Robert Fallar

The Incidence and Predictors of Job Burnout in First-Year Internal Medicine Residents: A Five-Institution Study

Purpose Job burnout is prevalent among U.S. internal medicine (IM) residents and may lead to depression, suboptimal patient care, and medical errors. This study sought to identify factors predicting new burnout to better identify at-risk residents. Method The authors administered surveys to first-year IM residents at five institutions twice between June 2008 and June 2009, linking individual pre- and postresponses. Surveys measured job burnout, sleepiness, personality traits, and other characteristics. Burnout was defined using the most commonly identified definition and another stricter definition. Results Of 263 eligible residents, 185 (70%) completed both surveys. Among 114 residents who began free of burnout and completed both surveys, 86 (75%) developed burnout, with no differences across institutions. They were significantly more likely to report a disorganized personality style (9 versus 0; 11% versus 0%; P = .019) and less likely to report receiving regular performance feedback (34 versus 13; 63% versus 87%; P = .057). Using a stricter definition, 50% (78/156) of residents developed burnout. They were less likely to plan to pursue subspecialty training (49 versus 63; 78% versus 93%; P = .016) or have a calm personality style (59 versus 70; 77% versus 90%; P = .029). There were no significant associations between burnout incidence and duty hours, clinical rotation, demographics, social supports, loan debt, or psychiatric history. Conclusions This study identified a high burnout incidence. The associations observed between burnout incidence and personality style, lack of feedback, and career choice uncertainty may inform interventions to prevent burnout and associated hazards.

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 Impact of Duty Hours Restrictions on Job Burnout in Internal Medicine Residents: A Three-institution Comparison Study

Purpose Internal medicine (IM) residents commonly develop job burnout, which may lead to poor academic performance, depression, and medical errors. The extent to which duty hours restrictions (DHRs) can mitigate job burnout remains uncertain. The July 2011 DHRs created an opportunity to measure the impact of decreased work hours on developing burnout in IM residents. Method A survey was administered twice to first-year IM residents at three academic medical centers between June 2011 and July 2012. To estimate the impact of the 2011 DHRs, data from this cohort, including demographics, sleepiness, hospital-based patient service characteristics, and burnout measures, were compared with data from 2008–2009 from first-year IM residents at the same institutions. Results Of eligible residents, 128/188 (68%) from the 2011–2012 cohort and 111/180 (62%) from the 2008–2009 cohort completed both surveys. Year-end burnout prevalence (92/123 [75%] versus 91/108 [84%], P = .08) and incidence (59/87 [68%] versus 55/68 [81%], P = .07) did not differ significantly between cohorts. There was no difference in year-end prevalence of excessive Epworth sleepiness (72/122 [59%] versus 71/108 [66%], P = .29) between cohorts; however, a greater percentage of residents who developed burnout in the 2011–2012 cohort reported caring for > 8 patients on their service (2011–2012 versus 2008–2009) (29/59 [49%] versus 5/34 [15%], P < .01). Conclusions Job burnout and self-reported sleepiness in IM resident physicians were unchanged after the 2011 DHRs at three academic institutions. Further investigation into the determinants of burnout can inform effective interventions.

The prevalence and correlations of medical student burnout in the pre-clinical years: A cross-sectional study

