John D. Yoon

The prevalence of medical student mistreatment and its association with burnout.

Purpose Medical student mistreatment has been recognized for decades and is known to adversely impact students personally and professionally. Similarly, burnout has been shown to negatively impact students. This study assesses the prevalence of student mistreatment across multiple medical schools and characterizes the association between mistreatment and burnout. Method In 2011, the authors surveyed a nation ally representative sample of third-year medical students. Students reported the frequency of experiencing mistreatment by attending faculty and residents since the beginning of their clinical rotations. Burnout was measured using a validated two-item version of the Maslach Burnout Inventory. Results Of 960 potential respondents from 24 different medical schools, 605 (63%) completed the survey, but 41 were excluded because they were not currently in their third year of medical school. Of the eligible students, the majority reported experiencing at least one incident of mistreatment by faculty (64% [361/562]) and by residents (76% [426/562]). A minority of students reported experiencing recurrent mistreatment, defined as occurring “several” or “numerous” times: 10% [59/562] by faculty and 13% [71/562] by residents. Recurrent mistreatment (compared with no or infrequent mistreatment) was associated with high burnout: 57% versus 33% (P < .01) for recurrent mistreatment by faculty and 49% versus 32% (P < .01) for recurrent mistreatment by residents. Conclusions Medical student mistreatment remains prevalent. Recurrent mistreatment by faculty and residents is associated with medical student burnout. Although further investigation is needed to assess causality, these data provide impetus for medical schools to address student mistreatment to mitigate its adverse consequences.

Third-year medical students' participation in and perceptions of unprofessional behaviors.

Background Students’ perceptions of and participation in unprofessional behaviors may change during clinical clerkships. Method Third-year students anonymously reported observation, participation, and perceptions of 27 unprofessional behaviors before and five months after clerkships. Results Student observation (21 of 27) and participation (17 of 27) in unprofessional behaviors increased (P < .05). Students perceived unprofessional behaviors as increasingly appropriate (P < .05 for six behaviors). Participation in unprofessional behaviors was associated with diminished likelihood of perceiving a behavior as unprofessional (P < .05 for nine behaviors). Conclusions Student observation and participation in unprofessional behaviors increased during clerkships. Participation in unprofessional behaviors is associated with perceiving these behaviors as acceptable.

Obstetrician-gynecologists' beliefs about assisted reproductive technologies.

OBJECTIVE: To characterize the prevalence of objections to assisted reproductive technologies among obstetrician–gynecologists. METHODS: We conducted a national probability sample mail survey of 1,800 practicing U.S. ob–gyns. Criterion variables were whether physicians object to artificial insemination or in vitro fertilization. We also presented seven patient scenarios and asked respondents if they would discourage use of assisted reproductive technologies and if they would help patients access such technologies. Covariates included physician demographic and religious characteristics. RESULTS: Of 1,760 eligible ob–gyns, 1,154 responded (66%). Few (less than 5%) object to artificial insemination or in vitro fertilization, and even fewer (less than 3%) would not help patients access these technologies. However, the majority of ob–gyns would discourage using assisted reproductive technologies if pregnancy has a 25% mortality risk (95%), if the patient is 56 years old (88%), or if the patient has human immunodeficiency virus (73%). Fewer would discourage use of assisted reproductive technologies if the patient already has five healthy biological children (24%), if she plans to be a single parent (17%), if she is not married to her male sexual partner (14%), or if her sexual partner is female (14%). Male (odds ratio, 2.2–2.8) and religious physicians (3.6–4.7) were more likely to discourage using assisted reproductive technologies if the patient was lesbian, single, or unmarried. CONCLUSION: Few ob–gyns object to assisted reproductive technologies. Most discourage use of such technologies for patients with advanced age or medical comorbidities. Male and religious physicians are more likely to limit access for lesbian, single, or unmarried patients. LEVEL OF EVIDENCE: III

An assessment of US physicians' training in religion, spirituality, and medicine.

