Well-being or the lack thereof: how do we support it?

For the last several years, there has been an increasing focus at the national level on physician burnout and its effect on our healthcare system. (1) A recent survey (2) of a community graduate medical education program in Wichita KS adds to the worry.  The authors surveyed all of the residents and core faculty in thirteen programs that are associated with the KUSOM in Wichita. The response rate was about 50 percent (281/439) with higher response from the faculty (55%) than the residents (47%55%) than the residents (47%).  The surveyed used the Abbreviated version of the Maslach Burnout Inventory (MBI-9).  The authors found that 32 percent of the residents and faculty had emotional exhaustion and 31 percent depersonalization.  Overall, 94/281 (43%) were considered burned out, with 51 percent of the residents meeting burnout criteria. There were three themes that emerged as activities that promote wellness among physicians: promotion of healthy and mindfulness activities; enhanced program leadership; and administration, program, and system modification to make the practice of medicine better for physicians.

Another survey of family medicine residents and faculty in Texas explored burnout. (3) Participants included 295 family medicine residents and faculty members across eleven FM programs within the Residency Research Network of Texas. The residents and faculty completed several measures that assessed resilience, burnout, flexibility, and stress. The primary outcome variables were burnout (depersonalization, emotional exhaustion, and personal achievement) and resilience. Depersonalization accounted for 27.1% of the variance (P<.001), with a moderate effect size (f²=.371). Risk factors included younger age, non-Hispanic white ethnicity, and lower resilience predicted. Resilience was the only variable that predicted depersonalization among program faculty while younger age and non-Hispanic white ethnicity along with resilience were significant predictors of depersonalization among residents. Emotional exhaustion accounted for 39% of the variance in the model (F [11,286] = 16.609, P<.001). Resiliency was significantly associated with younger age and greater psychological flexibility. Younger age, identifying as an ethnic minority, and psychological flexibility predicted resiliency among faculty, but there were no statistically significant predictors of resilience among the resident physicians.

And finally, a survey from the Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force (4) was done to help programs create a “culture of wellness.”  Of the 16 elements presented, 14 were rated as essential by at least 80% of the program directors. The five areas that were ranked as the most important after three rounds of questioning included: make wellness part of the residency vocabulary and culture by beginning wellness conversations in orientation and regularly thereafter; create a culture of safe, confidential disclosure for burnout, depression, suicidal ideation, and impairment; provide (directly or referral) accessible, confidential, affordable mental health services;  develop and maintain a regular recurring or longitudinal wellness curriculum (eg, building skills such as mindfulness, resilience, empathy); identify one or more wellness champions (faculty or resident) with explicit leadership support.

I am very excited that Family Medicine has given so much thought to this important issue.  Three studies in the journal that really add to the discourse!  Thanks.

References

(1)   https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources

(2)   Ofei-Dodoo S, Callaway P, Engels K. Prevalence and Etiology of Burnout in a Community-Based Graduate Medical Education System: A Mixed-Methods Study. Fam Med 2019; 51(9): 766-71.

(3)   Buck K, Williamson M, Ogbeide S, Norberg B. Family Physician Burnout and Resilience: A Cross-sectional Analysis. Fam Med 2019; 51(8): 657-663.

(4)   Penwell-Waines L, Runyan C, Kolobova I, et al.  Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.  Fam Med 2019; 51(8): 670-6.

What are some of the impacts of the Duty Hour Restrictions on Residency Training?

A new study was published in BMJ online this week (1) about the impact of work hour reform. The authors, Dr. Chaiyachati and colleagues performed a time-motion observation of internal medicine residents at six residency programs that were a part of the iCompare group (Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education).

Eighty interns were observed by 23 trained observers. They began recording the residents’ activities as soon as they arrived at the hospital. They stopped collecting data when the intern finished their shift. The residents’ time was divided into activities and coded into seven major categories (4 Required: Education, Rounds, Work, & Handoffs AND 3 Other Applicable: Direct Patient Care, Indirect Patient Care, & Miscellaneous). Residents were observed between May 10, 2016 and May 31, 2016 for 94 weekday shifts and a total of 2173 hours. 

The authors found that residents worked a mean of 10.5 hours per shift (9.6 to 12.5 hours).  Overnight call shifts were 20.9 hours long (16.7 to 26.7 hours). Indirect patient care was the most frequently observed activity across all 6-hour time periods in the day. Direct and Indirect patient care was often seen in multitasking. More than half of the time recorded by the observers included residents multitasking other activities with indirect patient care. More than 10 hours of a 24 hour period was spent interacting with the electronic medical record.

At AMEE 2019 in Vienna, I went to a session in the Postgraduate Training (Residency) tract.  The session was led by Dr David Gachoud and colleagues at the Lausanne University Hospital in Lausanne Switzerland (2). His team had originally used the time and motion study technique in 2015 to evaluate Internal Medicine residents’ time usage.  One of their findings was that residents switched tasks on average 15 times per minute. One outcome of this study was to work with their residents to improve the schedule, specifically to increase the amount of time that was available to prepare for morning rounds by delaying the start of rounds by one hour every morning. They also hired some new secretarial staff to relieve the administrative burden of the residents. 

In this study, they recorded 63 day shifts between May and July 2018.  What they found was a little surprising: ward rounding duration was decreased by 25 minutes and time allocated to direct patient contact went down by 18 minutes.  The percentage of rounding time remained at about 50 percent between the two studies (2015 to 2018).

So, two really interesting studies of time and motion in internal medicine residency programs. This seems to be a time-intensive but really useful method to look at work hours. And more importantly the actual work that is being done by residents during their shifts.   

References

(1)   ​Jena AB, Newhouse RL, Farid M, Blumenthal D, Bhattacharya J. Association of residency work hour reform with long term quality and costs of care of US physicians: observational study.  BMJ 2019; 366: 14134 (Published online 10 July 2019)

(2)   Gachoud D, Monti M, Marques-Vidal P, Kraege V, Aebischer O, Garnier A. Impact of Increased Preparation Time for Residents Before Ward Rounds: The MED2DAY study. AMEE 2019  Short Communications #4R4. August 26, 2019 Vienna Austria.