Burnout in Graduate Medical Education: Uncovering Resident Burnout Profiles Using Cluster Analysis.

Background: Burnout is common among residents and negatively impacts patient care and professional development. Residents vary in terms of their experience of burnout. Our objective was to employ cluster analysis, a statistical method of separating participants into discrete groups based on response patterns, to uncover resident burnout profiles using the exhaustion and engagement sub-scales of the Oldenburg Burnout Inventory (OLBI) in a cross-sectional, multispecialty survey of United States medical residents. Methods: The 2017 ACGME resident survey provided residents with an optional, anonymous addendum containing 3 engagement and 3 exhaustion items from the OBLI, a 2-item depression screen (PHQ-2), general queries about health and satisfaction, and whether respondents would still choose medicine as a career. Gaussian finite mixture models were fit to exhaustion and disengagement scores, with the resultant clusters compared across PHQ-2 depression screen results. Other variables were used to demonstrate evidence for the validity and utility of this approach. Results: From 14 088 responses, 4 clusters were identified as statistically and theoretically distinct: Highly Engaged (25.8% of respondents), Engaged (55.2%), Disengaged (9.4%), and Highly Exhausted (9.5%). Only 2% of Highly Engaged respondents screened positive for depression, compared with 8% of Engaged respondents, 29% of Disengaged respondents, and 53% of Highly Exhausted respondents. Similar patterns emerged for the general query about health, satisfaction, and whether respondents would choose medicine as a career again. Conclusion: Clustering based on exhaustion and disengagement scores differentiated residents into 4 meaningful groups. Interventions that mitigate resident burnout should account for differences among clusters.

Detection of infrared fluorescence of carbon dioxide in R Leonis with SOFIA/EXES.

We report on the detection of hot CO2 in the O-rich AGB star R Leo based on high spectral resolution observations in the range 12.8 - 14.3 µm carried out with the Echelon-cross-Echelle Spectrograph (EXES) mounted on the Stratospheric Observatory for Infrared Astronomy (SOFIA). We have found ≃ 240 CO2 emission lines in several vibrational bands. These detections were possible thanks to a favorable Doppler shift that allowed us to avoid contamination by telluric CO2 features. The highest excitation lines involve levels at an energy of ≃ 7000 K. The detected lines are narrow (average deconvolved width ≃ 2.5 km s-1) and weak (usually ≲ 10% the continuum). A ro-vibrational diagram shows that there are three different populations, warm, hot, and very hot, with rotational temperatures of ≃ 550, 1150, and 1600 K, respectively. From this diagram, we derive a lower limit for the column density of ≃ 2.2 × 1016 cm-2. Further calculations based on a model of the R Leo envelope suggest that the total column density can be as large as 7 × 1017 cm -2 and the abundance with respect to H2 - 2.5 × 10-5. The detected lines are probably formed due to de-excitation of CO2 molecules from high energy vibrational states, which are essentially populated by the strong R Leo continuum at 2.7 and 4.2 µm.

Residents' Ratings of Their Clinical Supervision and Their Self-Reported Medical Errors: Analysis of Data From 2009.

BACKGROUND: Medical errors and patient safety are major concerns for the medical and medical education communities. Improving clinical supervision for residents is important in avoiding errors, yet little is known about how residents perceive the adequacy of their supervision and how this relates to medical errors and other education outcomes, such as learning and satisfaction. METHODS: We analyzed data from a 2009 survey of residents in 4 large specialties regarding the adequacy and quality of supervision they receive as well as associations with self-reported data on medical errors and residents' perceptions of their learning environment. RESULTS: Residents' reports of working without adequate supervision were lower than data from a 1999 survey for all 4 specialties, and residents were least likely to rate "lack of supervision" as a problem. While few residents reported that they received inadequate supervision, problems with supervision were negatively correlated with sufficient time for clinical activities, overall ratings of the residency experience, and attending physicians as a source of learning. Problems with supervision were positively correlated with resident reports that they had made a significant medical error, had been belittled or humiliated, or had observed others falsifying medical records. CONCLUSIONS: Although working without supervision was not a pervasive problem in 2009, when it happened, it appeared to have negative consequences. The association between inadequate supervision and medical errors is of particular concern.

Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment.