Burnout is a psychological syndrome of emotional exhaustion, depersonalization, and impaired personal accomplishment induced by repeated workplace stressors. Current research suggests that physician burnout may have its origins in medical school. The consequences of medical student burnout include both personal and professional distress, loss of empathy, and poor health. We hypothesized that burnout occurs prior to the initiation of the clinical years of medical education. This was a cross-sectional survey administered to third‐year medical students at the Mount Sinai School of Medicine (MSSM) in New York, New York (a traditional-style medical school with a marked division between pre-clinical and clinical training occurring at the beginning of the third year). Survey included an instrument used to measure job burnout, a sleep deprivation screen, and questions related to demographic information, current rotation, psychiatric history, time spent working/studying, participation in extracurricular activities, social support network, autonomy and isolation. Of the 86 medical students who participated, 71% met criteria for burnout. Burnt out students were significantly more likely to suffer from sleep deprivation (p = 0.0359). They were also more likely to disagree with the following statements: “I have control over my daily schedule” (p = 0.0286) and “I am confident that I will have the knowledge and skills necessary to become an intern when I graduate” (p = 0.0263). Our findings show that burnout is present at the beginning of the third year of medical school, prior to the initiation of the clinical years of medical training. Medical student burnout is quite common, and early efforts should be made to empower medical students to both build the knowledge and skills necessary to become capable physicians, as well as withstand the emotional, mental, and physical challenges inherent to medical school.

A Randomized Controlled Trial to Decrease Job Burnout in First-Year Internal Medicine Residents Using a Facilitated Discussion Group Intervention

Background Burnout is common in internal medicine (IM) trainees and is associated with depression and suboptimal patient care. Facilitated group discussion reduces burnout among practicing clinicians. Objective We hypothesized that this type of intervention would reduce incident burnout among first-year IM residents. Methods Between June 2013 and May 2014, participants from a convenience sample of 51 incoming IM residents were randomly assigned (in groups of 3) to the intervention or a control. Twice-monthly theme-based discussion sessions (18 total) led by expert facilitators were held for intervention groups. Surveys were administered at study onset and completion. Demographic and personal characteristics were collected. Burnout and burnout domains were the primary outcomes. Following convention, we defined burnout as a high emotional exhaustion or depersonalization score on the Maslach Burnout Inventory. Results All 51 eligible residents participated; 39 (76%) completed both surveys. Initial burnout prevalence (10 of 21 [48%] versus 7 of 17 [41%], P = .69), incidence of burnout at year end (9 of 11 [82%] versus 5 of 10 [50%], P = .18), and secondary outcomes were similar in intervention and control arms. More residents in the intervention group had high year-end depersonalization scores (18 of 21 [86%] versus 9 of 17 [53%], P = .04). Many intervention residents revealed that sessions did not truly free them from clinical or educational responsibilities. Conclusions A facilitated group discussion intervention did not decrease burnout in resident physicians. Future discussion-based interventions for reducing resident burnout should be voluntary and effectively free participants from clinical duties.

Medical students' experiences with authorship in biomedical research: a national survey.

Purpose To explore authorship issues related to medical students’ primary research projects, assess medical students’ knowledge about authorship issues in biomedical research, and determine their interest in learning about authorship guidelines. Method In 2011, the authors developed and conducted an electronic survey of 243 U.S. medical students who attended an educational event at the National Institutes of Health as part of their funded, yearlong research fellowship programs. The authors then analyzed the results using descriptive statistics. Results Of 243 students, 152 (63%) responded. Most (120/151; 79%) had completed or were in the process of writing a manuscript based on their projects. Of these, most (95/119; 80%) wrote the entire manuscript independently or with guidance. Whereas almost two-thirds (99/152; 65%) indicated that expectations and criteria for authorship were clarified for them, 26% (40/152) indicated that they were not. Most students (108/118; 92%) were in the authorship position they expected and had no concerns about who the other authors were (91/119; 77%). Of those with concerns, 52% (11/21) did not raise the issue for fear of challenging their mentor. Two-thirds (95/145; 66%) never received formal training in authorship guidelines, and 41% (42/103) believed such training would be valuable. Conclusions Although a majority of students had conversations about authorship and were clear about the guidelines for ethical authorship, additional work is needed. The authors recommend that academic institutions develop a menu of options for teaching students about this important area in research ethics.

The use of standardised patients to assess clinical competence: does practice make perfect?

Context  The use of standardised patients (SPs) is now an integral component of the United States Medical Licensing Examination (USMLE). This new requirement has caused more schools to include SP examinations (SPEs) in their curricula. This study reviews the effect of prior experience with SPs in a medical school curriculum on SPE pass rates.

