Internal Medicine Residents' Perceived Responsibility for Patients at Hospital Discharge: A National Survey.
ABSTRACT: Medical residents are routinely entrusted with transitions of care, yet little is known about the duration or content of their perceived responsibility for patients they discharge from the hospital.To examine the duration and content of internal medicine residents' perceived responsibility for patients they discharge from the hospital. The secondary objective was to determine whether specific individual experiences and characteristics correlate with perceived responsibility.Multi-site, cross-sectional 24-question survey delivered via email or paper-based form.Internal medicine residents (post-graduate years 1-3) at nine university and community-based internal medicine training programs in the United States.Perceived responsibility for patients after discharge as measured by a previously developed single-item tool for duration of responsibility and novel domain-specific questions assessing attitudes towards specific transition of care behaviors.Of 817 residents surveyed, 469 responded (57.4 %). One quarter of residents (26.1 %) indicated that their responsibility for patients ended at discharge, while 19.3 % reported perceived responsibility extending beyond 2 weeks. Perceived duration of responsibility did not correlate with level of training (P?=?0.57), program type (P?=?0.28), career path (P?=?0.12), or presence of burnout (P?=?0.59). The majority of residents indicated they were responsible for six of eight transitional care tasks (85.1-99.3 % strongly agree or agree). Approximately half of residents (57 %) indicated that it was their responsibility to directly contact patients' primary care providers at discharge. and 21.6 % indicated that it was their responsibility to ensure that patients attended their follow-up appointments.Internal medicine residents demonstrate variability in perceived duration of responsibility for recently discharged patients. Neither the duration nor the content of residents' perceived responsibility was consistently associated with level of training, program type, career path, or burnout, suggesting there may be unmeasured factors such as professional role modeling that shape these perceptions.
Project description:There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges.We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital.A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014-2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility.Of 817 residents surveyed, 469 (57%) responded. Teaching about care transitions on rounds was the most common educational experience reported by residents (74%, 327 of 439). Learning opportunities with postdischarge patient contact were less common (clinic visits: 32%, 142 of 439; telephone calls: 12%, 53 of 439; and home visits: 4%, 18 of 439). On a 1-10 scale (10 = highest impact), residents rated postdischarge clinic as having the highest impact on their motivation to ensure safe transitions of care (mean = 7.61). Prior experiences with a postdischarge clinic visit, home visit, or telephone call were each correlated with increased perceived responsibility for transitional care tasks (correlation coefficients 0.12 [P?=?.004], 0.1 [P?=?.012], and 0.13 [P?= ?001], respectively).IM residents learn to facilitate hospital discharges most often through direct patient care. Opportunities to interact with patients across the postdischarge continuum are uncommon, despite correlating with increased perceived responsibility for ensuring safe transitions of care.
Project description:BACKGROUND: Increasing complexity of medical care, coupled with limits on resident work hours, has prompted consideration of extending Internal Medicine training. It is unclear whether further hour reductions and extension of training beyond the current duration of 3 years would be accepted by trainees. OBJECTIVE: We aimed to determine if further work-hour reductions and extension of training would be accepted by trainees and whether resident burnout affects their opinions. DESIGN: A postal survey was sent to all 143 Internal Medicine residents at the University of Colorado School of Medicine in May 2004. MEASUREMENTS: The survey contained questions related to opinions on work-hour limits using a 5-point Likert scale ranging from strongly agree to strongly disagree. Burnout was measured using the Maslach Burnout Inventory, organized into three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment, with burnout defined as high EE or DP. RESULTS: Seventy-four percent (106/143) of residents returned the survey. The vast majority (84%) of residents disagreed or strongly disagreed with extending training to 4 or 5 years. Burnout residents were less averse to extending training (strongly agree or agree, 18.9% vs 4.3%, P = .04). The majority of residents (68.9%) disagreed or strongly disagreed with establishing a 60-hour/week limit. Residents who met the criteria for burnout were more likely to agree that a 60-hour limit would be better than an 80-hour limit (strongly agree or agree, 22% vs 8%, P = .02). CONCLUSIONS: In this program, most Internal Medicine residents are strongly opposed to extending their training to 4 or 5 years and would prefer the current 80 hours/week cap. A longer, less intense pace of Internal Medicine training seems to be less attractive in the eyes of current trainees.
Project description:The Accreditation Council for Graduate Medical Education expects resident duty hours to be monitored, yet no previous studies have examined the effect of after-hours electronic health record (EHR) use on resident hours or burnout.We assessed internal medicine residents' perceived and actual time spent on after-hours outpatient EHR use and calculated increased duty hours if after-hours EHR use were included; we also assessed its effect on resident burnout.We retrospectively aggregated time spent logged on to the outpatient EHR for residents in a general internal medicine clinic for 13 weeks in 2011. Residents completed a survey on EHR use, which was correlated with objectively recorded data on EHR usage. We compared actual and self-reported EHR time and identified violations that would be generated if these hours were included in reported duty hours. We also correlated resident after-hours EHR use with responses to an internally developed burnout survey.The 44 residents in this study overestimated time spent on the ambulatory EHR (they spent 3.03 hours/week on after-hours use compared with a recorded 1.20 hours/week). In total, 190 duty hour violations (mean duration of violation = 37 minutes) would have been generated if after-hours EHR usage were included in residents' reported duty hours.Resident estimates of EHR use by residents were not accurate; including after-hours EHR use would increase the number of reported duty hour violations. There was no association between after-hours EHR use and resident burnout.
