Assessment of medical student burnout: toward an implicit measure to address current issues.

The feasibility of implicitly assessing medical student burnout was explored, using the Implicit Relational Assessment Procedure (IRAP), to measure longitudinal student burnout over the first two years of medical school and directly comparing it with an existing explicit measure of burnout (Maslach Burnout Inventory; MBI). Three successive cohorts of medical students completed both implicit and explicit measures of burnout at several time points during their first two years of medical school. Both assessments were conducted via the internet within a one-week period during the first week of medical school, the end of the first year of medical school, and the end of the second year, though not all cohorts were able to complete the assessments at all time points. Mixed linear models were used to compare the two measures directly, as well as to evaluate changes over time in each measure separately. Minimal correspondence was observed between the implicit and explicit measures of burnout on a within-subject basis. However, when analyzed separately, all subscales of both measures detected significant change over time in the direction of greater levels of burnout, particularly during the first year of medical school. These results provide preliminary evidence the IRAP is able to assess implicit attitudes related to burnout among medical students, though additional research is needed. The IRAP detected consistent improvements in positive implicit attitudes toward medical training during students' second year of medical school, which was not detected by the MBI. Possible implications of these findings are discussed.

Physician Suicide in the United States:Updated Estimates from the National Violent Death Reporting System.

Physician suicide and well-being are critical issues but studies use varying methodologies and suicide is frequently underreported. This study sought to update data on physician suicides in the United States. The National Violent Death Reporting System (NVDRS) at the Centers for Disease Control collects details about violent deaths. The study used 2010-2015 data from 27 NVDRS states to identify suicide deaths among physicians or non-physicians and calculate annual standardized mortality rates (SMR). Of 63,780 victims total, there were 357 physicians identified over 6 years, (307 men and 50 women). If results are extrapolated to all 50 states, there would be approximately 119 physician suicides annually. The SMR for physicians overall was not statistically different from that of non-physicians. This is the first study in 16 years to update estimated physician suicide rates in the United States. The research used strict criteria to identify physicians so results likely represent the lower boundary of physician suicides. Findings show that physician suicide is not significantly lower than that of non-physicians and emphasizes the importance of focusing on structural changes to reduce stigma around mental health in the medical community.

Electronic Health Records, Medical Practice Problems, and Physician Distress.

BACKGROUND: This study assessed direct and indirect associations between problems with electronic health records (EHRs) and physician distress via problems encountered during the day-to-day practice of medicine and access to social support. METHODS: One-hundred and ninety physicians in the state of Nevada completed an online survey in spring of 2019 regarding problems with EHRs, their medical practice, social support, and mental health. A parallel mediator model was tested with 10,000 bias-corrected bootstrap samples to assess associations between EHRs and distress directly and indirectly via medical practice problems and social support. RESULTS: Frequency of EHR problems was positively associated with problems with the day-to-day practice of medicine, and negatively associated with access to social support. Medical practice problems were positively associated with physician distress, and social support was negatively associated with it. Mediation analyses suggest that EHR problems indirectly affect physician distress via problems encountered during the practice of medicine and social support. CONCLUSIONS: Physician wellbeing is a critical priority for health care. This study suggests that reducing EHR problems may improve physician well-being directly and indirectly by addressing problems in the practice of medicine that compound mental health effects of EHRs. Suggestions for improving the integration of EHRs into medical practice are discussed.

US direct-to-consumer medical service advertisements fail to provide adequate information on quality and cost of care.

BACKGROUND: In the 1970s, the Federal Trade Commission declared that allowing medical providers to advertise directly to consumers would be "providing the public with truthful information about the price, quality or other aspects of their service." However, our understanding of the advertising content is highly limited. OBJECTIVE: To assess whether direct-to-consumer medical service advertisements provide relevant information on access, quality and cost of care, a content analysis was conducted. METHOD: Television and online advertisements for medical services directly targeting consumers were collected in two major urban centres in Nevada, USA, identifying 313 television advertisements and 200 non-duplicate online advertisements. RESULTS: Both television and online advertisements reliably conveyed information about the services provided and how to make an appointment. At the same time, less than half of the advertisements featured insurance information and hours of operation and less than a quarter of them contained information regarding the quality and price of care. The claims of quality were substantiated in even fewer advertisements. The scarcity of quality and cost information was more severe in television advertisements. CONCLUSION: There is little evidence that medical service advertising, in its current form, would contribute to lower prices or improved quality of care by providing valuable information to consumers.

What a medical school chair wants from the dean.

Economic pressure has led the evolution of the role of the medical school dean from a clinician educator to a health care system executive. In addition, other dynamic requirements also have likely led to changes in their leadership characteristics. The most important relationship a dean has is with the chairs, yet in the context of the dean's changing role, little attention has been paid to this relationship. To frame this discussion, we asked medical school chairs what characteristics of a dean's leadership were most beneficial. We distributed a 26-question survey to 885 clinical and basic science chairs at 41 medical schools. These chairs were confidentially surveyed on their views of six leadership areas: evaluation, barriers to productivity, communication, accountability, crisis management, and organizational values. Of the 491 chairs who responded (response rate =55%), 88% thought that their dean was effective at leading the organization, and 89% enjoyed working with their dean. Chairs indicated that the most important area of expertise of a dean is to define a strategic vision, and the most important value for a dean is integrity between words and deeds. Explaining the reasons behind decisions, providing good feedback, admitting errors, open discussion of complex or awkward topics, and skill in improving relations with the teaching hospital were judged as desirable attributes of a dean. Interestingly, only 23% of chairs want to be a dean in the future. Financial acumen was the least important skill a chair thought a dean should hold, which is in contrast to the skill set for which many deans are hired and evaluated. After reviewing the literature and analyzing these responses, we assert that medical school chairs want their dean to maintain more traditional leadership than that needed by a health care system executive, such as articulating a vision for the future and keeping their promises. Thus, there appears to be a mismatch between what medical school chairs perceive they need from their dean and how the success of a dean is evaluated.

