Resident wellness: institutional trends over 10 years since 2003.

BACKGROUND: The surveys in this study were carried out at the Graduate Medical Education Division at Oregon Health & Science University (OHSU). OHSU implemented two significant wellness initiatives: a wellness program in 2004, and a policy allowing 4 half-days off each academic year to pursue personal or family health care needs in 2010. This study provides a secondary data analysis of five cross-sectional surveys of career satisfaction of resident and fellow trainees. METHODS: All trainees were surveyed five times over a 10-year period using anonymous, cross-sectional web-based survey instruments. Surveys included questions about career satisfaction, perceived stress, sleep hours, burnout, and related factors. RESULTS: This represents 10 years of accumulated responses from over 2,200 residents with results showing continual improvement in their career satisfaction. Response rates ranged from 56% to 72%. During the study period, there was a significant positive change in overall resident career satisfaction, with little change in factors traditionally considered to be predictive of overall career satisfaction such as sleep hours or perceived stress level. In addition, our data support that availability of time for personal tasks could positively impact the overall training experience. CONCLUSION: We postulate that the improvements in satisfaction relate to two major institutional innovations designed to promote resident wellness.

Use of a voice and video internet technology as an alternative to in-person urgent care clinic visits.

This study aimed to determine the feasibility of patient-initiated online Internet urgent care visits, and to describe patient characteristics, scope of care, provider adherence to protocols, and diagnostic and therapeutic utilization. A total of 456 unique patients were seen via Internet-based technology during the study period, generating 478 consecutive total patient visits. Of the 82 patients referred for an in-person evaluation, 75 patients (91.5%) reported to the clinic as instructed. None of the 82 patients recommended for in-person evaluation required an emergency department referral, hospital admission or urgent consultative referral. We conclude that real-time online primary and urgent care visits are feasible, safe and potentially beneficial in increasing convenient access to urgent and primary care.

Promoting resident wellness: evaluation of a time-off policy to increase residents' utilization of health care services.

PURPOSE: To evaluate awareness and utilization of a new institutional policy to grant residents time off to access personal and family health care. METHOD: In 2012, two years after policy implementation, an electronic survey was sent to all 546 residents and fellows at a tertiary care academic medical center in the United States. Residents were asked questions regarding awareness of the time-off policy, use of the policy, health care status, reasons for policy use, and barriers to use. RESULTS: A total of 490 (90%) residents responded. Eighty-nine percent of those surveyed were aware of the policy. Of those who were aware, 49.7% used the policy to access health care. Top reasons for policy use were for personal routine or preventive health care, dental care, and urgent health care needs. The most commonly reported barrier to policy use was concern about the impact the resident's absence would have on colleagues. CONCLUSIONS: Implementation of policies to prospectively schedule residents' time off during business hours to address health care needs is an important means to promote resident wellness. Such policies remove one commonly cited barrier to residents' access to health care. However, residents still reported concerns about impact on peers and patients as the main reason they were reluctant to take the time off to address their health care needs. More work is needed on both wellness policy implementation practices and on refining the systems that will allow seamless and guiltless transitions of care.

"If you build it, they will come": attitudes of medical residents and fellows about seeking services in a resident wellness program.

BACKGROUND: High rates of burnout and distress in resident physicians suggest a significant number would benefit from counseling. INTERVENTION: A resident wellness program (RWP) was designed to lower known barriers limiting resident access to services. METHODS: In 2011, medical residents and fellows were surveyed and logistic regression analyses were conducted to identify demographic and training program differences in perceived barriers and willingness to access the RWP. RESULTS: Of the 88% of trainees who knew about the RWP, 87% indicated they would be very likely or somewhat likely to seek out services. Time remained the biggest barrier for residents to getting help. Being male (odds ratio [OR]  =  0.54, 95% confidence interval [CI] 0.34-0.84) or an ethnic/racial minority (OR  =  0.49, 95% CI 0.28-0.85) was associated with greater unwillingness to seek counseling. Reluctance to access the RWP was associated with concerns about helpfulness, confidentiality, being unable to take a break, and stigma. Women (OR  =  1.60, 95% CI 1.06-2.42) and primary care residents (OR  =  1.58, 95% CI 0.98-2.54) were more likely to be concerned about taking a break. Men were more likely to question the helpfulness of counseling (OR  =  0.55, 95% CI 0.36-0.85). CONCLUSIONS: The RWP removed barriers of cost and knowledge about counseling services. More educational outreach is needed to address sex and ethnic differences about RWP utilization and attitudes in medical culture about a physician's right to address personal health care needs.

