Impact of COVID-19 on American Family Physicians' Intent to Retreat from Clinical Care.

PURPOSE: This survey evaluated whether the COVID-19 pandemic was a traumatic stress event for family physicians associated with burnout, changes in life priorities, and intentions to retreat from clinical practice. METHODS: We report on 683 clinically active family physicians surveyed through the Council of Academic Family Medicine's Educational Research Alliance (CERA) in the fall of 2021. RESULTS: Overall, 35.2% of family physicians experienced the pandemic as a traumatic stress like event. This was associated with changing life priorities (OR 2.6, CI 1.8-3.9), burnout (OR 1.6, CI 1.1 to 2.4), and withdrawal from clinical practice in various ways. Those who changed their priorities in life were more likely to restrict scope of practice (OR 3.9, CI 2.6-5.9), reduce clinical work effort (OR 3.4, 2.3 to 5.1), relocate (OR 3.1, CI 2.0 to 4.8), retire (OR 2.7, CI 1.4-4.9), reroute their career away from patient care (OR 2.1, CI 1.4-3.1) and less likely to avoid redesigning the practice to improve well-being (OR 0.3, CI 0.2-0.7). Those who experienced burnout were more likely to retire (OR 5.5, CI 2.8 to 10.5), reduce clinical work effort (OR 4.2, CI 2.9-6.1), reroute their career away from patient care (OR 3.9, CI 2.6-5.8), relocate (OR 3.8, CI 2.4 to 5.9), and restrict scope of practice (OR 3.3, CI 2.3 to 4.9). Overall, 48.5% of family physicians expressed some intention to retreat from clinical practice. CONCLUSION: The COVID-19 pandemic impacted family physician's career plans. Remedying burnout is a high-yield opportunity for retaining clinically active family physicians. Physicians retreating from clinical medicine related to changing life's priorities needs further exploration.

Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians.

Importance: Physician turnover interrupts care delivery and creates health care system financial burden. Objective: To describe the prevalence of burnout, professional fulfillment, and intention to leave (ITL) among physicians at academic-affiliated health care systems and identify institutional and individual factors associated with ITL. Design, Setting, and Participants: This cross-sectional study administered a survey to 37 511 attending-level medical specialists at 15 academic medical institutions participating in the Healthcare Professional Well-Being Academic Consortium. Data were collected from October 2019 to July 2021. Statistical analysis was performed from May 2022 to March 2023. Exposures: Hypothesized institutional and individual determinants of occupational well-being. Main Outcomes and Measures: The main outcome was ITL, defined as having at least a moderate intention (a score of 2 on a 0-4 scale) to leave one's institution within the next 2 years. Additional outcomes included burnout and professional fulfillment, defined using published Professional Fulfillment Index cut points. Results: Of 18 719 academic physician survey respondents (8381 [44.8%] male; 2388 [12.8%] Asian, 10 599 [56.6%] White, 1039 [5.6%] other race, 4693 [25.1%] unknown race; 294 [1.6%] Hispanic or Latina/Latino/Latinx), 6903 of 18 217 (37.9%) met criteria for burnout and 7301 of 18 571 (39.3%) for professional fulfillment; 5177 of 15 890 (32.6%) reported moderate or greater ITL. Burnout, professional fulfillment, and ITL varied across specialties. After adjusting for demographics, each 1-point increase (range 0-10) in burnout was directly associated with ITL (odds ratio [OR], 1.52 [95% CI, 1.49-1.55])c, and each 1-point increase in professional fulfillment was inversely associated with ITL (OR, 0.64 [95% CI, 0.63-0.65]). After adjusting for demographics, burnout, and professional fulfillment, each 1-point increase (range 0-10) in supportive leadership behaviors (OR, 0.83 [95% CI, 0.82-0.84]), peer support (OR, 0.93 [95% CI, 0.91-0.95]), personal-organizational values alignment (OR, 0.81 [95% CI, 0.80-0.82]), perceived gratitude (OR, 0.95 [95% CI, 0.92-0.97]), COVID-19 organizational support (OR, 0.88 [95% CI, 0.85-0.91]), and electronic health record helpfulness (OR, 0.95 [95% CI, 0.93-0.97]) were inversely associated with ITL, whereas each 1-point increase (range 0-10) in depression (OR, 1.08 [95% CI, 1.05-1.10]) and negative impact of work on personal relationships (OR, 1.09 [1.07-1.11]) were directly associated with ITL. Conclusions and Relevance: In this cross-sectional study of academic physicians, 32.6% indicated moderate or higher ITL within 2 years. Burnout, lack of professional fulfillment, and other well-being factors were associated with ITL, suggesting the need for a comprehensive approach to reduce physician turnover.