PURPOSE: To systematically study the number of U.S. resident deaths from all causes, including suicide. METHOD: The more than 9,900 programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) annually report the status of residents. The authors aggregated ACGME data on 381,614 residents in training during years 2000 through 2014. Names of residents reported as deceased were submitted to the National Death Index to learn causes of death. Person-year calculations were used to establish resident death rates and compare them with those in the general population. RESULTS: Between 2000 and 2014, 324 individuals (220 men, 104 women) died while in residency. The leading cause of death was neoplastic disease, followed by suicide, accidents, and other diseases. For male residents the leading cause was suicide, and for female residents, malignancies. Resident death rates were lower than in the age- and gender-matched general population. Temporal patterns showed higher rates of death early in residency. Deaths by suicide were higher early in training, and during the first and third quarters of the academic year. There was no upward or downward trend in resident deaths over the 15 years of this study. CONCLUSIONS: Neoplastic disease and suicide were the leading causes of death in residents. Data for death by suicide suggest added risk early in residency and during certain months of the academic year. Providing trainees with a supportive environment and with medical and mental health services is integral to reducing preventable deaths and fostering a healthy physician workforce.

How Residents Say They Learn: A National, Multi-Specialty Survey of First- and Second-Year Residents.

Relatively little is known about how, from whom, and under what conditions residents say they most effectively learn. We examined the relationships between residents' self-reported ratings of 11 different sources of learning and a number of empirical variables, using a national, random sample of postgraduate year (PGY) 1 and PGY-2 residents in the 1998-1999 training year. Residents were surveyed by mail. Completed surveys were received from 64.2% of 5616 residents contacted. The most often reported sources of learning were other residents and attending physicians. Ratings varied by specialty, level of training, and US medical graduates (USMGs) versus international medical graduates (IMGs). Factor analysis identified 3 primary modes of learning: faculty-organized, peer-oriented, and self-directed. Residents in different specialties varied in their use of these 3 sources of learning. IMG residents reported significantly less learning from peers and more self-directed learning. Increased resident duty hours were associated with a decrease in faculty-organized and self-directed learning, and an increase in peer-oriented learning.

Simultaneous determination of phenolic compounds in Cynthiana grape (Vitis aestivalis) by high performance liquid chromatography-electrospray ionisation-mass spectrometry.

Phenolic acids, flavanols, flavonols and stilbenes (PAFFS) were isolated from whole grapes, juice, or pomace and purified using enzymatic hydrolysis. Only anthocyanin mono-glucosides and a few of the oligomers from Cynthiana grape (Vitis aestivalis) were analysed. Flavonoid-anthocyanin mono-glucosides (FA) were isolated using methanol/0.1% hydrochloric acid extraction. In addition, crude extractions of phenolic compounds from Cynthiana grape using 50% methanol, 70% methanol, 50% acetone, 0.01% pectinase, or petroleum ether were also evaluated. Reverse phase high performance liquid chromatography (RP-HPLC) with photodiode array (PDA) detector was used to identify phenolic compounds. A method was developed for simultaneous separation, identification and quantification of both PAFFS and FA. Quantification was performed by the internal standard method using a five points regression graph of the UV-visible absorption data collected at the wavelength of maximum absorbance for each analyte. From whole grape samples nine phenolic compounds were tentatively identified and quantified. The individual phenolic compounds content varied from 3 to 875 mg kg⁻¹ dry weight. For juice, twelve phenolic compounds were identified and quantified. The content varied from 0.07 to 910 mg kg⁻¹ dry weight. For pomace, a total of fifteen phenolic compounds were tentatively identified and quantified. The content varied from 2 mg kg⁻¹ to 198 mg kg⁻¹ dry matter. Results from HPLC analysis of the samples showed that gallic acid and (+)-catechin hydrate were the major phenolic compounds in both whole grapes and pomace. Cyanidin and petunidin 3-O-glucoside were the major anthocyanin glucosides in the juice.

Evaluation of a modified pH-shift process to reduce 2-methylisoborneol and geosmin in spiked catfish and produce a consumer acceptable fried catfish nugget-like product.

