Improving physician well-being and reducing burnout using a peer-to-peer recognition program.

Background: Drivers of physician burnout include an intricate interplay between health care organizational structures, societal influences, and individual-level factors. In the traditional workforce, peer-to-peer recognition programs (PRPs) have reduced burnout by building a sense of community and effectively creating a "wellness culture." We implemented a PRP in an emergency medicine (EM) residency and determined its impact on subjective symptoms of burnout and wellness. Methods: This was a prospective, pre- and postintervention study conducted in a single residency over a 6-month period. All 84 EM residents of the program were sent a voluntary anonymized survey that included a validated instrument on wellness and burnout. A PRP was initiated. After 6 months, a second survey was distributed. The outcome of the study was to examine whether the addition of a PRP reduced burnout and improved wellness. Results: There were 84 respondents to the pre-PRP survey and 72 to the post-PRP survey. Respondents reported an improvement after the inception of the use of the PRP in two factors that contribute to a physician's wellness: feeling recognized for accomplishments at work, which improved from 45% (38/84) affirmative to 63% (45/72; 95% confidence interval [CI] 2.3%-32.4%, p = 0.025) and a comfortable and supportive work environment, which improved from 68% (57/84) to 85% (61/72; 95% CI 3.5%-29.3%, p = 0.014). There was no significant effect in the Stanford Professional Fulfillment Index (PFI) as a result of this intervention over the 6 months. Conclusions: A PRP initiative resulted in improvements in several factors that drive physician wellness but overall burnout measured by the Stanford PFI did not show any improvement over the 6-month period. A future longitudinal study examining the continuous assessment of PRP on the EM residents throughout the entire course of 4 years of residency training would be beneficial to determine if it could change burnout from year to year.

Moving beyond personal factors: A national study of wellness interventions in emergency medicine residency programs.

BACKGROUND: In 2017, the Accreditation Council for Graduate Medical Education (ACGME) revised its Common Program Requirements to support trainees and faculty by mandating programs to provide dedicated wellness resources and education. Emergency medicine may benefit from this change due to high burnout rates within the specialty. However, the current state of wellness interventions in emergency medicine (EM) residency programs has not yet been well described. Understanding current practices is necessary to assess unmet needs and inform the development and evaluation of future interventions that aim to improve trainee wellness. OBJECTIVES: The goal of this study was to describe currently implemented wellness interventions in EM residency programs. METHODS: This descriptive study surveyed 250 ACGME-accredited EM residency programs between March 1 and June 1, 2020, regarding wellness interventions. The survey included demographic questions; structured multiple-choice questions about cost, frequency, and champions; and free-text response options to briefly describe interventions. Respondents were also asked to classify the interventions according to the seven factors described in the National Academy of Medicine Model of Clinician Well-Being and Resilience. RESULTS: Ninety of 250 (36% response rate) residency programs participated, describing 162 unique wellness interventions. Respondents classified the majority of interventions (n = 136) as targeting personal factors according to the National Academy of Medicine model. Qualitative analysis revealed five major themes describing the interventions: program culture, program factors, environmental and clinical factors, wellness activities and practices, and wellness resources. CONCLUSIONS: Results of this survey may help to inform a national needs assessment addressing the current state of wellness interventions in EM residency programs. Our results highlight the need for more interventions targeting external factors impacting resident wellness.

A 2-Question Summative Score Correlates with the Maslach Burnout Inventory.

