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Purpose Physicians are expected to provide compassionate, error-free care while navigating systemic challenges and organizational demands. Many are burning out. While organizations are scrambling to address the burnout crisis, physicians often resist interventions aimed at enhancing their wellness and building their resilience. The purpose of this research was to empirically study this phenomenon. Method Constructivist grounded theory was used to inform the iterative data collection and analysis process. In spring 2018, 22 faculty physicians working in Canada participated in semistructured interviews to discuss their experiences of wellness and burnout, their perceptions of wellness initiatives, and how their experiences and perceptions influence their uptake of the rapidly proliferating strategies aimed at nurturing their resilience. Themes were identified using constant comparative analysis. Results Participants suggested that the values of compassion espoused by health care organizations do not extend to physicians, and they described feeling dehumanized by professional values steeped in an invincibility myth in which physicians are expected to be "superhuman" and "sacrifice everything" for medicine. Participants described that professional values and organizational norms impeded work-life balance, hindered personal and professional fulfillment, and discouraged disclosure of struggles. In turn, participants seemed to resist wellness and resilience-building interventions focused on fixing individuals rather than broader systemic, organizational, and professional issues. Participants perceived that efforts aimed at building individual resilience are futile without changes in professional values and sustained organizational support. Conclusions Findings suggest that professional and organizational norms and expectations trigger feelings of dehumanization for some physicians. These feelings likely exacerbate burnout and may partly explain physicians' resistance to resilience-building strategies. Mitigating burnout and developing and sustaining a resilient physician workforce will require both individual resistance to problematic professional values and an institutional commitment to creating a culture of compassion for patients and physicians alike.

Burnout is a growing concern, with significant negative consequences for physicians and patient care. Burnout is negatively associated with physician empathy, while resilience may be a protective factor against the development of burnout but few studies have examined all three constructs in the same cohort. Understanding the associations between these constructs could aid in the development of interventions for physicians experiencing burnout and improve the delivery of compassionate care. We conducted a cross-sectional survey to determine levels of burnout, empathy and resilience in a sample of academic physicians and investigate the relationships between these variables. Validated scales were administered online to measure burnout (Maslach Burnout Inventory - Human Services Survey, MBI-HSS), empathy (Jefferson Scale of Empathy - Physicians/Health Professions Version, JSE) and resilience (Connor-Davidson Resilience Scale, CD-RISC). Descriptive statistics, correlation coefficients, and group comparisons were examined. Eighty-three physicians completed the JSE and CD-RISC, while a subset of 49 physicians also completed the MBI-HSS. Response rates were 31.9% and 18.8%, respectively. High burnout was reported by 49% of the sample. Physicians with high burnout reported lower levels of resilience than those who were not burnt-out. No differences in levels of empathy were observed between these two groups. Older physicians (>45 years) reported higher resilience scores than younger physicians. Resilience and empathy were significantly positively correlated. The reported rate of physician burnout in this sample of academic physicians is concerning, with burnout associated with lower levels of resilience. Further research is required to explore the relationship between physician age and resilience, the impact of resilience-building interventions on burnout and empathy in physicians, and how modifying these variables influences the delivery of compassionate care for patients.

Simulation-based education requires significant time and resources. As such, educators are often called on to provide evidence that their program or activities accomplish the desired goals and return on the investment. This is an essential, but often under-recognized, aspect of running a simulation program. Program evaluation is conducted to determine whether a program meets set goals; leads to the desired outcomes; and how the program was implemented [1].

Simulation is a pedagogical method known to be a generator of stress, that could be influenced by previous stressful experiences.The purpose of this study was to determine the impact of previous experience with a clinical critical event on the stress experienced by nursing students during simulation session of critical events, and on the stress experienced during clinical critical events subsequent to the training.Observational case-control study.Four critical event scenarios were created using full-scale simulation.Two hundred and fifteen undergraduate nursing students of semester four. The control group (n = 112) consisted of learners who had not previously experienced a critical event. The prior exposure group (n = 103) consisted of learners who had experienced a critical event prior to the course.Stress levels were assessed using the self-report stress numerical rating scale-11.There was no significant difference in the level of stress between the prior exposure group and the control group before, during or expected after the simulation session. A significant decrease in stress was observed in both groups from before the course to during the session (p 0.05) and expected after the session (p 0.05). There was no significant difference between the expected post-session stress level and the stress levels reported four months after the training (p = 0.966). At four months, there was no significant difference in stress levels between the groups (p = 0.212).The prior experience of a clinical critical event before a simulation course did not influence their reported stress level during the simulation session. Conversely, simulation-based training of critical situations appears to reduce the level of self-assessed stress during critical events in clinical practice after the training.