Do US Medical Licensing Applications Treat Mental and Physical Illness Equivalently?

BACKGROUND AND OBJECTIVES: State medical licensing boards are responsible for evaluating physician impairment. Given the stigma generated by mental health issues among physicians and in the medical training culture, we were interested in whether states asked about mental and physical health conditions differently and whether questions focused on current impairment. METHODS: Two authors reviewed physician medical licensing applications for US physicians seeking first-time licensing in 2013 in the 50 states and the District of Columbia. Questions about physical and mental health, as well as substance abuse, were identified and coded as to whether or not they asked about diagnosis and/or treatment or limited the questions to conditions causing physician impairment. RESULTS: Forty-three (84%) states asked questions about mental health conditions, 43 (84%) about physical health conditions, and 47 (92%) about substance use. States were more likely to ask for history of treatment and prior hospitalization for mental health and substance use, compared with physical health disorders. Among states asking about mental health, just 23 (53%) limited all questions to disorders causing functional impairment and just 6 (14%) limited to current problems. CONCLUSIONS: While most state medical licensing boards ask about mental health conditions or treatment, only half limited queries to disorders causing impairment. Differences in how state licensing boards assess mental health raise important ethical and legal questions about assessing physician ability to practice and may discourage treatment for physicians who might otherwise benefit from appropriate care.

"I would never want to have a mental health diagnosis on my record": A survey of female physicians on mental health diagnosis, treatment, and reporting.

INTRODUCTION: Physicians have high rates of suicide and depression. Most state medical boards require disclosure of mental health problems on physician licensing applications, which has been theorized to increase stigma about mental health and prevent help-seeking among physicians. METHODS: We surveyed a convenience sample of female physician-parents on a closed Facebook group. The anonymous 24-question survey asked about mental health history and treatment, perceptions of stigma, opinions about state licensing questions on mental health, and personal experiences with reporting. RESULTS: 2106 women responded, representing all 50 states and the District of Columbia. Most respondents were aged 30-59. Almost 50% of women believed that they had met the criteria for mental illness but had not sought treatment. Key reasons for avoiding care included a belief they could manage independently, limited time, fear of reporting to a medical licensing board, and the belief that diagnosis was embarrassing or shameful. Only 6% of physicians with formal diagnosis or treatment of mental illness had disclosed to their state. CONCLUSIONS: Women physicians report substantial and persistent fear regarding stigma which inhibits both treatment and disclosure. Licensing questions, particularly those asking about a diagnosis or treatment rather than functional impairment may contribute to treatment reluctance.

Educational Value of a Free Medical Clinic Operated by Medical Students.

BACKGROUND AND OBJECTIVES: The Student Outreach Clinic (SOC) at the University of Nevada School of Medicine is one of several student-run free medical clinics associated with US medical schools. We report on the educational value of the SOC to medical students who volunteer at this clinic. METHODS: The records of all patients seen between August 1, 2012, and July 31, 2013, at the SOC were abstracted on a deidentified basis to collect key demographic and clinical components of the visit, including past medical history, components of the physical exam performed, clinical diagnoses recorded, patient disposition, and medications prescribed. RESULTS: A total of 593 clinic visits were reviewed. Students performed a full physical exam on 80% of patients, primarily for educational purposes. The most frequent diagnoses mapped to a considerable extent to the top diagnoses seen in primary care as well as to the medical school curriculum, and the most frequent medications prescribed mapped to a considerable extent to the pharmacology curriculum. CONCLUSIONS: The SOC provides incremental opportunities for medical students to gain valuable clinical experience during their first 2 years of medical school. The diagnoses encountered and medications prescribed parallel and supplement the medical school curriculum, with a particular focus on primary care. The educational value of these experiences should influence curriculum development and decisions.

Predictors of Depression Stigma in Medical Students: Potential Targets for Prevention and Education.

INTRODUCTION: Suicide rates are higher among U.S. physicians than the general population. Untreated depression is a major risk factor, yet depression stigma presents a barrier to treatment. This study aims to identify early career indications of stigma among physicians-in-training and to inform the design of stigma-reduction programs. METHODS: A cross-sectional student survey administered at a large, Midwestern medical school in fall 2009 included measures of depression symptoms, attitudes toward mental health, and potential sources of depression stigma. Principal components factor analysis and linear regression were used to examine stigma factors associated with depression in medical students. RESULTS: The response rate was 65.7%, with 14.7% students reporting a previous depression diagnosis. Most students indicated that, if depressed, they would feel embarrassed if classmates knew. Many believed that revealing depression could negatively affect professional advancement. Factor analyses revealed three underlying stigma constructs: personal weakness, public devaluation, and social/professional discrimination. Students associating personal weakness with depression perceived medication as less efficacious and the academic environment as more competitive. Those endorsing public stigma viewed medication and counseling as less efficacious and associated depression with an inability to cope. Race, gender, and diagnosis of past/current depression also related to beliefs about stigma. Depression measures most strongly predicted stigma associated with personal weakness and social/professional discrimination. CONCLUSIONS: Recommendations for decreasing stigma among physicians-in-training include consideration of workplace perceptions, depression etiology, treatment efficacy, and personal attributes in the design of stigma reduction programs that could facilitate help-seeking behavior among physicians throughout their career.