October 2020

posted in: 2020 Journal Clubs | 0

Spoiler alert---it gets worse Natural history of burnout, stress and fatigue in a pediatric resident cohort over three years.

Koressel L, Groothuis E, Tanz R, Palac H, Sanguino S. Medical Education Online (2020). DOI: 10.1080/10872981.2020.1815386



Reviewed by Dana Goplerud and Amit Pahwa What was the study question? How do measures of burnout, stress and resilience change throughout the course of pediatric residency? How was the study done? This study surveyed a cohort of 33 incoming pediatric residents at one institution. The authors used 5 validated tools to describe resident’s wellbeing, including the Abbreviated Maslach Burnout Inventory (AMBI), the Perceived Stress Scale (PSS), the Epworth Sleepiness Scale (ESS), the Connor-Davidson Resilience Scale (CS-RISC10), and the Social Connectedness Scale-Revised (SCS-R). Residents were surveyed twice yearly for a total of 6 surveys, with the first survey administered in orientation prior to PGY1 and the last at graduation. What were the results? 30 residents (91%) completed more than 1 survey, and 23 residents (70%) completed at least 4 out of 6 surveys. The best scores for each of the AMBI, PSS, ESS, CS-RISC10 were recorded at orientation before PGY-1, and scores tended to deteriorate over time. The worst mean scores for burnout and perceived stress occurred at mid-PGY1 and the PGY1/2 transition. The mean scores for the burnout subscales of emotional exhaustion and depersonalization exceeded the reference range at each time point after PGY1 orientation. The mean sleepiness score peaked at mid-PGY2. Resilience decreased over time, with its worst mean score at the PGY2/3 transition. Social connectedness declined with its worst score at the PGY2/3 transition, but rebounded to above the baseline at the end of residency. Other than the social connectedness scale, no other survey returned to its best baseline score. More than 65% of residents had scores worse than baseline on 90% of follow-up surveys. What are the implications? This study demonstrates that burnout, stress, and fatigue are prevalent among pediatric residents. These pressures peak mid-PGY1 through PGY2, and trainees do not return to their baseline at the completion of their residency. Residency programs should anticipate in this decline in wellbeing and introduce effective interventions early in training. Importantly, systemic interventions should be built into residency programs to prevent burnout from occurring, rather than simply responding after the damage has occurred. Editor’s Comments: I was surprised to see that the residents’ best level of function occurred at the beginning of residency. Many of us who are involved with medical student education have seen a high level of burnout, stress and fatigue in medical school as well. It would be interesting to see how the scores on these surveys change during the four years of medical school. (JG) It takes a village What Are the Unique Mentorship Needs of Fourth-Year Medical Students Applying to Pediatrics Residency? Lester TR, Rassbach CE, Blankenburg R. [published online ahead of print, 2020 May 8]. Acad Pediatr. 2020;S1876-2859(20)30181-9. https://doi.org/10.1016/j.acap.2020.05.002 Reviewed by Aleisha Nabower What was the study question? What are the mentorship needs of fourth year medical students applying to pediatrics residency? How was the study done? Categorical pediatric interns from a single institution participated in four focus groups led by near-peer investigators using a guide. Discussions were recorded and transcribed and participants filled out a demographic survey. Based on grounded theory, data analysis was conducted on an ongoing basis, with the transcripts being coded by 2 investigators using the constant comparative approach. Codes were then organized into categories and themes which a third investigator reviewed for validation. A member check was performed, with 89% of participants providing validation that the themes were consistent with their views. What were the results? Eighteen participants from 15 different medical schools were included. All were assigned a mentor by their medical school, but only 61% reported that this assigned mentor was effective. Sixteen participants identified near-peer mentors, only one of which was assigned. 88% of students reported near peer mentors as effective. Four themes were identified: Effective mentors guide self-reflection by students; multiple mentors from varied backgrounds are helpful; key components were often missing from discussions with mentors (couples matching, leaving geographic area, financial aspects, and emotional support); and students found it difficult to be honest with their mentors if there was a perceived conflict of interest. What are the implications? Fourth year medical students have unique mentoring needs that often require multiple people. Encouraging and facilitating students to have both faculty and near-peer mentors is important. Ensuring at least one mentor without a conflicting interest is available and maintaining a list of potential mentors for unique circumstances can help address areas students reported as lacking. Editor’s Comments: This study nicely highlights different factors that students may require mentorship on as they apply for pediatric residency programs, including preparation for the specialty, the application process itself, and consideration of personal factors. It makes sense, then that different mentors with different areas of expertise and different relationships with the students would be needed to address each of these factors. While the study focused specifically on the experiences of those entering a pediatrics residency program, it seems likely that these same broad factors would be applicable to any discipline. (KFo) Clerkship grades for residency applicants The Current Status of Medical School Clerkship Grades in Residency Applicants Vokes, J., Greenstein, A., Carmody, E., & Gorczyca, J.T. Journal of Graduate Medical Education, 2020, 12(2), 145-149 https://doi.org/10.4300/JGME-D-19-00468.1 Reviewed by Michele Haight What was the study question? What is the utility of using an “Honors” clerkship grade as a data point in evaluating residency applicants? How was the study done? Data in ERAS were gleaned from student applicants to the 2017 orthopedic NRMP Match at one institution. The data collected included grade distribution data. Of 146 allopathic medical schools in the US, 86 matched the criteria to be included in this study. Data for percentage of assigned “honors” grades were extracted via graphs and tables included in the students’ MSPE. The same was done for grades of “high pass” and “pass.” Grade distribution data were collected for the following core clerkships: family medicine, psychiatry, pediatrics, OB-GYN, surgery, and internal medicine. The national average percent of honors grades was calculated for each clerkship using the combined data for all schools with complete data. Sixteen of the schools included in this study were ranked in the top quartile of the US News and World Report. Their percentage of assigned honors grades was compared with the other 70 schools included in the study. A one-tailed t-test was then performed to compare the percentage of honors grades given by the individual clerkships within the two groups. Descriptive statistics were performed, and inter-quartile ranges were identified. What were the results? For the surgery clerkship, between 9% and 80% of students received a “high pass,” and between 2% and 84% received a “pass.” This high rate of inter-institutional variability was present across all clerkships. Schools in the top quartile of awarding honors grades did so consistently across all clerkships when compared with schools in the other quartiles. What are the implications of this study? Because there is not a standardized process for determining clerkship grades for all US medical schools, there is a high degree of inter-institutional variability. As a result, an honors grade as a data point for residency selection is unreliable. These results support the results of the 2009 study by Harris et al., which concluded that because it is difficult to compare honors grades among different medical schools, an “honors” designation as a less useful to appraise resident applicants. A more standardized grading system across medical schools can serve to increase the utility of clerkship grades in evaluating potential residents. Editor’s comments: I surmise that most of us will not be surprised by these findings. MSPEs that display the distribution of clerkship grades at any given institution can be helpful, e.g., an Honors grade in a clerkship where 20% of students receive an Honors grade is likely to be more helpful for residency program directors than an Honors grade in a clerkship where 60% of students get that grade. The High Pass grade can be tricky because, while it might advantage the students who are close to Honors, it is likely to disadvantage the students who receive a Pass grade because it makes that grade appear much worse. (RR) “As Step 1 has gone to P/NP, it seems that this has re-energized the discussion to reevaluate residency selection criteria.” (RR)