This study examined US physicians’ training in religion and medicine and its association with addressing religious and spiritual issues in clinical encounters. Reports of receiving training were higher for highly spiritual physicians, psychiatrists, and physicians with high numbers of critically ill patients. Discussing religion or spirituality with patients was associated with having received training through a book or CME literature or during Grand Rounds, through ones religious tradition and from other unspecified sources but not with having received such training in medical school.

Religion, sense of calling, and the practice of medicine: findings from a national survey of primary care physicians and psychiatrists.

Objectives A sense of calling is a concept with religious and theological roots; however, it is unclear whether contemporary physicians in the United States still embrace this concept in their practice of medicine. This study assesses the association between religious characteristics and endorsing a sense of calling among practicing primary care physicians (PCPs) and psychiatrists. Methods In 2009, we surveyed a stratified random sample of 2016 PCPs and psychiatrists in the United States. Physicians were asked whether they agreed with the statement, “For me, the practice of medicine is a calling.” Primary predictors included demographic and self-reported religious characteristics, (eg, attendance, affiliation, importance of religion, intrinsic religiosity) and spirituality. Results Among eligible respondents, the response rate was 63% (896/1427) for PCPs and 64% (312/487) for psychiatrists. A total of 40% of PCPs and 42% of psychiatrists endorsed a strong sense of calling. PCPs and psychiatrists who were more spiritual and/or religious as assessed by all four measures were more likely to report a strong sense of calling in the practice of medicine. Nearly half of Muslim (46%) and Catholic (45%) PCPs and the majority of evangelical Protestant PCPs (60%) report a strong sense of calling in their practice, and PCPs with these affiliations were more likely to endorse a strong sense of calling than those with no affiliation (26%, bivariate P < 0.001). We found similar trends for psychiatrists. Conclusions In this national study of PCPs and psychiatrists, we found that PCPs who considered themselves religious were more likely to report a strong sense of calling in the practice of medicine. Although this cross-sectional study cannot be used to make definitive causal inferences between religion and developing a strong sense of calling, PCPs who considered themselves religious are more likely to embrace the concept of calling in their practice of medicine.

Obstetrician-gynecologists' views on contraception and natural family planning: a national survey

OBJECTIVE The objective of the study was to characterize beliefs about contraception among obstetrician-gynecologists. STUDY DESIGN National mailed survey of 1800 US obstetrician-gynecologists. Criterion variables were whether physicians have a moral or ethical objection to, and whether they would offer, 6 common contraceptive methods. Covariates included physician demographic and religious characteristics. RESULTS One thousand one hundred fifty-four of 1760 eligible obstetrician-gynecologists responded (66%). Some obstetrician-gynecologists object to intrauterine devices (4.4% object, 3.6% would not offer), progesterone implants and/or injections (1.7% object, 2.1% would not offer), tubal ligations (1.5% object, 1.5% would not offer), oral contraceptive pills (1.3% object, 1.1% would not offer), condoms (1.3% object, 1.8% would not offer), and the diaphragm or cervical cap with spermicide (1.3% object, 3.3% would not offer). Religious physicians were more likely to object (odds ratio, 7.4) and to refuse to provide a contraceptive (odds ratio, 1.9). CONCLUSION Controversies about contraception are ongoing but among obstetrician-gynecologists, objections and refusals to provide contraceptives are infrequent.

Relevance of the rationalist-intuitionist debate for ethics and professionalism in medical education

Abstract Despite widespread pedagogical efforts to modify discrete behaviors in developing physicians, the professionalism movement has generally shied away from essential questions such as what virtues characterize the good physician, and how are those virtues formed? Although there is widespread adoption of medical ethics curricula, there is still no consensus about the primary goals of ethics education. Two prevailing perspectives dominate the literature, constituting what is sometimes referred to as the “virtue/skill dichotomy”. The first perspective argues that teaching ethics is a means of providing physicians with a skill set for analyzing and resolving ethical dilemmas. The second perspective suggests that teaching ethics is a means of creating virtuous physicians. The authors argue that this debate about medical ethics education mirrors the Rationalist–Intuitionist debate in contemporary moral psychology. In the following essay, the authors sketch the relevance of the Rationalist–Intuitionist debate to medical ethics and professionalism. They then outline a moral intuitionist model of virtuous caring that derives from but also extends the “social intuitionist model” of moral action and virtue. This moral intuitionist model suggests several practical implications specifically for medical character education but also for health science education in general. This approach proposes that character development is best accomplished by tuning-up (activating) moral intuitions, amplifying (intensifying) moral emotions related to intuitions, and strengthening (expanding) intuition-expressive, emotion-related moral virtues, more than by “learning” explicit ethical rules or principles.