The effects of electronic health record implementation on medical student educators.

BACKGROUND: Electronic heath records (EHRs) are being rapidly adopted. Little attention has been paid to the effects of EHR implementation on teaching. PURPOSE: The goal was to determine the effect of EHR implementation on medical student educators and to characterize features that might influence their responses. METHODS: A survey of all clinical faculty at Oregon Health & Science University was taken. The authors inquired about the effect of EHR implementation on enthusiasm for teaching and characterized factors that might contribute to responses. RESULTS: Nearly half of the faculty reported decreased enthusiasm for teaching following EHR implementation (48.2%). Most (65.1%) reported that the EHR distracted from teaching, and few saw its advantages. Most reported that EHR implementation led them to teach less (62.3%); the most enthusiastic teachers were most affected. CONCLUSIONS: EHR implementation in an academic medical center has substantial effects on educators. Further work is needed to determine how to train medical educators and modify the EHR to best support teaching.

A comparison between physicians and demographically similar peers in accessing personal health care.

PURPOSE: Residents are a unique subpopulation of physicians, training in a complex work and educational environment that may create barriers to accessing preventive and illness-related health care. This study was designed to investigate residents' utilization of personal health care services and compare with those of demographically similar peers. METHOD: All 675 residents in a large, urban, tertiary care U.S. academic medical center were invited to participate in a confidential, Web-based, cross-sectional survey in January 2008. Survey responses to questions addressing personal health care were compared with those of a demographically similar group using the 2008 survey from the Behavioral Risk Factor Surveillance System (BRFSS). The final weights in BRFSS were used for a post hoc stratified adjustment in analysis. Logistic regression was employed to compare subgroups. RESULTS: Sixty-six percent of residents completed the survey. A significantly lower percentage of residents reported having a primary care provider (44%) or dentist (65%) or having routine health and dental care visits (39% and 53%, respectively) within the past year than those in the demographically similar group of 2008 BRFSS. In that group, 83% reported having a primary care provider, and 63% and 79% reported having routine primary and dental health care visits, respectively. CONCLUSIONS: The residents were significantly less likely than demographically similar peers to have a primary care provider or dentist or to participate in routine health maintenance. Further research into barriers preventing residents from accessing health care, and opportunities to address them, is needed.

Plug the leak: align public spending with public need.

We explore the history behind the current structure of graduate medical education funding and the problems with continuing along the current funding path. We then offer suggestions for change that could potentially manage this health care spill. Some of these changes include attracting more students into primary care, aligning federal graduate medical education spending with future workforce needs, and training physicians with skills they will require to practice in systems of the future.

A novel approach to increase residents' involvement in reporting adverse events.

PURPOSE: In the wake of the Patient Safety and Quality Improvement Act of 2005, national attention has increasingly focused on adverse-event reporting as a means of identifying systems changes to improve patient safety. However, physicians and residents have demonstrated meager involvement in this effort. METHOD: In 2008-2009, the authors measured participation in adverse-event reporting by 680 residents at Oregon Health & Science University before and after implementing a quality improvement initiative, which consisted of a financial incentive and multifaceted educational campaign. The primary measure of success was an increase in the average monthly adverse-event reports submitted by residents to greater than 5% of the institution's overall report submissions. RESULTS: The average number of adverse events reported by residents increased from 1.6% to 9.0% of the institution's overall event reports, representing a 5.6-fold increase during the initiative (P < .001). The relative percentage of resident-submitted reports defined as "near-misses" increased from 6% to 27% during the initiative (P < .001). CONCLUSIONS: The novel approach of integrating a retirement benefit and educational campaign to increase residents' involvement in adverse-event reporting was successful. In addition to increasing residents' contributions to adverse-event reporting to levels higher than any documented in the current literature, there was also a remarkable increase in the relative frequency of near-miss reporting by residents.