IntroductionThe proportion of older acute care physicians (ACPs) has been steadily increasing. Ageing is associated with physiological changes and prospective research investigating how such age-related physiological changes affect clinical performance, including crisis resource management (CRM) skills, is lacking. There is a gap in the literature on whether physician’s age influences baseline CRM performance and also learning from simulation. We aim to investigate whether ageing is associated with baseline CRM skills of ACPs (emergency, critical care and anaesthesia) using simulated crisis scenarios and to assess whether ageing influences learning from simulation-based education.Methods and analysisThis is a prospective cohort multicentre study recruiting ACPs from the Universities of Toronto and Ottawa, Canada. Each participant will manage an advanced cardiovascular life support crisis-simulated scenario (pretest) and then be debriefed on their CRM skills. They will then manage another simulated crisis scenario (immediate post-test). Three months after, participants will return to manage a third simulated crisis scenario (retention post-test). The relationship between biological age and chronological age will be assessed by measuring the participants CRM skills and their ability to learn from high-fidelity simulation.Ethics and disseminationThis protocol was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB Number 140–2015) and the Ottawa Health Science Network Research Ethics Board (#20150173–01H). The results will be disseminated in a peer-reviewed journal and at scientific meetings.Trial registration numberNCT02683447.

Simulation is now commonly used in health care education, and a growing body of evidence supports its positive impact on learning. However, simulation-based medical education (SBME) involves a range of modalities, instructional methods, and presentations associated with different advantages and limitations. This review aims at better understanding the nature of SBME, its theoretic and proven benefits, its delivery, and the challenges posed by SBME. Areas requiring further research and development are also discussed.

Purpose The goal of this study was to better understand how clinical supervisors integrate teaching interactions with medical trainees into 2 types of clinical activities in the critical care setting: multidisciplinary rounds and medical crises. Methods We conducted a qualitative, observational study based on an ethnographic approach. We observed the teaching interactions among clinical supervisors and medical trainees during 12 multidisciplinary rounds and 74 medical crises in 2 academic hospitals. Grounded theory methods (theoretical sampling and saturation, inductive thematic coding, and constant comparison) were used to analyze data. Results Two models of integration of teaching interactions into clinical activities are described: the in series model, typical of multidisciplinary rounds and characterized by well-structured learning bubbles uninterrupted by patient care, and the in parallel model, common during medical crises and involving multiple, short learning flashes intricately related to and frequently interrupted by patient care. By adopting a model over the other, supervisors appeared to adapt to 2 contexts that differed in terms of priority, supervisor's understanding of events, and social context of interactions. Each model presented complementary opportunities and limitations for learning. Conclusions Modern views of medical apprenticeship and clinical teaching need to take into account the specific clinical context in which learning occurs. Teaching interactions that differ in structure and content in response to changing clinical circumstances could impact learning in unique ways. Learning outcomes resulting from different models of integration of teaching into clinical activities need to be further explored.

Suicide risk assessment is a critical component of mental health practice for which the stakes are high and the outcomes uncertain. This research examines the consistency with which clinicians make determinations of suicide risk and factors influencing clinical confidence. Seventy-one social workers interviewed two standardized patients performing in scenarios depicting suicidal ideation, judged whether the patient required hospitalization, and completed standardized suicide risk assessment measures. Self-ratings and qualitative interviews explored participants’ confidence in their judgment of risk. Participants had highly divergent views regarding whether or not the risk of suicide was sufficiently high to require hospitalization. However, regardless of the ultimate decision reached, participants were equally confident when recommending either clinical course of action. The variation in risk assessment appraisals in this study, despite at times high rates of confidence in risk appraisals, speaks ...