INTRODUCTION: There is a high prevalence of burnout among emergency medicine (EM) residents. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) is a widely used tool to measure burnout. The objective of this study was to compare the MBI-HSS and a two-question tool to determine burnout in the EM resident population. METHODS: Based on data from the 2017 National Emergency Medicine Resident Wellness Survey study, we determined the correlation between two single-item questions with their respective MBI subscales and the full MBI-HSS. We then compared a 2-Question Summative Score to the full MBI-HSS with respect to primary, more restrictive, and more inclusive definitions of burnout previously reported in the literature. RESULTS: Of 1,522 residents who completed the survey 37.0% reported "I feel burned out from my work," and 47.1% reported "I have become more callous toward people since I took this job" once a week or more (each item >3 on a scale of 0-6). A 2-Question Summative Score totaling >3 correlated most closely with the primary definition of burnout (Spearman's rho 0.65 [95% confidence interval 0.62-0.68]). Using the summative score, 77.7% of residents were identified as burned out, compared to 76.1% using the full MBI-HSS, with a sensitivity and specificity of 93.6% and 73.0%, respectively. CONCLUSION: An abbreviated 2-Question Summative Score correlates well with the full MBI-HSS tool in assessing EM resident physician burnout and could be considered a rapid screening tool to identify at-risk residents experiencing burnout.

Vomiting in Pediatric Patients.

Audience: This classic team-based learning activity is specifically designed for emergency medicine bound medical students and junior residents; however, general pediatrics residents and general medical students may also benefit from this activity. Senior residents and fellows felt that the cases were too basic for them but enjoyed acting as facilitators. Introduction/Background: Vomiting is a common chief complaint in pediatric patients seen in the Emergency Department. 1-3 Presentations include acute, chronic, and cyclic vomiting, with underlying etiologies such as toxin injection, emotional disturbances, and movement disequilibrium. 1 By understanding these various pathways, it is helpful for physicians to distinguish between gastrointestinal and non-gastrointestinal causes of vomiting. 1 Most cases of vomiting in the pediatric population are self-limiting and require only supportive treatment; however, physicians must be able to recognize red flags associated with vomiting that warrant further evaluation. 1,3 This task may be challenging for medical students and residents in emergency medicine and those with infrequent exposure to pediatric patients. Therefore, this team-based learning activity was developed to help junior learners in differentiating non-emergent and emergent cases of pediatric vomiting. This activity aids learners in formulating a differential based on age, history, and characteristics of vomiting. We also review specific causes of pediatric vomiting that physicians cannot miss including intussusception, pyloric stenosis, malrotation, intestinal atresia, and intracranial pathology. Educational Objectives: By the end of this TBL session, learners should be able to:Identify red flag symptoms that should prompt referral for urgent intervention by GI or surgical specialists.Recognize how chronicity of the vomiting can alter the differential diagnosisDescribe the varying pathways that can cause nausea and vomiting.Determine the necessity of imaging tests to confirm and possibly treat various causes of vomiting.Interpret imaging studies associated with specific causes of vomiting. Educational Methods: Classic Team Based Learning (cTBL). Research Methods: Learners and instructors provided verbal feedback after the session in a large group format. Learners were specifically asked if they felt the session was education, relevant, high-yield and level appropriate. One instructor provided written feedback to the cases as well. Results: Overall learners and instructors found the session to be engaging, informative and educational. Learners felt that the session was level appropriate for medical students and junior residents. As a result of feedback from the session, several of the iRAT/gRAT questions were adjusted and the group application cases were re-written and implemented. Discussion: Overall, the educational content and delivery was effective. This session was presented to a group of emergency medicine students, interns and residents. Learners were divided into smaller groups, and each group had a variety of level of learners, including pediatric emergency medicine fellows, present. The fellows, while not necessary to the delivery of the TBL, were extremely helpful in aiding the residents during the session. The final debriefing and answer review were essential to ensure that learners met all educational objectives and fully understood the materials. Topics: Pediatric vomiting, intussusception, pyloric stenosis, intestinal atresia, malrotation, gastroesophageal reflux disease, superior mesenteric artery (SMA) syndrome, hyperemesis.

Wellness Interventions in Emergency Medicine Residency Programs: Review of the Literature Since 2017.