Designing and Building a Portfolio of Individual Support Resources for Physicians.

As health care organizations in the United States move toward recovery from the COVID-19 pandemic, physicians and clinical faculty are experiencing occupational burnout and various manifestations of distress. To mitigate these challenges, health care organizations must optimize the work environment and provide support for individual clinicians using a variety of approaches, including mentoring, group-based peer support, individual peer support, coaching, and psychotherapy. While often conflated, each of these approaches offers distinct benefits. Mentoring is a longitudinal 1-on-1 relationship, typically focused on career development, usually with an experienced professional guiding a junior professional. Group-based peer support involves regular, longitudinal meetings of health professionals to discuss meaningful topics, provide mutual support to one another, and foster community. Individual peer support involves training peers to provide timely 1-on-1 support for a distressed colleague dealing with adverse clinical events or other professional challenges. Coaching involves a certified professional helping an individual identify their values and priorities and consider changes that would allow them to adhere to these more fully, and providing longitudinal support that fosters accountability for action. Individual psychotherapy is a longitudinal, short- or long-term professional relationship during which specific therapeutic interventions are delivered by a licensed mental health professional. When distress is severe, this is the best approach. Although some overlap exists, these approaches are distinct and complementary. Individuals may use different methods at different career stages and for different challenges. Organizations seeking to address a specific need should consider which approach is most suitable. Over time, a portfolio of offerings is typically needed to holistically address the diverse needs of clinicians. A stepped care model using a population health approach may be a cost-effective way to promote mental health and prevent occupational distress and general psychiatric symptoms.

The Impact of Stigma and Personal Experiences on the Help-Seeking Behaviors of Medical Students With Burnout.

PURPOSE: Because of the high prevalence of burnout among medical students and its association with professional and personal consequences, the authors evaluated the help-seeking behaviors of medical students with burnout and compared their stigma perceptions with those of the general U.S. population and age-matched individuals. METHOD: The authors surveyed students at six medical schools in 2012. They measured burnout, symptoms of depression, and quality of life using validated instruments and explored help-seeking behaviors, perceived stigma, personal experiences, and attitudes toward seeking mental health treatment. RESULTS: Of 2,449 invited students, 873 (35.6%) responded. A third of respondents with burnout (154/454; 33.9%) sought help for an emotional/mental health problem in the last 12 months. Respondents with burnout were more likely than those without burnout to agree or strongly agree with 8 of 10 perceived stigma items. Respondents with burnout who sought help in the last 12 months were twice as likely to report having observed supervisors negatively judge students who sought care (odds ratio [OR] 2.06 [95% confidence interval (CI) 1.25-3.39], P < .01). They also were more likely to have observed peers reveal a student's emotional/mental health problem to others (OR 1.63 [95% CI 1.08-2.47], P = .02). A smaller percentage of respondents would definitely seek professional help for a serious emotional problem (235/872; 26.9%) than of the general population (44.3%) and age-matched individuals (38.8%). CONCLUSIONS: Only a third of medical students with burnout seek help. Perceived stigma, negative personal experiences, and the hidden curriculum may contribute.

Distress among matriculating medical students relative to the general population.