Project description:PURPOSE:To measure changes in markers of resident well-being over time as progressive work hours limitations (WHLs) were enforced, and to investigate resident perceptions of the 2011 WHLs. METHOD:A survey study of internal medicine residents was conducted at the University of Washington's multihospital residency program in 2012. The survey included validated well-being questions: the Maslach Burnout Inventory, the two-question PRIME-MD depression screen, and career satisfaction questions. Chi-square tests were used to compare 2012 well-being questionnaire responses against nearly identical surveys conducted in 2001 and 2004 at the same institution. In addition, residents were asked to rate the impact of WHLs on resident well-being and education as well as patient care, and to state preferences for future WHLs. RESULTS:Significantly different proportions of residents met burnout criteria across time, with fewer meeting criteria in 2012 than in 2001 (2001: 76% [87/115]; 2004: 64% [75/118]; 2012: 61% [68/112]; P = .039). Depression screening results also differed across time, with fewer screening positive in 2012 than in 2004 (2001: 45% [52/115]; 2004: 55% [65/118]; 2012 [35/112]: 31%; P = .001). Residents, especially seniors, reported perceived negative impacts of WHLs on their well-being, education, and patient care. Most senior residents favored reverting to the pre-July 2011 system of WHLs. Interns were more divided. CONCLUSIONS:Validated measures of resident well-being changed across the three time points measured. Residents had the lowest rates of burnout and depression in 2012. Resident perceptions of the 2011 WHLs, however, were generally negative.
Project description:Objectives:To assess the prevalence of burnout and associated factors among family medicine residents in Thailand. Materials and Methods:This cross-sectional study was conducted by all Thai Family Medicine residents year 1 to 3 during February 2019. Self-reported questionnaires, including demographic data, and the Thai version of the Maslach Burnout Inventory were distributed to 703 residents via electronic transmissions, including e-mail, Facebook, and Line instant communication application. Burnout was diagnosed by the following criteria: high-level emotional exhaustion, high-level depersonalization, and low-level personal accomplishment. Factors associated with burnout were explored by the univariate logistic regression model. Multivariate logistic regression analysis was applied to examine the independent risk factors of burnout among Thai Family Medicine residents. Results:There were 149 residents who participated in this study, with a response rate of 21% (n?=?703). As no residents diagnosed with burnout using the proposed criteria, burnout was, therefore, redefined as residents reporting high-level emotional exhaustion and high-level depersonalization. The prevalence of burnout in family medicine residents in this study was 10.74% (95% confidence interval [CI]: 6.26%-16.85%). Our study found that having relationship problems with patients, having relationship problems with colleagues, and having thought of resigning from the training program were independently associated with burnout with odds ratios of 6.93 (95% CI: 1.64-29.27), 6.31 (95% CI: 1.89-21.12), and 4.16 (95% CI: 1.09-15.81), respectively. Conclusions:Burnout at high level in emotional exhaustion and high level in depersonalization can occur among family medicine residents. Concerning factors were found to be patient and colleague relationship problems and having thought of resigning from the residency program. Other factors that may contribute to burnout were type of training programs, insufficient income, and family relationship. We recommend that the training institute should be able to monitor residents' stress level and to help prevent those who have burnout and reduce its impact.
Project description:Background?:Burnout rates for internal medicine residents are among the highest of all specialties, yet little is known about how residents recover from burnout. Objective?:We identified factors promoting recovery from burnout and factors that assist with the subsequent avoidance of burnout among internal medicine residents. Methods?:A purposive sample of postgraduate year 2 (PGY-2), PGY-3, and recent graduates who experienced and recovered from burnout during residency participated in semistructured, 60-minute interviews from June to August 2016. Using qualitative methods derived from grounded theory, saturation of themes occurred after 25 interviews. Coding was performed in an iterative fashion and consensus was reached on major themes. Results?:Coding revealed 2 different categories of resident burnout-circumstantial and existential-with differing recovery and avoidance methods. Circumstantial burnout stemmed from self-limited circumstances and environmental triggers. Recovery from, and subsequent avoidance of, circumstantial burnout arose from (1) resolving workplace challenges; (2) nurturing personal lives; and (3) taking time off. In contrast, existential burnout stemmed from a loss of meaning in medicine and an uncertain professional role. These themes were identified around recovery: (1) recognizing burnout and feeling validated; (2) connecting with patients and colleagues; (3) finding meaning in medicine; and (4) redefining a professional identity and role. Conclusions?:Our study suggests that residents experience different types of burnout and have variable methods by which they recover from and avoid further burnout. Categorizing residents' burnout into circumstantial versus existential experiences may serve as a helpful framework for formulating interventions.