Personal time off and residents' career satisfaction, attitudes and emotions.

OBJECTIVES: Doctors who are satisfied with their careers have less stress and burnout and are less likely to make medical errors and more likely to provide a higher quality of patient care. In response to reports that residents experienced barriers to taking time off, Oregon Health and Science University designed a survey to evaluate residents' awareness of their programmes' policies for time off, their ability to find time for personal needs, and associations of both with career satisfaction, emotions and training experience. METHODS: All 675 residents in a large, urban, tertiary care academic medical centre located in the USA were invited to participate in a confidential, web-based, cross-sectional survey in 2008; 66% completed the survey. The survey instrument consisted of a variety of items including yes/no, multiple choice, Likert scale and narrative response types. RESULTS: Only 41% of respondents were aware of their programmes' policies regarding time off. Residents who reported awareness of a policy were more able to find time to take care of personal needs (odds ratio=1.553, p=0.026). These respondents reported more positive experiences and emotions, fewer negative experiences and emotions, higher levels of career satisfaction and relatively less perceived stress than those who were unaware of a time-off policy. In addition, these respondents reported, on average, fewer work and more sleep hours. CONCLUSIONS: Our results highlight the importance of ensuring mechanisms for residents to find time to fulfil personal needs in order to enhance resident well-being and career satisfaction. Ensuring resident awareness of time-off policies is one way to do this. Our study demonstrates that ensuring residents are able to find time for personal needs has significant consequences with respect to resident perceptions of well-being and may be an effective strategy to promote career satisfaction and prevent burnout.

Education to return nonpracticing physicians to clinical activity: a case study in physician reentry.

INTRODUCTION: Physician shortages in the United States are estimated to reach as high as 85 000 by 2020. One strategy for addressing the shortage is to encourage physicians who left clinical practice to return to work, but few programs exist to prepare physicians to reenter practice. The Divisions of Continuing Medical Education and Graduate Medical Education (GME), Oregon Health & Science University, collaborated with clinical departments to establish a physician reentry program. METHODS: A case-study of education designed to return nonpracticing physicians to clinical activity was undertaken. RESULTS: Fourteen candidates were accepted into the program. Accepted candidates were appointed special fellows at the university and provided with restricted institutional license and liability coverage. Based on retraining assessment and planned scope of practice, applicants and program directors designed individualized curricula. As trainees demonstrated clinical proficiency, their level of independence increased in a condensed version of the residency training model. Of the 14 accepted candidates, 13 successfully completed the program and are actively engaged in clinical practice. One trainee did not successfully complete the program. DISCUSSION: This reentry program reintroduced clinically inactive physicians into supervised direct patient care. Use of the GME model allowed acceptance of special fellows and provided institutional malpractice coverage for them.

Institute of medicine committee report on resident duty hours: a view from a trench.

BACKGROUND: In late 2008, the Institute of Medicine (IOM) published a report recommending more restrictive limits on resident work hours to promote patient safety. Reaction from the graduate medical education community has focused on concerns about a lack of evidence supporting the IOM's recommendations. We highlight 3 concerns with the report: 1) a disproportionate attention to resident fatigue when changes in other areas may have a larger impact on patient safety. Data supporting a causal link between resident fatigue and medical errors that harm patients are not robust. Two areas where data support a stronger impact on patient safety include resident supervision and transitions of care; 2) a "one size fits all" model when specialty-specific recommendations may be more appropriate. For example, 16 hours on task is not at all similar for residents in different specialties (ie, surgery and primary care); and 3) the absence of a process to evaluate the impact of current or potential duty hour requirements on outcomes. Because these potential impacts have not been sufficiently researched, it is premature to support additional changes at this time. RECOMMENDATIONS: TO MOVE FORWARD IN A COMPREHENSIVE MANNER, WE RECOMMEND THE FOLLOWING: 1) support more research to evaluate the effects of duty hours in conjunction with other interrelated factors on patient safety, 2) encourage individual Accreditation Council for Graduate Medical Education (ACGME) Review committees to develop specialty specific duty hour limitations, and 3) develop partnerships between the IOM, ACGME, and the institutions directly involved with medical education to study how to maximize patient safety while maintaining quality educational outcomes.

