Burnout Status and Milestone Performance in Pediatric Residents
Burnout Status and Milestone Performance in Pediatric Residents Betty B. Staples, Maneesh Batra, John Mahan, Alan Schwartz, Charles Schubert, Paria Wilson, Hilary Mc. Clafferty, Kathi J. Kemper, Janet R. Serwint For the Pediatric Resident Burnout – Resilience Study Consortium
All authors have documented that we have no financial relationships to disclose or Conflicts of Interest (COIs) to resolve
Pediatric Resident Burnout-Resilience Study Consortium (PRB-RSC) Established in 2015 Goals: 1. Improve pediatric resident resilience and attributes of wellness 2. Describe the epidemiology and relationships between burnout, resilience, and attributes of wellness 3. Test interventions that positively impact burnout, resilience, and attributes of wellness
Background Prevalence of burnout among pediatricians: • 30 -50% Prevalence of burnout among pediatric residents: • 46 -75% Mc. Clafferty Pediatrics 2014; Pantaleoni, Acad Pediatr 2014; Fahrenkopf 2008
Background Resident burnout has been associated with: • Poor resident health • Impaired resident performance Dyrbye, JAMA 2010; Is. Hak, J Grad Med Ed 2009, Baer, Pediatrics 2017
Background Limitations of previous resident performance studies: • Performance based on self-report • Most limited to a single/few programs with one recent exception • Conflicting data with external assessment Baer Pediatrics 2013, West JAMA 2011, Fahrenkopf, BMJ 2008, Lafreniere, J Gen Intern Med 2016, Beckman, J Gen Intern Med 2012.
Background Resident Performance Assessment: Milestones “. . . Milestones are competency-based developmental outcomes (e. g. , knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents/fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. ” ACGME. "Frequently Asked Questions: Milestones. " ACGME. org. 2015
Background Domains of Competence: PC- Patient Care SBP- Systems Based Practice PBLI- Practice Based Learning and Improvement PROF- Professionalism ICS- Interpersonal and Communication Skills MK- Medical Knowledge
Background Clinical Competency Committees (CCC): • Three or more members of the active teaching faculty …reviews the progress of all residents in the program. • Utilizes data from all assessments in the program. • Prepare and ensure reporting of Milestone evaluations of each resident/fellow semiannually to the ACGME. Andolsek, Clinical Competency Committees A Guidebook for Programs. ACGME, 2015.
Objective • To compare the mean Milestone scores between pediatric residents who met criteria for burnout and those who did not by level of training. Hypothesis • We hypothesized that burnout would be most closely associated with decreased Milestone performance in patient care, professionalism and interpersonal communication skills and the association would not differ by program level.
Participating Institutions 31 institutions
Methods • Burnout – Resilience: confidential, online survey of all PRB-RSC residents via APPD LEARN from April-June of 2016 • No exclusion criteria • IRB approval at each individual institution
Methods: Survey Tool • Total of 141 items, 12 -15 min to complete • Demographics & Residency Characteristics Age, Race Gender Marital status Debt Year of training Proximity to weekend and vacation Type of rotation Recent experiences (e. g. , night call, patient death) • Attributes of Wellness Maslach Burnout Inventory Global Health Scale Perceived Stress Scale Hatch Spirituality Cognitive and Affective Mindfulness Scale Brief Resilience Scale Neff’s Self Compassion Scale Perspective Taking Scale Empathic Concern Scale Calm Compassionate Care Scale Epworth Sleepiness Scale
Methods Maslach Burnout Inventory (MBI) • Criterion standard for measuring burnout • Validated 22 -item questionnaire • 3 subscales: • Depersonalization (DP) • Emotional Exhaustion (EE) • Personal Accomplishment (PA) • By convention, high score in DP (≥ 27) or EE (≥ 10) defined ‘burned out’
Methods Milestone Reporting • Milestone assessment data generated by CCC • Data submitted by program to APPD LEARN • Data paired with MBI result
Methods: Statistical Analyses Mean Milestone performance was calculated for each resident in each domain of competence. Multivariate analyses were performed: • Dependent variable o Domains of competence • Independent variables o o Post-Graduate Year (PGY) MBI score (overall burnout score or specific burnout domain score) Interactions between PGY and MBI were conducted, accounting for clustering within program by means of a random effect.