UNLABELLED: Muddy and/or musty off-flavors in farmed-raised catfish occur as a result of the absorption of geosmin (GEO) and 2-methylisoborneol (MIB), compounds produced by algae. Previous research suggests the acid pH-shift method may be able to reduce off-flavors to produce a consumer acceptable product. The objective of this research was to evaluate application of the acid pH-shift method using a shaker sieve for protein recovery and to evaluate consumer acceptability of a resultant batter-coated fried nugget-like catfish product. Farm-raised catfish were either allowed to depurate (control) or treated with 1 ppb GEO or MIB. Fillets from each replicate were collected and ground and treated by the acid pH-shift process. Samples from all treatments and replicates were evaluated for residual GEO and MIB. In addition, batter-coated fried catfish samples were prepared for a consumer sensory evaluation. Results demonstrated that the pH-shift process decreased moisture, ash, and collagen content of catfish fillet tissue (P < 0.05). Flavor of control samples was preferred (P < 0.05). Texture of catfish samples treated by the pH-shift process was preferred (P < 0.05). Results demonstrate the pH-shift process can be utilized to reduce off-flavors and increase the acceptability of a processed catfish product. PRACTICAL APPLICATION: Use of a sieve as an economic alternative for the pH-shift process was evaluated for removing off-flavors from catfish. Difficulties were encountered with regard to protein recovery using the sieve and suggestions are made to, perhaps, make the process more applicable for a sieve-based recovery step. The process as described reduced off-flavors, but only 2-fold suggesting the process would work best on catfish near or just over off-flavor thresholds. Results also indicated the pH-shift process could be used to improve texture of a fried catfish product designed to be similar to chicken nuggets.

What do residents do when not working or sleeping? A multispecialty survey of 36 residency programs.

PURPOSE: To determine how residents spend their time when not working or sleeping, and to examine correlates of these outside activities. METHOD: In 2009, the authors surveyed 36 internal medicine, surgery, pediatrics, and obstetrics-gynecology programs. Residents answered questions about their recently completed first and second residency years, including, "During your past year of residency, outside of working hours, about how often did you…," followed by 10 listed activities and a four-point rating scale (1 = "less than once a week"; 4 = "almost daily"). RESULTS: The most frequent activity reported across all 634 respondents was using the Internet, followed by watching television and doing household tasks. The lowest reported activity was moonlighting, followed by seeing a movie. K-cluster analyses divided residents into three clusters: (1) "Friend Focused," reporting higher means for time with friends, Internet use, physical exercise, and watching television, (2) "Family Focused," reporting higher means for time with family, Internet use, household tasks, and watching television, and (3) "Low Activity," reporting the lowest ratings for all activities. Comparisons among these three clusters showed the Low Activity residents to have significantly higher scores on validated depression, anxiety, and sleepiness scales; higher stress; more reported work hours and sleep deprivation; and lower ratings for satisfaction, time with attendings, and learning. Scores for Friend-Focused and Family-Focused clusters were similar to each other. CONCLUSIONS: These data provide new information about the residency experience and suggest that activities outside of work and sleep hours correlate highly with residents' mood, learning, and satisfaction.

Retail display evaluation of steaks from select beef strip loins injected with a brine containing 1% ammonium hydroxide. Part 1: Fluid loss, oxidation, color, and microbial plate counts.

Select beef loin pairs (n = 10) were injected (10% pump) with brine containing either 4.5% sodium-based phosphates, (CON), or 1% ammonium hydroxide treatment (AHT). Both brines also contained 3.6% NaCl and 1% Rosemary Herbalox. Steaks cut from loins were high oxygen (80% O(2)/20% CO(2)) modified atmosphere packaged, stored 4 d at 4 °C in the dark to simulate transportation, and then placed in retail display for 14 d (4 °C). On day 0, 7, and 14 of retail display steak properties were measured. Purge from AHT steaks was higher than CON (P < 0.05). Panelists were not able to visually discriminate between AHT and CON steaks through the first 6 d of retail display. After day 6, panelists rated AHT steaks higher for muscle color, percent discoloration, and overall color. Steaks from both treatments started at day 0 retail display with similar total plate counts (P > 0.05). Microbial counts increased more rapidly for AHT steaks than CON steaks (P < 0.05). AHT and CON steaks were not different in terms of lipid oxidation through day 7 retail display. By day 14 retail display CON steaks were above the threshold for consumer perception of oxidized flavors in fresh meat. However, results also indicated the AHT and CON steaks were no longer acceptable by day 14 in terms of color, were questionable in terms of microbial load, and likely were beyond their reasonable shelf life. Based on retail display properties, results indicated 1% AHT could successfully replace 4.5% SP in a meat injection brine. Practical Application: The research in this report compares steaks that have been injected with a commercial brine formulated with SP to steaks that have been injected with a brine, where the SP in the formulation are replaced with 1% AHT. Ammonium hydroxide is an USDA-FSIS approved ingredient in brines injected into fresh meats. Successful replacement of sodium phosphate with ammonium hydroxide would allow processors to significantly reduce the sodium content of injected fresh meat.