Primary care physicians’ and psychiatrists’ approaches to treating mild depression

Lawrence RE, Rasinski KA, Yoon JD, Meador KG, Koenig HG, Curlin FA. Primary care physicians’ and psychiatrists’ approaches to treating mild depression.

Association of Intrinsic Motivating Factors and Markers of Physician Well-Being: A National Physician Survey

BackgroundAlthough intrinsic motivating factors play important roles in physician well-being and productivity, most studies have focused on extrinsic motivating factors such as salary and work environment.ObjectiveTo examine the association of intrinsic motivators with physicians’ career satisfaction, life satisfaction, and clinical commitment, while accounting for established extrinsic motivators as well.Design and ParticipantsA nationally representative survey of 2000 US physicians, fielded October to December 2011.Main MeasuresOutcome variables were five measures of physician well-being: career satisfaction, life satisfaction, high life meaning, commitment to direct patient care, and commitment to clinical practice. Primary explanatory variables were sense of calling, personally rewarding hours per day, meaningful, long-term relationships with patients, and burnout. Multivariate logit models with survey design provided nationally representative individual-level estimates.Key ResultsAmong 1289 respondents, 85.8% and 86.5% were satisfied with their career and life, respectively; 88.6% had high life meaning; 54.5% and 79.5% intended to retain time in direct patient care and continue clinical practice, respectively. Sense of calling was strongly positively associated with high life meaning (odds ratio [OR] 5.14, 95% confidence interval [95% CI] 2.87–9.19) and commitment to direct patient care (OR 2.50, 95% CI 1.53–4.07). Personally rewarding hours per day were most strongly associated with career satisfaction (OR 5.28, 95% CI 2.72–10.2), life satisfaction (OR 4.46, 95% CI 2.34–8.48), and commitment to clinical practice (OR 3.46, 95% CI 1.87–6.39). Long-term relationships with patients were positively associated with career and life satisfaction and high life meaning. Burnout was strongly negatively associated with all measures of physician well-being.ConclusionsIntrinsic motivators (e.g., calling) were associated with each measure of physician well-being (satisfaction, meaning, and commitment), but extrinsic motivators (e.g., annual income) were not associated with meaning or commitment. Understanding the effects of intrinsic motivators may help inform efforts to support physician well-being.

Physician Burnout and the Calling to Care for the Dying: A National Survey.

Background: Physician burnout raises concerns over what sustains physicians’ career motivations. We assess whether physicians in end-of-life specialties had higher rates of burnout and/or calling to care for the dying. We also examined whether the patient centeredness of the clinical environment was associated with burnout. Methods: In 2010 to 2011, we conducted a national survey of US physicians from multiple specialties. Primary outcomes were a validated single-item measure of burnout or sense of calling to end-of-life care. Primary predictors of burnout (or calling) included clinical specialty, frequency of encounters with dying patients, and patient centeredness of the clinical environments (“My clinical environment prioritizes the need of the patient over maximizing revenue”). Results: Adjusted response rate among eligible respondents was 62% (1156 of 1878). Nearly a quarter of physicians (23%) experienced burnout, and rates were similar across all specialties. Half of the responding physicians (52%) agreed that they felt called to take care of patients who are dying. Burned-out physicians were more likely to report working in profit-centered clinical environments (multivariate odds ratio [OR] of 1.9; confidence interval [CI]: 1.3-2.8) or experiencing emotional exhaustion when caring for the dying (multivariate OR of 2.1; CI: 1.4-3.0). Physicians who identified their work as a calling were more likely to work in end-of-life specialties, to feel emotionally energized when caring for the dying, and to be religious. Conclusion: Physicians from end-of-life specialties not only did not have increased rates of burnout but they were also more likely to report a sense of calling in caring for the dying.