PURPOSE: Many medical students experience distress during medical school. If matriculating medical students (MMSs) begin training with similar or better mental health than age-similar controls, this would support existing concerns about the negative impact of training on student well-being. The authors compared mental health indicators of MMSs versus those of a probability-based sample of the general U.S. population. METHOD: In 2012 all MMSs at six U.S. medical schools were invited to participate in a survey during orientation. The research team surveyed a probability-based sample of U.S. individuals using the same questions in 2011. Individuals from the population sample who completed a four-year college degree and matched within the appropriate age strata (< 30, 31-35, 36-40, > 40) were compared with MMSs. Surveys included demographics and validated instruments to measure burnout; depression symptoms; and mental, emotional, physical, and overall of quality of life (QOL). RESULTS: Demographic characteristics of the 582/938 (62%) responding MMSs were similar to U.S. MMSs. Relative to 546 age-similar college graduates, MMSs had lower rates of burnout (27.3% versus 37.3%, P < .001) and depression symptoms (26.2% versus 42.4%, P < .0001) and higher scores across the four QOL domains assessed relative to controls (all P < .0001). These findings persisted on multivariate analysis after adjusting for age, sex, relationship status, and race/ethnicity. CONCLUSIONS: These findings, along with high rates of distress reported in medical students and residents, support concerns that the training process and environment contribute to the deterioration of mental health in developing physicians.

Relationship between medical student service and empathy.

BACKGROUND: Student participation in service activities during medical school is believed to enhance student professionalism and empathy. Yet, there are no studies that measure medical student empathy levels in relation to service activities. METHOD: Medical students from four classes (2007-2010) were surveyed at graduation using the Jefferson Scale of Physician Empathy-Student Version and questions about service activity during medical school. For two classes, empathy scores were also obtained at orientation. The data were analyzed using Statistical Package for the Social Sciences. Means comparison tests were performed. RESULTS: Mean empathy scores at graduation were higher for students who participated in service activities compared with those who reported no service (115.18 versus 107.97, P < .001). At orientation, students with no service had lower empathy scores, and those with any service had higher empathy scores. CONCLUSIONS: Student empathy and service activities during medical school are related. This may have implications for admissions committees.

Relationships between medical student burnout, empathy, and professionalism climate.

BACKGROUND: Medical student burnout is prevalent, and there has been much discussion about burnout and professionalism in medical education and the clinical learning environment. Yet, few studies have attempted to explore relationships between those issues using validated instruments. METHOD: Medical students were surveyed at the beginning of their fourth year using the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy-Student Version, and the Professionalism Climate Instrument. The data were analyzed using Statistical Package for the Social Sciences, and Spearman correlation analysis was performed. RESULTS: Scores indicative of higher medical student burnout were associated with lower medical student empathy scores and with lower professionalism climate scores observed in medical students, residents, and faculty. CONCLUSIONS: Investigators observed relationships between medical student burnout, empathy, and professionalism climate. These findings may have implications for the design of curriculum interventions to promote student well-being and professionalism.

Do state medical board applications violate the americans with disabilities act?

PURPOSE: To determine whether medical licensing board application questions about the mental or physical health or substance use history of the applicant violate the Americans with Disabilities Act (ADA) of 1990. METHOD: Content analysis of 51 allopathic licensing applications (50 states and District of Columbia) was performed at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School in 2005. Questions referencing physical or mental health or substance use were identified by a team of physicians and reviewed and categorized based on the ADA and appropriate case law by legal counsel. RESULTS: Of the 51 applications reviewed, 49 (96%) contained questions pertaining to the physical or mental health or substance use history of the applicant. Thirty-four of the 49 (69%) state medical licensing applications contained at least one "likely impermissible" or "impermissible" item based on the ADA and appropriate case law. CONCLUSIONS: Most state medical licensing applications contain questions that ask about the physical or mental health and substance use of physician applicants. Many licensing applications appear to be in violation of the ADA, even 19 years after enactment of the regulation. These questions do not elicit responses by which professional competence can be judged. The presence of these questions on licensing applications may cause physicians to avoid or delay treatment of personal illness.

Collaboration Between Mental Health Professionals and Family Physicians: A Survey of New Jersey Family Physicians.

