Resident Preferences for Program Director Role in Wellness Management.

BACKGROUND: Burnout and depression are prevalent among resident physicians, though the supportive role of the program director (PD) is not well defined. OBJECTIVE: To understand the residents' view of the residency program director's role in assessing and promoting resident wellness. METHODS: A single institution survey of all house staff was conducted in 2017. Rates of burnout and depression were identified via the 2-item Maslach Burnout Inventory (MBI) and the Patient Health Questionaire-2 (PHQ-2), respectively. Residents then qualified their preferences for various assistance services and for the role of their program directors in assisting them. RESULTS: One-hundred sixty-one of 202 (79.7%) residents completed the survey. The rate of depression was 28%. Rates of emotional exhaustion and depersonalization (2-item MBI) were 44 and 62%, respectively. Only 4% of respondents had used the Employee Assistance Program (EAP) in the prior 12 months. Eighty-two percent of residents were in favor of PDs inquiring about wellness regardless of their job performance and only 1% of residents stated the PD should not inquire about wellness at all. Thirty-three percent of residents reported that they would be likely to contact EAP on their own if they felt unwell. Significantly more residents (62%) reported being more likely to contact EAP if recommended by their PD (33 vs 62%, p < 0.001%). Important perceived barriers to seeking assistance were lack of time (65%), lack of knowledge of how to contact EAP (41%), and concerns about appearing weak (35%). CONCLUSIONS: Despite a high prevalence of burnout and depression, residents are unlikely to seek help on their own. Program directors have an important role in assessing and promoting the wellness of their residents. The majority of residents wants their PD to inquire about wellness and may be more likely to seek and receive help if recommended and facilitated by their PD.

The practice patterns of recently graduated internal medicine-pediatric hospitalists.

OBJECTIVES: To identify the current practice patterns and professional activities of internal medicine-pediatrics (med-peds) hospitalists who have graduated in the past 5 years (June 2009-June 2013). METHODS: The national Medicine-Pediatrics Program Directors Association (MPPDA) conducted a cross-sectional survey study of the 79 residency program directors who are members of the MPPDA regarding the practice patterns of recent graduates (from 2009-2013) currently practicing as hospitalists. The survey was distributed in the spring of 2014 on the MPPDA listserv. The survey inquired about time spent caring for hospitalized adults and children, medical school appointments, practice in freestanding children's hospitals, and completion of hospital medicine (HM) fellowships. RESULTS: Forty-nine program directors (62%) completed the survey and provided data on 1042 graduates from 46 programs. Of those graduates, 26.4% (n=275) practice as hospitalists, and none had completed an HM fellowship. Approximately two-thirds (65%) of med-peds hospitalists provide care to hospitalized children and adults, with one-third providing care solely to hospitalized adults. Approximately one-half (53.5%) have an appointment with a medical school and roughly one-quarter (28%) practice in a freestanding children's hospital. CONCLUSIONS: An increasing percentage of recent med-peds graduates are pursuing careers in HM, and two-thirds are providing care to hospitalized children. As consideration for an accredited pediatric HM fellowship continues, certifying and accrediting bodies should consider how this will impact the med-peds workforce and allow med-peds graduates flexibility in their training requirements that will permit them to acquire the necessary skills to care for hospitalized children and adults.

Pediatric resident education in palliative care: a needs assessment.

OBJECTIVE: The goal was to characterize pediatric residents' perceived educational needs for pediatric palliative care. The data generated from this study will facilitate the planning of specific educational interventions. METHODS: All residents in the Children's Hospital of Pittsburgh pediatrics residency program were asked to complete a survey in September 2003. Participation in the study was voluntary. Residents rated their previous training, personal experience, knowledge, competence, and emotional comfort with 10 specific aspects of pediatric palliative care. This rating was followed by 13 questions related to attitudes about palliative care practices and training. The last section asked the respondents to rank 11 palliative care educational topics in order of importance. RESULTS: Forty-nine of 75 eligible residents participated. Although residents thought that pediatricians should have an important role in providing palliative care, residents reported minimal training, experience, knowledge, competence, and comfort in virtually all areas of palliative care for children. We found no significant improvement in any of these areas from the pediatric level-1 year to the pediatric level-3 year. Residents wanted more training regarding pain management. After pain control, the next 4 educational needs were communication skills, namely, discussing prognosis, bad news, and code status and talking with children about end-of-life care. CONCLUSIONS: There is a clear need for increased efforts in pediatric palliative care education during residency training. Pediatric residents do not think that they are trained adequately in palliative care, and this perception does not improve with time. Pediatric residents view palliative care as important for primary care physicians and desire more education.

Advance care planning.

BACKGROUND: Advance directives (AD) with specific treatment preferences can be difficult to apply in actual clinical situations. As an alternative, advance directives that outline patient goals and values have been advocated. OBJECTIVE: To compare patient reactions to values-based and treatment-based advance directive forms. SETTING: Two academic general medicine outpatient clinics in Pittsburgh, Pa. METHODS: Outpatients age 55 or older who did not have an AD and were not demented were randomly assigned to complete either Emanuel's Medical Directive (EMD) or Pearlman's values history (PVH) form. MEASUREMENTS: Length of time to complete and number of questions asked about the AD forms; proportions of patients discussing the AD with family, designating a surrogate, returning the AD by mail, and desiring to have the AD in the medical record; patient ratings of AD by telephone interview; physician report of patient-initiated AD discussions. RESULTS: Of the 275 patients approached, 143 refused, 69 already had an AD, 63 patients were enrolled, and 25 in each group completed the telephone interview. A majority of individuals in both groups had conversations with others about the AD (60% EMD, 56% PVH; P = .77). All PVH forms designated a surrogate, whereas 79% of EMD forms did so (P = .02). One patient in each group initiated a conversation with his or her physician about AD following study completion. Both forms were thought to be a good first step in planning care at the end of life (92% EMD vs 84% PVH totally or mostly agree; P = .06). Patients completing the EMD thought it would give them control over the way their doctor cared for them at the end of their lives more than did the PVH group (84% EMD vs 48% PVH totally or mostly agree; P = .02). More patients completing the EMD form worried that it would be difficult to change answers on the form if they later changed their minds (20% EMD vs 4% PVH totally or mostly agree; P = .02). CONCLUSIONS: Both the values-based and treatment-based AD forms were rated favorably overall. Patients thought the treatment-based directive would give them more control over their care. Patients completing the values history form were more likely to designate a surrogate. Patients are likely to discuss both types of AD with family, but neither form alone is likely to lead to AD conversations with physicians.

Objectives for advance care planning.

Identifying objectives for advance care planning (ACP) is an important step toward improving care at the end of life. Previous studies of ACP have used many different measures of success. However, there has been no consensus on what should be the objectives for ACP. Lack of attention to specific objectives for ACP may lead to ineffective communication and research. The first step to improving outcomes in ACP is to acknowledge the diversity of objectives that ACP may achieve. Health care providers, patients, and surrogates should identify and agree on common objectives for particular conversations. Various methods, conversations, and forms may be used to achieve these objectives over time. Clarifying objectives from various perspectives is an important step toward achieving the level of understanding necessary to make these difficult decisions. It is time for physicians to reconsider the way in which they think about and discuss ACP with patients. If we are to improve care at the end of life, future patient care, research, and education about ACP should proceed with specific objectives in mind.