Project description:Residents learn and participate in care within hospital cultures that 5 tolerate unprofessional conduct and cynical attitudes, labeled the "hidden curriculum." We hypothesized that this hidden curriculum 5 have deleterious effects on residents' professional development and investigated whether witnessing unprofessional behavior during residency was associated with burnout and cynicism.We surveyed internal medicine residents at 2 academic centers for 3 years (2008-2010). Hidden curriculum items assessed exposure to unprofessional conduct. We used regression analyses to examine if hidden curriculum scores were associated with cynicism and the Maslach Burnout Inventory depersonalization and emotional exhaustion domain scores.The response rate was 48% (337 of 708). In the 284 surveys analyzed, 45% of respondents met burnout criteria and had significantly higher hidden curriculum scores (26 versus 19, P < .001) than those not meeting criteria. In cross-sectional analyses, the hidden curriculum score was significantly associated with residents' depersonalization, emotional exhaustion, and cynicism scores. Cynicism scores were also associated with burnout.Exposure to unprofessional conduct was associated with higher burnout and cynicism scores among internal medicine residents. We also found that cynicism and burnout were significantly associated and 5 be measures of similar but not necessarily identical responses to the challenges posed by residency. Measuring the hidden curriculum and cynicism 5 provide direction for educators attempting to reform hospital culture and improve resident well-being.
Project description:BACKGROUND: Care transitions are common and highly vulnerable times during illness. Physicians need better training to improve care transitions. Existing transitional care curricula infrequently involve settings outside of the hospital or other health care disciplines. INTERVENTION: We created a curriculum to teach internal medicine residents how to provide better transitional care at hospital discharge through experiential, interdisciplinary learning in different care settings outside of the acute hospital, and we engaged other health care disciplines frequently involved in care transitions. SETTING/PARTICIPANTS: Nineteen postgraduate year-1 internal medicine trainees at an academic medical center in an urban location completed experiences in a postacute care facility, home health care, and outpatient clinics. PROGRAM DESCRIPTION: The 2-week required curriculum involved teachers from geriatric medicine; physical, occupational, and speech therapy; and home health care, with both didactic and experiential components and self-reflective exercises. PROGRAM EVALUATION: The curriculum was highly rated (6.86 on a 9-point scale) and was associated with a significant increase in the rating of the overall quality of transitional care education (from 4.09 on a 5-point scale in 2011 to 4.53 in 2012) on the annual residency program survey. Learners reported improved knowledge in key curricular areas and that they would change practice as a result of the curriculum. CONCLUSIONS: Our transitional care curriculum for internal medicine residents provides exposure to care settings and health care disciplines that patients frequently encounter. The curriculum has shown positive, short-term effects on learners' perceived knowledge and behavior.
Project description:Purpose. To determine family medicine residents' perceived knowledge and attitudes towards the built environment and their responsibility for health advocacy and to identify their perceived educational needs and barriers to patient education and advocacy. Methods. A web-based survey was conducted in Canada with University of Toronto family medicine residents. Data were analyzed descriptively. Results. 93% agreed or strongly agreed that built environment significantly impacts health. 64% thought educating patients on built environment is effective disease prevention; 52% considered this a role of family physicians. 78% reported that advocacy for built environment is effective disease prevention; 56% perceived this to be the family physician's role. 59% reported being knowledgeable to discuss how a patient's environment may affect his/her health; 35% reported being knowledgeable to participate in community discussions on built environment. 78% thought education would help with integration into practice. Inadequate time (92%), knowledge (73%), and remuneration (54%) were barriers. Conclusions. While residents perceived value in education and advocacy as disease prevention strategies and acknowledged the importance of a healthy built environment, they did not consider advocacy towards this the family physician's role. Barrier reduction and medical education may contribute to improved advocacy, ultimately improving physical activity levels and patient health outcomes.
Project description:BACKGROUND: Burnout has negative effects on work performance and patient care. The current standard for burnout assessment is the Maslach Burnout Inventory (MBI), a well-validated instrument consisting of 22 items answered on a 7-point Likert scale. However, the length of the MBI can limit its utility in physician surveys. OBJECTIVE: To evaluate the performance of two questions relative to the full MBI for measuring burnout. DESIGN AND PARTICIPANTS: Cross-sectional data from 2,248 medical students, 333 internal medicine residents, 465 internal medicine faculty, and 7,905 practicing surgeons. MEASUREMENTS AND MAIN RESULTS: The single questions with the highest factor loading on the emotional exhaustion (EE) ("I feel burned out from my work") and depersonalization (DP) ("I have become more callous toward people since I took this job") domains of burnout were evaluated in four large samples of medical students, internal medicine residents, internal medicine faculty, and practicing surgeons. Spearman correlations between the single EE question and the full EE domain score minus that question ranged from 0.76-0.83. Spearman correlations between the single DP question and the full DP domain score minus that question ranged from 0.61-0.72. Responses to the single item measures of emotional exhaustion and depersonalization stratified risk of high burnout in the relevant domain on the full MBI, with consistent patterns across the four sampled groups. CONCLUSIONS: Single item measures of emotional exhaustion and depersonalization provide meaningful information on burnout in medical professionals.