A Model for the Assessment of Medical Students’ Competency in Medical Ethics

Background: This article focuses on the goals of our medical ethics education program and our formative assessments of students’ competency at various points during this education. Methods: Because of the critical relationship between a programs goals and the design of an assessment strategy, we provide an overview of the theoretical basis of our curriculum, our programs objectives, and teaching methods. In order to verify that our students had achieved minimum competency in the objectives of our ethics curriculum, we developed assessments that evaluated their ability to identify and apply ethical principles to clinical cases and to use moral reasoning to resolve dilemmas. We verified the reliability of these assessment instruments by correlating two different Mount Sinai raters’ scores of the same assessments with each other and the validity of these assessments with external reviewers. Results: For interrater reliability, paired raters scored the same student written exercise within 5 points of each other on 119 of the exercises (87% rater consensus). Therefore, we found our assessment tools to be reliable. Regarding validity, all three expert external reviewers agreed that our instruments were well suited for evaluating medical student competency in medical ethics and that they measured what we intended to measure. Conclusions: Our efforts in medical ethics education and competency assessment have produced an integrated model of goals, methodology, curriculum, and competency assessment. The entire model is directed at providing students with the ethical knowledge, skills, and attitudes required of an exemplary physician. We have developed reliable and valid assessment tools that allow us to evaluate the competency of students in medical ethics and to identify students who require remediation, and that are useful for other ethics programs.

A Patient Safety and Transitions of Care Curriculum for Third-Year Medical Students

The elderly are the most vulnerable to adverse events during and after hospitalization. This study sought to evaluate the effectiveness of a curriculum on patient safety and transitions of care for medical students during an Internal Medicine-Geriatrics Clerkship on students’ knowledge, skills, and attitudes. The curriculum included didactics on patient safety, health literacy, discharge planning and transitions of care, and postdischarge visits to patients. Analysis of pre- and postassessments showed afterwards students were significantly more comfortable assessing a patient’s health literacy and confident performing a medication reconciliation, providing education regarding medications, and identifying barriers during transitions. More students were able to identify the most common source of adverse events after discharge (86% vs. 62% before), risk factors for low health literacy (28% vs. 14%), and ways to assess a patient’s health literacy (14% vs. 2%). It was feasible to implement a postdischarge visit assignment in an urban tertiary care setting and only required on average of approximately an one and one half hours for students to complete.

The Effect of Burnout on Medical Errors and Professionalism in First-Year Internal Medicine Residents

BACKGROUND Burnout is a common issue in internal medicine residents, and its impact on medical errors and professionalism is an important subject of investigation. OBJECTIVE To evaluate differences in medical errors and professionalism in internal medicine residents with and without burnout. METHODS A single institution observational cohort study was conducted between June 2011 and July 2012. Burnout was measured using the Maslach Burnout Inventory to generate subscores for the following 3 domains: emotional exhaustion, depersonalization, and sense of personal accomplishment. By convention, burnout was defined as a high emotional exhaustion or depersonalization subscore. Medication prescription error rate was the chosen measure of medical errors. Professionalism was measured cumulatively through examining discharge summaries completed within 48 hours, outpatient charts completed within 72 hours, and the average time to review outpatient laboratory tests. RESULTS Of a total of 54 eligible first-year residents, 53 (98%) and 32 (59%) completed the initial and follow-up surveys, respectively. Residents with year-end burnout had a lower rate of medication prescription errors (0.553 versus 0.780, P = .007). Discharge summaries completed within 48 hours of discharge (83.8% versus 84.0%, P = .93), outpatient charts completed within 72 hours of encounter (93.7% versus 94.3%, P = .31), and time (minutes) to review outpatient laboratory test results (72.3 versus 26.9, P = .28) were similar between residents with and without year-end burnout. CONCLUSIONS This study found a small decrease in medical errors in residents with year-end burnout compared to burnout-free residents and no difference in selected measures of professionalism.