Retail display evaluation of steaks from select beef strip loins injected with a brine containing 1% ammonium hydroxide. Part 2: Cook yield, tenderness, and sensory attributes.

The impact of 2 different brines on the palatability and tenderness of select beef strip loin steaks was evaluated. Brines were differentiated by the type of alkaline agent, 4.5% sodium-based phosphate (control brine; CON) or 1% ammonium hydroxide (ammonium hydroxide treatment; AHT), incorporated into the formula. Injected steaks were placed in high oxygen (80% O(2)/20% CO(2)) MAP, stored 4 d at 4 °C in dark storage to simulate transportation, and then placed in retail display. Steaks were selected randomly on day 0, 7, and 14 retail display to measure pH, cook loss, shear force, and sensory characteristics. The pH for AHT steaks (pH 5.96) was slightly higher than CON steaks (pH 5.86; P < 0.05). Cook loss was lower (21%) for CON than AHT steaks (23%). There was neither a treatment nor day effect on tenderness as measured by Warner-Braztler shear force (P > 0.05). Sensory evaluation indicated that on day 0, retail display the initial juiciness, sustained juiciness, tenderness 1st impression, tenderness overall impression, and connective tissue in AHT steaks was not different from CON steaks (P > 0.05). A day effect (decrease) for those sensory parameters was observed only for sustained juiciness (P < 0.05). AHT steaks were rated higher in cooked beef flavor while CON steaks were higher in peppery and salty flavor. There was no difference in soapy and ammonia intensity between treatments. Results indicated that despite lower performance in cook loss the replacement of 4.5% sodium-based phosphate in a meat injection brine with 1% ammonium hydroxide produced a beef loin steak with comparable tenderness and palatability. Practical Application: The research in this study compares steaks that have been injected with a commercial brine formulated with sodium phosphates to steaks that have been injected with a brine where the sodium phosphate in the formulation was replaced with 1% ammonium hydroxide. Ammonium hydroxide is an USDA-FSIS approved ingredient in brines injected into fresh meats. Successful replacement of sodium phosphate with ammonium hydroxide would allow processors to significantly reduce the sodium content of injected fresh meat.

Antimicrobial effect of ammonium hydroxide when used as an alkaline agent in the formulation of injection brine solutions.

Paired U.S. Department of Agriculture Select strip loins were injected with either a conventional brine (4.5% potassium and sodium polyphosphate blend [Brifisol 750], 3.6% NaCl, 1% Herbalox seasoning HT-S, and 90.9% ice water) or an ammonium hydroxide (AH) brine (1% AH, 3.6% NaCl, 1% Herbalox seasoning HT-S, and 94.4% ice water). The steaks were sliced, high-oxygen modified atmosphere packaged, placed at 5°C in dark storage for 5 days, and then transferred to a retail display at 5°C for another 14 days. Steaks injected with AH brine appeared to have lower counts of psychrotrophic, mesophilic, and gram-negative bacteria. Immediately after injection, there was ∼1 log CFU/g difference between treatments in gram-negative bacterial counts. No differences in coliform and lactic acid bacterial counts were found.

The ascent of Mt. Everest.

Earlier this Spring, I reread the account of the 1924 attempt of Mallory and Irvine to summit the highest mountain in the world, Mt. Everest. Apart from the recurring mystery of whether the English climbers actually achieved their goal before disappearing on the upper reaches of the mountain, what emerged for me were the many failed attempts (including two earlier ones of their own) before the summit was finally conquered by Sir Edmund Hillary and Tenzing Norgay in 1953. This put me in mind of the current efforts to once more try to implement the concept of interprofessional education and teamwork in the solution to our many problems in delivering quality health care to all our citizens. The recurring calls in every recent report on health care by the Institute of Medicine and other national groups for greater implementation of collaborative practice models and interprofessional education (IPE) have reawakened the hope that this time, at last, we might succeed. But looming over the horizon, like the storm clouds constantly shrouding the summit of Everest, are the oft-dashed hopes that resurfaced throughout the last century; such that the course of IPE and IPP (interprofessional practice) often has been described as one of successive cycles of "boom and bust."