Progressive trainee autonomy is considered essential for clinical learning, but potentially harmful for patients. How clinical supervisors and medical trainees establish progressive levels of autonomy in acute care environments without compromising patient safety is largely unknown.To explore how bedside interactions among supervisors and trainees relate to trainee involvement in patient care and to clinical oversight.We conducted a qualitative study based on constructivist grounded theory methodology. We used participant observation for our data collection. We observed the overt teaching interactions among trainees and staff physicians in the critical care units of two university-affiliated hospitals during 74 acute care episodes. Our analysis led to the elaboration of a theoretical model of clinical supervision.A model of interactive clinical supervision is proposed on the basis of three themes: engaging without enactment, sharing care with support, and caring independently with feedback. Each theme regroups different teaching interactions. Engaging in monologues and dialogues about patient care and facilitating hands-off care provision involved progressive levels of trainee involvement without risk for patients. Facilitating hands-on provision of care and providing support-in-action encouraged further trainee involvement with limited risks for patients. Providing feedback-on-action created additional learning opportunities based on trainee independent involvement in clinical activities.Engaging in teaching interactions during acute care episodes allows trainees to exercise progressive autonomy and supervisors to provide adequate clinical oversight. Our model of interactive clinical supervision can inform faculty development initiatives. Learning outcomes resulting from different levels of trainee autonomy should be further explored.

Professional judgment in complex clinical situations such as the assessment of suicide risk encompasses a multifaceted cognitive understanding of the substantive issues, technical expertise, and emotional awareness. This experimental design study investigated the degree to which the previous work-related experiences of clinicians and their preexisting emotional state influence professional judgment regarding acute risk in patients presenting with suicidal ideation. Experienced social workers and social work students conducted suicide risk assessments on 2 standardized patients performing in scenarios constructed to depict individuals presenting with suicidal ideation. This study revealed significant variations in clinical judgments of practitioners assessing suicide risk. While scores on standardized risk assessment measures were the strongest predictor of judgments regarding the need for hospitalization to ensure the safety of the patient, other influences included clinician age and levels of posttraumatic stress symptoms. Mental health clinicians and organizations that employ them should be aware of possible individual influences on professional judgments related to suicide risk.

Despite research identifying high levels of stress and traumatic stress symptoms among those in the emergency services, the impact of these symptoms on performance and hence public safety remains uncertain. This review paper discusses a program of research that has examined the effects of prior critical incident exposure, acute stress, and current post-traumatic symptoms on the performance and decision-making during an acutely stressful event among police officers, police communicators, paramedics and child protection workers. Four studies, using simulation methods involving video simulators, human-patient simulators, and/or standardized patients, examined the performance of emergency workers in typical workplace situations related to their individual profession. Results varied according to level of acuity of stress and the nature of performance and decision-making. There was no evidence that PTSD had a direct impact on global performance on tasks for which emergency responders are highly trained. However, PTSD was associated with assessment of risk in situations that required professional judgement. Further, individuals experiencing PTSD symptoms reported higher levels of acute stress when faced with high acuity situations. Acute stress in these studies was associated with performance deficits on complex cognitive tasks, verbal memory impairment and heightened assessment of risk.