INTRODUCTION: Recent research demonstrates burnout prevalence rates as high as 76% in emergency medicine (EM) residents. In 2017 the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs provide dedicated wellness education for their trainees as a requirement for accreditation. We aimed to conduct a systematic review of published wellness interventions conducted in EM residency programs following the implementation of the 2017 ACGME Common Program Requirements change in order to characterized published intervention and evaluate their effectiveness. METHODS: We applied a published approach to conducting systematic reviews of the medical education literature. We performed a search of the literature from January 1, 2017-February 1, 2020. Studies were included for final review if they described a specific intervention and reported outcomes with the primary goal of improving EM resident wellness. Outcomes were characterized using the Kirkpatrick training evaluation model. RESULTS: Eight of 35 identified studies met inclusion criteria. Most described small convenience samples of EM residents from single training programs and used the satisfaction rates of participants as primary outcome data. Only quantitative assessment methods were used. Studies addressed only a limited number of factors affecting resident wellness. The majority of interventions focused on personal factors, although a few also included sociocultural factors and the learning and practice environment. CONCLUSION: There is a relative dearth of literature in the area of research focused on interventions designed to improve EM resident wellness. Furthermore, the studies we identified are narrow in scope, involve relatively few participants, and describe programmatic changes of limited variety. Future directions include an increase and emphasis on multi-institutional studies, randomized controlled trials, qualitative methodology, and opportunities for funded research.

A Targeted Mindfulness Curriculum for Medical Students During Their Emergency Medicine Clerkship Experience.

INTRODUCTION: Despite high rates of burnout in senior medical students, many schools provide the majority of their wellness training during the first and second preclinical years. Students planning a career in emergency medicine (EM) may be at particularly high risk of burnout, given that EM has one of the highest burnout rates of all the specialties in the United States We developed an innovative, mindfulness-based curriculum designed to be integrated into a standard EM clerkship for senior medical students to help students manage stress and reduce their risk of burnout. METHODS: The curriculum included these components: (1) four, once-weekly, 60-minute classroom sessions; (2) prerequisite reading assignments; (3) individual daily meditation practice and journaling; and (4) the development of a personalized wellness plan with the help of a mentor. The design was based on self-directed learning theory and focused on building relatedness, competence, and autonomy to help cultivate mindfulness. RESULTS: Thirty students participated in the curriculum; 20 were included in the final analysis. Each student completed surveys prior to, immediately after, and six months after participation in the curriculum. We found significant changes in the self-reported behaviors and attitudes of the students immediately following participation in the curriculum, which were sustained up to six months later. CONCLUSION: Although this was a pilot study, our pilot curriculum had a significantly sustained self-reported behavioral impact on our students. In the future, this intervention could easily be adapted for any four-week rotation during medical school to reduce burnout and increase physician wellness.

Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management.

BACKGROUND: There is controversy regarding whether children with perforated appendicitis should receive early appendectomy (EA) versus medical management (MM) with antibiotics and delayed interval appendectomy. The objective of this study was to compare outcomes of children with perforated appendicitis who receive EA versus MM. METHODS: Case review of consecutive children <18 years of age with perforated appendicitis who received either EA or MM during an 8-year period. Criteria for hospital discharge included patient being afebrile for at least 24 hours, pain-free and able to tolerate oral intake. RESULTS: Of 203 patients diagnosed with perforated appendicitis, 122 received EA and 81 received MM. All received parenteral antibiotic therapy initiated in the emergency department and continued during hospitalization. There were no significant differences between groups in mean patient age, mean complete blood count total white blood cells count, gender distribution, rates of emergency department fever or rates of intra-abdominal infection (abscess or phlegmon) identified on admission. Compared with patients receiving MM, those receiving EA experienced significantly fewer (1) days of hospitalization, parenteral antibiotic therapy and in-hospital fever; (2) radiographic studies, percutaneous drainage procedures and placement of central venous catheters performed; (3) post admission intra-abdominal complications and (4) unscheduled repeat hospitalizations after hospital discharge. Only 1 EA-managed patient developed a postoperative wound infection. CONCLUSIONS: Children with perforated appendicitis who receive EA experience significantly less morbidity and complications versus those receiving MM. The theoretical concern for enhanced morbidity associated with EA management of perforated appendicitis is not supported by our analysis.