How residents view their clinical supervision: a reanalysis of classic national survey data.

BACKGROUND: Concerns over patient safety have made adequacy of clinical supervision an important component of care in teaching settings. Yet, few studies have examined residents' perceptions about the quality and adequacy of their supervision. We reanalyzed data from a survey conducted in 1999 to explore residents' perspectives on their supervision. METHODS: A national, multispecialty survey was distributed in 1999 to a 14.5% random sample of postgraduate year 2 (PGY-2) and PGY-3 residents. The response rate was 64.4%. Residents (n  =  3604) were queried about how often they had cared for patients "without adequate supervision" during their preceding year of training. RESULTS: Of responding residents, 21% (n  =  737) reported having seen patients without adequate supervision at least once a week, with 4.5% saying this occurred almost daily. Differences were found across specialties, with 45% of residents in ophthalmology, 46% in neurology, and 44% in neurosurgery stating that they had experienced inadequate supervision at least once a week throughout the year, compared with 1.5% of residents in pathology and 3% in dermatology. Inadequate supervision was found to be inversely correlated with residents' positive ratings of their learning, time with attendings, and overall residency experience (P < .001 for all), and positively correlated with negative features of training, including medical errors, sleep deprivation, stress, conflict with other medical personnel, falsifying patient records, and working while impaired (P < .001). CONCLUSIONS: In residents' self-report, inadequate clinical supervision correlates with other reported negative aspects of training. Collectively, this may detrimentally affect resident learning and patient safety.

Evaluation of 0.1% ammonium hydroxide to replace sodium tripolyphosphate in fresh meat injection brines.

Paired USDA Select beef strip loins (n = 10), aged 2 d, were injected with either an alkaline-based (3.6% sodium chloride, 1% Herbalox seasoning, adjusted to pH 10 with ammonium hydroxide [approximately 0.1%, FFC grade]) or a phosphate-based (3.6% sodium chloride, 1% Herbalox seasoning, 4.5% sodium tripolyphosphate) brine. Steaks were evaluated for 19 d. Overall, phosphate-injected steaks performed better than alkaline-injected steaks with respect to cook yield, water holding capacity, lipid oxidation, color stability, tenderness, and juiciness. Phosphate-injected steaks also had less purge than alkaline-injected steaks, as confirmed by composition analysis. Phosphate-injected steaks were higher in moisture and ash content, and were nearly 2% lower in protein content. Alkaline-injected steaks had significantly lower aerobic (approximately 1 log lower) and anaerobic (approximately 2 log lower) plate counts. Final meat pH probably contributed to the differences observed between treatments. The final pH of phosphate-injected steak was 5.99 while that of alkaline-injected steak was 5.73. Further research should be conducted to determine the concentration of ammonium hydroxide needed in the alkaline-based brine to increase the final meat pH to similar levels found in the phosphate-injected steaks.

Interprofessional conflict and medical errors: results of a national multi-specialty survey of hospital residents in the US.

Clear communication is considered the sine qua non of effective teamwork. Breakdowns in communication resulting from interprofessional conflict are believed to potentiate errors in the care of patients, although there is little supportive empirical evidence. In 1999, we surveyed a national, multi-specialty sample of 6,106 residents (64.2% response rate). Three questions inquired about "serious conflict" with another staff member. Residents were also asked whether they had made a "significant medical error" (SME) during their current year of training, and whether this resulted in an "adverse patient outcome" (APO). Just over 20% (n = 722) reported "serious conflict" with another staff member. Ten percent involved another resident, 8.3% supervisory faculty, and 8.9% nursing staff. Of the 2,813 residents reporting no conflict with other professional colleagues, 669, or 23.8%, recorded having made an SME, with 3.4% APOs. By contrast, the 523 residents who reported conflict with at least one other professional had 36.4% SMEs and 8.3% APOs. For the 187 reporting conflict with two or more other professionals, the SME rate was 51%, with 16% APOs. The empirical association between interprofessional conflict and medical errors is both alarming and intriguing, although the exact nature of this relationship cannot currently be determined from these data. Several theoretical constructs are advanced to assist our thinking about this complex issue.