Barriers to innovation in continuing medical education.

INTRODUCTION: Criteria for maintenance of certification (MOC) emphasize the importance of competencies such as communication, professionalism, systems-based care, and practice performance in addition to medical knowledge. Success of this new competency paradigm is dependent on physicians' willingness to engage in activities that focus on less traditional competencies. We undertook this analysis to determine whether physicians' preferences for CME are barriers to participation in innovative programs. METHODS: A geographically stratified, random sample of 755 licensed, practicing physicians in the state of Oregon were surveyed regarding their preferences for type of CME offering and instructional method and plans to recertify. RESULTS: Three hundred seventy-six of 755 surveys were returned for +/-5% margin of error at 95% confidence level; 91% of respondents were board certified. Traditional types of CME offerings and instructional methods were preferred by the majority of physicians. Academic physicians were less likely than clinical physicians to prefer nontraditional types of CME offerings and instructional methods. Multiple regression analyses did not reveal any significant differences based on demography, practice location, or physician practice type. DISCUSSION: Physicians who participate in CME select educational opportunities that appeal to them. There is little attraction to competency-based educational activities despite their requirement for MOC. The apparent disparity between the instructional methods a learner prefers and those that are the most effective in changing physician behavior may represent a barrier to participating in more innovative CME offerings and instructional methods. These findings are important for medical educators and CME program planners developing programs that integrate studied and effective educational methods into CME programs that are attractive to physicians.

Awareness of and participation in maintenance of professional certification: a prospective study.

INTRODUCTION: National health care concerns have led to the emergence of maintenance of certification (MOC) as a means to ensure the competence of practicing physicians. Little is known about physician perceptions of the barriers and/or benefits of MOC or proportions of physicians who participate in MOC programs. The purposes of this study were to assess physicians' plans for participating in MOC and to identify influences on decisions to participate. METHODS: A geographically stratified, random sample of 755 licensed practicing physicians in the state of Oregon were surveyed regarding certification status, awareness of MOC requirements, influences on decision to participate in MOC, and resources available and/or desired to assist with MOC. RESULTS: Three hundred seventy-six of 755 surveys were returned for +/-5% margin of error at 95% confidence level. Of the respondents 91% were board certified; 95% with time-limited certificates planned to recertify. Factors rated "extremely important" in decisions to recertify were to "demonstrate expertise in my specialty" (50%), to "demonstrate my medical knowledge is up to date" (52%), and to "demonstrate my competency to provide patient care in my specialty" (51%). Practice groups provided physicians with few resources for MOC; 29% report that their practices provided no resources for the MOC process. DISCUSSION: These results are important for hospitals, medical institutions, medical educators, and CME program planners. Although the large majority of physicians with time-limited certificates plan to participate in maintenance of certification, lack of some resources (time, money, and administrative support) and reluctance to utilize others (systems-based care) are identified as barriers to the success of MOC.

The impact of the implementation of work hour requirements on residents' career satisfaction, attitudes and emotions.