Response Rates • 71% (1690/2368) of eligible residents completed the MBI • 92% (2173/2368) of residents had Milestones submitted to APPD LEARN • 1495 residents completed an MBI and had Milestones submitted • 1307 categorical peds, 116 med/peds, 72 combined programs
Results Milestone Performance vs Burnout Status in All Residents n = 1495, burnout prevalence= 56% 4 Burnout + 3. 9 Performance 3. 8 3. 7 3. 6 3. 5 3. 4 3. 3 3. 2 Performance Differential *PC *SBP *PBLI *PROF *ICS *MK 0. 16 0. 15 0. 14 0. 13 0. 15 0. 11 *P < 0. 005
Results Milestone Performance vs Burnout Status in Categorical PGY 1 s n = 442, burnout prevalence= 60% 4 Burnout + 3. 5 Performance 3 2. 5 2 1. 5 1 0. 5 0 Performance Differential *PC *SBP *PBLI *PROF *ICS MK 0. 20 0. 18 0. 16 0. 15 0. 17 0. 01 *P < 0. 05
Results Milestone Performance vs Burnout Status in All Categorical PGY 2 s n = 435, burnout prevalence= 56% 4 Burnout + 3. 5 Performance 3 2. 5 2 1. 5 1 0. 5 0 Performance Differential PC SBP PBLI PROF ICS MK 0. 08 0. 10 0. 05 *P < 0. 05
Results Milestone Performance vs Burnout Status in All Categorical PGY 3 s n = 429, burnout prevalence= 49% Burnout - 4 Burnout + 3. 5 Performance 3 2. 5 2 1. 5 1 0. 5 0 Performance Differential PC SBP PBLI PROF ICS MK -0. 02 0. 03 -0. 01 0. 00 -0. 01 0. 04 *P < 0. 05
Results Multivariate Models PC SBP PBLI PROF ICS Depersonalization Lack of Personal Accomplishment Indicates that the burnout component/ resilience is associated with lower milestone domain scores with a p<0. 05. MK
Limitations • Dependent on self-reporting of burnout • Cross-sectional study design • Program participation in PRB-RSC voluntary
Conclusions • Burnout status is significantly associated with decreased Milestones for first year categorical pediatric residents. • Multivariate analyses in first year categorical pediatrics residents demonstrates that depersonalization and lack of personal accomplishment components of burnout are associated with lower Milestone scores. Emotional exhaustion was not.
Speculation • Are first year residents more susceptible to ‘paying the price’ for burnout with burnout affecting performance adversely? • Conversely do senior residents learn over time (with experience) how to perform as well even when burned out? • Should we particularly focus on ‘preserving personalization’ (preventing depersonalization) and ‘promoting the sense of personal accomplishment’ as important targets in efforts to prevent burnout in early residents (interns)?
Future Directions • Continue to follow same residents for 2 more years to provide longitudinal data. • Follow same residents for 3 total years • Obtain larger data set for Med/Peds • Future research to address whether strategies to mitigate burnout result in improved PGY 1 performance. • Interventions to improve Milestone performance for PGY 1 s may specifically target depersonalization and personal accomplishment.
Participating PRB-RSC Institutions Albert Einstein College of Medicine U of California San Diego/ Rady Children’s Baylor College of Medicine/Texas Children’s U of Cincinnati/Cincinnati Children’s Boston Children’s Hospital U of Colorado/Denver Children's Carolinas Medical Center U of Illinois Chicago Case Western/Rainbow Babies and Children's U of Kansas Duke U U of Louisville Inova Fairfax Medical Campus U of Michigan Johns Hopkins U U of Minnesota Mayo Clinic College of Medicine U of New Mexico Medical College of Wisconsin U of Oklahoma- Oklahoma City Northwestern U/Lurie Children's U of Oklahoma- Tulsa Ohio State U/Nationwide Children's U of Pittsburgh Tufts Medical Center U of Washington/Seattle Children's U of Arizona U of Wisconsin U of California Davis Wright State U U of California Los Angeles/Mattel Children’s
http: //pedsresresilience. com
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