.1% vs. 30.3%, P<.001). More respondents in 1997 than 1995 reported having no health insurance (41.4% vs. 29.4%, P<.001). While there was no difference in the overall proportion reporting a source for usual care (78.3% in 1997 vs. 80.2% in 1995, P=.55), fewer persons reported use of the emergency department and more persons reported using a shelter-based clinic for usual care in 1997 compared with 1995. These findings suggest more need for medical care among homeless and urban poor persons in 1997 compared with 1995 and support the continued need for outreach and support services despite a vigorous economy.

Psychometric Properties of the Mentor Role Instrument when Used in an Academic Medicine Setting

The Ragins and McFarlin Mentor Role Instrument (RMMRI) was originally developed to measure perceptions of mentoring relationships in research and development organizations. The current study was designed to evaluate the RMMRIs reliability and validity when the instrument was administered to clinical and translational science trainees at an academic medical center. The 33‐item RMMRI was administered prospectively to a cohort of 141 trainees at the University of Pittsburgh in 2007–2008. Likert‐scale items focused on perceptions of five mentoring roles in the career dimension (sponsor, coach, protector, challenger, and promoter) and six mentoring roles in the psychosocial dimension (friend, social associate, parent, role model, counselor, and acceptor). Outcome items included overall perceptions of mentoring satisfaction and effectiveness. Of 141 trainees, 53% were male, 66% were white, 22% were Asian, and 59% were medical doctors. Mean age was 32 years. Analyses showed strong within‐factor inter‐item correlations (Pearson Coefficients of 0.57–0.93); strong internal consistency (Cronbach alphas of 0.82–0.97); confirmatory factorial validity, as demonstrated by confirmatory factor analysis of the two mentoring dimensions, 11 mentoring roles, and 33 RMMRI items; and concurrent validity, as demonstrated by strong correlations (Pearson Coefficients of 0.56–0.71) between mentoring dimensions, satisfaction, and effectiveness. This article concludes that the RMMRI shows reliability and validity in capturing the multidimensional nature of mentoring when administered to clinical and translational science trainees in the academic setting. Clin Trans Sci 2010; Volume 3: 104–108

Brief Report: Burnout Among Early Career Clinical Investigators

Burnout is a pervasive problem among clinicians. However, little is known about burnout among early career clinical investigators, who must balance clinical responsibilities with challenges related to research. We aimed to determine the prevalence of and demographic associations with burnout in a cohort of early career clinical investigators.

A Shortened Version of the Clinical Research Appraisal Inventory: CRAI-12

Purpose The original Clinical Research Appraisal Inventory (CRAI), which assesses the self-confidence of trainees in performing different aspects of clinical research, comprises 92 items. Completing the lengthy CRAI is time-consuming and represents a considerable burden to respondents, yet the CRAI provides useful data for evaluating research training programs. The purpose of this study is to develop a shortened version of the CRAI and to test its validity and reliability. Method Trainees in clinical research degree and career development programs at the University of Pittsburgh’s Institute for Clinical Research Education completed the 92-item CRAI between 2007 and 2012, inclusive. The authors conducted, first, exploratory factor analysis on a training dataset (2007–2010) to reduce the number of items and, then, confirmatory factor analyses on a testing dataset (2011–2012) to test the psychometric properties of the shortened version. Results Of 546 trainees, 394 (72%) provided study data. Exploratory factor analysis revealed six distinct factors, and confirmatory factor analysis identified the two items with the highest loadings per factor, for a total of 12 items. Cronbach alpha for the six new factors ranged from 0.80 to 0.94. Factors in the 12-item CRAI were strongly and significantly associated with factors in the 92-item CRAI; correlations ranged from 0.82 to0.96 (P < .001 for each). Conclusions The 12-item CRAI is faster and less burdensome to complete but retains the strong psychometric properties of the original CRAI.

Measurement of Social Capital among Clinical Research Trainees

While physical and human capital are established as important predictors of success among early‐career clinical investigators, less is known about the role of social capital. The authors aimed to develop a brief scale to assess social capital in this population and test its reliability and validity. A three‐item assessment was developed based on a conceptual framework and measures of social capital from other fields and was administered to 414 clinical research trainees at the University of Pittsburgh in 2007–2012. The measure exhibited good internal consistency reliability (α = 0.71) and a normal distribution. On a 10‐point scale, mean social capital was 6.4 (SD = 1.7). Social capital was significantly associated with 7 of the 9 expected constructs: sex, age, confidence in research skills, work‐related motivation, burnout, and social support. Exploratory multivariable regression analysis demonstrated that social capital was most strongly associated with higher research confidence (β = 0.35, p < 0.001), higher extrinsic motivation (β = 0.50, p = 0.003), and lower burnout (ptrend = 0.02). This three‐item scale measures social capital in this population with adequate internal consistency reliability, face validity, and construct validity. This brief assessment provides a tool that may be valuable to benchmark social capital of clinical research trainees and to better contextualize programmatic and trainee outcomes.

Shortening the Work Preference Inventory for Use with Physician Scientists: WPI-10

The Work Preference Inventory (WPI) is a four‐factor, 30‐item measure that assesses work motivation. Used to help individuals choose appropriate career paths, its length contributes to response burden, especially when combined with other measures. We aimed to develop a shortened, valid, and reliable version of the WPI. Trainees at the University of Pittsburghs Institute for Clinical Research Education completed the 30‐item WPI between 2007 and 2012. We conducted exploratory and confirmatory factor analyses to reduce the number of items. Of the 402 eligible trainees, 371 (92%) provided data for the exploratory factor analysis (EFA), and 134 of the eligible 144 trainees (93%) provided data for the confirmatory factor analysis (CFA). EFA revealed four factors that were roughly equivalent to those of the original. CFA used the three items with the highest loadings on each factor, with two items removed due to low loadings and R‐squareds, resulting in a 10‐item scale. Cronbachs alpha for each of the four factors ranged from 0.68 to 0.76. Factors in the WPI‐10 were strongly and significantly associated with factors in the original WPI, indicating strong validity of the shortened measure. The WPI‐10 shows evidence for similar validity and reliability to the original instrument while reducing respondent burden.

Characterization of investigators' approach to translational research: a qualitative study.

Little is known about how investigators approach their research programs along the translational research continuum. Many consider the translational continuum to be linear, with research beginning at the bench and concluding with research at the bedside or in the community. We aimed to understand if translational investigators approach and view their research in this fashion.