BACKGROUND: To assess the impact of work hours' limitations required by the Accreditation Council for Graduate Medical Education (ACGME) on residents' career satisfaction, emotions and attitudes. METHODS: A validated survey instrument was used to assess residents' levels of career satisfaction, emotions and attitudes before and after the ACGME duty hour requirements were implemented. The "pre" implementation survey was distributed in December 2002 and the "post" implementation one in December 2004. Only the latter included work-hour related questions. RESULTS: The response rates were 56% for the 2002 and 72% for the 2004 surveys respectively. Although career satisfaction remained unchanged, numerous changes occurred in both emotions and attitudes. Compared to those residents who did not violate work-hour requirements, those who did were significantly more negative in attitudes and emotions. CONCLUSION: With the implementation of the ACGME work hour limitations, the training experience became more negative for those residents who violated the work hour limits and had a small positive impact on those who did not violate them. Graduate medical education leaders must innovate to make the experiences for selected residents improved and still maintain compliance with the work hour requirements.

A mid year comparison study of career satisfaction and emotional states between residents and faculty at one academic medical center.

BACKGROUND: The Accreditation Council for Graduate Medical Education's (ACGME) new requirements raise multiple challenges for academic medical centers. We sought to evaluate career satisfaction, emotional states, positive and negative experiences, work hours and sleep among residents and faculty simultaneously in one academic medical center after implementation of the ACGME duty hour requirements. METHODS: Residents and faculty (1330) in the academic health center were asked to participate in a confidential survey; 72% of the residents and 66% of the faculty completed the survey. RESULTS: Compared to residents, faculty had higher levels of satisfaction with career choice, competence, importance and usefulness; lower levels of anxiousness and depression. The most positive experiences for both groups corresponded to strong interpersonal relationships and educational value; most negative experiences to poor interpersonal relationships and issues perceived outside of the physician's control. Approximately 13% of the residents and 14% of the faculty were out of compliance with duty hour requirements. Nearly 5% of faculty reported working more than 100 hours per week. For faculty who worked 24 hour shifts, nearly 60% were out of compliance with the duty-hour requirements. CONCLUSION: Reasons for increased satisfaction with career choice, positive emotional states and experiences for faculty compared to residents are unexplained. Earlier studies from this institution identified similar positive findings among advanced residents compared to more junior residents. Faculty are more frequently at risk for duty-hour violations. If patient safety is of prime importance, faculty, in particular, should be compliant with the duty hour requirements. Perhaps the ACGME should contain faculty work hours as part of its regulatory function.

A comparison study of career satisfaction and emotional states between primary care and speciality residents.

OBJECTIVE: To evaluate career satisfaction, emotional states and positive and negative experiences among residents in primary care and speciality programmes in 1 academic medical centre prior to the implementation of the Accreditation Council for Graduate Medical Education's (ACGME) duty hour requirements. DESIGN: Cross-sectional survey. MEASUREMENTS: All 581 residents in the academic health centre were asked to participate voluntarily in a confidential survey; 327(56%) completed the survey. RESULTS: Compared to their primary care colleagues, speciality residents had higher levels of satisfaction with career choice, feelings of competence and excitement, lower levels of inferiority and fatigue and different perceptions of positive and negative training experiences. However, 77% of all respondents were consistently or generally pleased with their career choices. The most positive residents' experiences related to interpersonal relationships and their educational value; the most negative experiences related to interpersonal relationships and issues perceived to be outside of residents' control. Age and training level, but not gender also influenced career satisfaction, emotional states and positive and negative opinions about residency. CONCLUSIONS: Less satisfaction with career choice and more negative emotional states for primary care residents compared to speciality residents probably relate to the training experience and may influence medical students' selections of careers. The primary care residents, compared to speciality residents, appear to have difficulty in fulfilling their ideals of professionalism in an environment where they have no control. These data provide baseline information with which to compare these same factors after the implementation of the ACGME duty hours' and competency requirements.

Using systems-based practice to integrate education and clinical services.

The authors describe one institution's strategies to implement the Accreditation Council for Graduate Medical Education's (ACGME) Outcomes Project requirements while simultaneously exploring and implementing standards of quality healthcare as endorsed by the Institute of Medicine's (IOM) Crossing the Quality Chasm (2001). Of real interest, application of the authors' institution's paradigm is identical to many of the parameters for system competence as recommended in the IOM's April 2003 report, Health Professions Education: A Bridge to Quality (2003).