The Retrospective Stressor Analysis (RSA): a novel qualitative tool for identifying causes of burnout and mitigation strategies during residency.

BACKGROUND: Resident physicians are at an increased risk of burnout due to their high-pressure work environments and busy schedules which can lead to poor mental health outcomes and decreased performance quality. Given variability among training programs and institutions across the United States, stressors likely differ, and interventions must be tailored to the local context, but few tools exist to assist in this process. METHODS: A tool commonly used in adverse event analysis was adapted into a "retrospective stressor analysis" (RSA) for burnout prevention. The RSA was tested in a group of chief residents studying quality improvement and patient safety in veteran's hospitals across the United States. The RSA prompted them to identify stressors experienced during their residencies across four domains (clinical practice, career development, personal life, and personal health), perceived causes of the stressors, and potential mitigation strategies. RESULTS: Fifty-eight chief residents completed the RSA. Within the clinical domain, they describe the stress of striving for efficiency and clinical skills acquisition, all while struggling to provide quality care in high pressure environments. In the career domain, identifying mentors and opportunities for research engagement was stressful. Within their personal lives, a lack of time-constrained their ability to maintain hobbies, relationships, and attend meaningful social events while also reducing their engagement in healthy behaviors such as exercise, optimal nutrition, and attending medical appointments. Within each of these domains, they identified and described stress mitigation strategies at the individual, departmental, and national levels. CONCLUSION: The RSA is a novel tool that can identify national trends in burnout drivers while simultaneously providing tailored prevention strategies for residents and their training sites.

High-mileage study of on-board diagnostic emissions.

The 1990 Clean Air Act amendments require the U.S. Environmental Protection Agency (EPA) to set guidelines for states to follow in designing and running vehicle inspection and maintenance (I/M) programs. Included in this charge was a requirement to implement an on-board diagnostic (OBD) test for both basic and enhanced I/M programs. This paper provides the results to date of an ongoing EPA study undertaken to assess the durability of the OBD system as vehicles age and as mileage is accrued. The primary results of this effort indicate the points described below. First, the majority of high-mileage vehicles tested had emission levels within their certification limits, and their malfunction indicator light (MIL) was not illuminated, indicating that the systems are capable of working throughout the life of a vehicle. Second, OBD provides better air quality benefits than an IM240 test (using the federal test procedure [FTP] as the benchmark comparison). This statement is based on greater emissions reductions from OBD-directed repairs than reductions associated with IM240-identified repairs. In general, the benefits of repairing the OBD fails were smaller, but the aggregate benefits were greater, indicating that OBD tests find both the high-emitting and a number of marginally high-emitting vehicles without false failures that can occur with any tailpipe test. Third, vehicles that truly had high-tailpipe emissions as confirmed by laboratory IM240 and FTP testing also had illuminated MILs at a statistically significant level. Last, field data from state programs have demonstrated MIL illumination rates comparable with those seen in this work, suggesting that the vehicles sampled in this study were representative of the larger fleet. Nonetheless, it is important to continue the testing of high-mileage OBD vehicles into the foreseeable future to ensure that the systems are operating correctly as the fleet ages and as changes in emission certification levels take effect.