Background: Mental health problems are frequent in primary care, and there are many barriers to their detection and treatment. Clinical research protocols that include close collaboration between mental health professionals and primary care physicians have been found to be beneficial. This study explores the opinions of community family physicians regarding mental health professionals working directly in the primary care office.Method: Members of the New Jersey Academy of Family Physicians (N = 709) were sent a 25-item questionnaire about collaboration with mental health professionals. Three mailings were sent, with a 62% response rate. The surveys were mailed between May and July 1999.Results: Of family physicians included in the analysis, 13.5% reported having an in-office mental health professional. Of those who did not, 60.2% responded that they would consider having one. Compared with physicians who would not consider having an in-office mental health professional, physicians with a mental health professional and those without an in-office mental health professional but who would consider one were statistically more likely (p < .01) to respond that an in-office mental health professional would result in increased use of mental health services, improved acceptance of referrals to mental health professionals, and improved detection and treatment of mental health problems.Conclusion: Although few family physicians have an in-office mental health professional, many more would consider this arrangement and recognize the potential benefits of such collaboration.

Evaluating the effect of cultural competency training on medical student attitudes.

BACKGROUND AND OBJECTIVES: Developing skills for taking care of patients from a wide variety of backgrounds is a growing area of importance in medical education. Incorporating cultural competency training into undergraduate medical education is an accreditation requirement. Although there are an increasing number of such curricula reported in the literature, there has been little evaluation of their effectiveness. We describe a new undergraduate cultural competency curriculum, the reliability of an instrument for assessing student attitudes in this area, and the effects of our curriculum on student attitudes. METHODS: Two introductory clinical medicine courses focused on the importance of providing culturally competent care to all patients. The courses used problem-based learning and a history-taking mnemonic to teach students to assess patients' perspectives. The authors verified the reliability of the Health Beliefs Attitudes Survey (HBAS) and used it to determine changes in students' attitudes on issues relating to cultural competency. RESULTS: The HBAS reliably measured four cultural competency concepts. Student attitudes regarding the importance of assessing patient opinions and determining health beliefs improved significantly following the courses. CONCLUSIONS: The method used here to teach students cultural competency skills early in medical school positively affects student attitudes on cultural competency issues.

Changing an existing OSCE to a teaching tool: the making of a teaching OSCE.

OBJECTIVE: The teaching OSCE (objective structured clinical examination) was developed from existing OSCE materials to provide direct observation and feedback to students on their doctor-patient relationship skills, students' abilities to do a focused history and physical examination, and to familiarize students with this type of examination. DESCRIPTION: Existing OSCE cases were modified to ten minutes and to focus on case scenarios using standardized patients. Faculty facilitators were trained in giving feedback and oriented to the new OSCE format. Clerkship students are told in advance the general topics of the Teaching OSCE stations, so they can prepare. Students are divided in three groups of six to eight students and each group is assigned a faculty facilitator. Each student performs a ten-minute OSCE station and is observed directly by the faculty facilitator and the remaining students in the group using a video monitor. The faculty facilitator then leads a 12-minute feedback session on focused history-taking skills, physical examination skills, and the doctor-patient relationship skills. Students selected at random by the faculty facilitator also give feedback to their peer. Teaching OSCEs take three hours and are held twice during the clerkship such that each student is actively observed twice and watches a total of ten to 14 additional interactions. Facilitators grade students on attendance, participation, and evidence of preparation. The actual interaction with the standardized patient is used entirely for formative purposes and is not graded. DISCUSSION: Our department has used OSCEs for six years to evaluate students at the end of the third-year family medicine clerkship. Even after continuous improvement, our OSCE did not meet higher standards of reliability and would need at least three hours of testing per student to meet those standards. The low number of students in the rotation and limited resources to increase the duration of the OSCE made it very difficult to construct a more reliable examination. At the same time, both faculty and students wanted more direct observation and feedback on performance with clinical scenarios. Using existing OSCE resources to change the OSCE to a teaching tool proved to be an efficient use of teaching resources while increasing our educational impact. Students report that they appreciate the opportunity to have constructive discussions of their strengths and weaknesses in clinical encounters, observe a variety of doctor-patient interaction styles, and practice for future OSCE-type examinations. Faculty members enjoy this active teaching format and find the process of students giving feedback to their peers educationally useful. The teaching OSCE has been extremely well rated in the end-of-rotation evaluations and will be continued in future clerkships.