Contains fulltext : 175727.pdf (Publisher’s version ) (Open Access) BACKGROUND: Simulation-based medical education (SBME) has traditionally been conducted as off-site simulation in simulation centres. Some hospital departments also provide off-site simulation using in-house training room(s) set up for simulation away from the clinical setting, and these activities are called in-house training. In-house training facilities can be part of hospital departments and resemble to some extent simulation centres but often have less technical equipment. In situ simulation, introduced over the past decade, mainly comprises of team-based activities and occurs in patient care units with healthcare professionals in their own working environment. Thus, this intentional blend of simulation and real working environments means that in situ simulation brings simulation to the real working environment and provides training where people work. In situ simulation can be either announced or unannounced, the latter also known as a drill. This article presents and discusses the design of SBME and the advantage and disadvantage of the different simulation settings, such as training in simulation-centres, in-house simulations in hospital departments, announced or unannounced in situ simulations. DISCUSSION: Non-randomised studies argue that in situ simulation is more effective for educational purposes than other types of simulation settings. Conversely, the few comparison studies that exist, either randomised or retrospective, show that choice of setting does not seem to influence individual or team learning. However, hospital department-based simulations, such as in-house simulation and in situ simulation, lead to a gain in organisational learning. To our knowledge no studies have compared announced and unannounced in situ simulation. The literature suggests some improved organisational learning from unannounced in situ simulation; however, unannounced in situ simulation was also found to be challenging to plan and conduct, and more stressful among participants. The importance of setting, context and fidelity are discussed. Based on the current limited research we suggest that choice of setting for simulations does not seem to influence individual and team learning. Department-based local simulation, such as simulation in-house and especially in situ simulation, leads to gains in organisational learning. The overall objectives of simulation-based education and factors such as feasibility can help determine choice of simulation setting.

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.

Simulation-based education requires significant time and resources. As such, educators are often required to provide evidence that the program accomplishes the desired goals, and that the performance measures obtained in this format are valid and reliable. In this light, the current chapter provided an overview of two related concepts. Program evaluation is conducted to determine whether a program led to the desired outcomes (outcomes-based evaluation) and to determine how a program was implanted (process-based evaluation). In a related goal, assessment of learning is conducted to determine a learner’s level of knowledge or ability, and requires attention to ensuring the reliability and validity of the measures used.

Enhanced podcasts increase learning, but evidence is lacking on how they should be designed to optimize their effectiveness. This study assessed the impact two learning instructional design methods (mental practice and modeling), either on their own or in combination, for teaching complex cognitive medical content when incorporated into enhanced podcasts. Sixty-three medical students were randomised to one of four versions of an airway management enhanced podcast: (1) control: narrated presentation; (2) modeling: narration with video demonstration of skills; (3) mental practice: narrated presentation with guided mental practice; (4) combined: modeling and mental practice. One week later, students managed a manikin-based simulated airway crisis. Knowledge acquisition was assessed by baseline and retention multiple-choice quizzes. Two blinded raters assessed all videos obtained from simulated crises to measure the students’ skills using a key-elements scale, critical error checklist, and the Ottawa global rating scale (GRS). Baseline knowledge was not different between all four groups (p = 0.65). One week later, knowledge retention was significantly higher for (1) both the mental practice and modeling group than the control group (p = 0.01; p = 0.01, respectively) and (2) the combined mental practice and modeling group compared to all other groups (all ps = 0.01). Regarding skills acquisition, the control group significantly under-performed in comparison to all other groups on the key-events scale (all ps ≤ 0.05), the critical error checklist (all ps ≤ 0.05), and the Ottawa GRS (all ps ≤ 0.05). The combination of mental practice and modeling led to greater improvement on the key events checklist (p = 0.01) compared to either strategy alone. However, the combination of the two strategies did not result in any further learning gains on the two other measures of clinical performance (all ps > 0.05). The effectiveness of enhanced podcasts for knowledge retention and clinical skill acquisition is increased with either mental practice or modeling. The combination of mental practice and modeling had synergistic effects on knowledge retention, but conveyed less clear advantages in its application through clinical skills.

Contains fulltext : 152730.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact. DESIGN: Investigator-initiated single-centre randomised superiority educational trial. SETTING: Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark. PARTICIPANTS: 100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology. INTERVENTIONS: Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting. PRIMARY OUTCOME: Knowledge assessed by a multiple choice question test. EXPLORATORY OUTCOMES: Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes. RESULTS: The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level. CONCLUSIONS: In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes. TRIAL REGISTRATION NUMBER: NCT01792674.

Both enhancements and impairments of clinical performance due to acute stress have been reported, often as a function of the intensity of an individual's response. According to the broader stress literature, peripheral or extrinsic stressors (ES) and task-contingent or intrinsic stressors (IS) can be distinguished within a stressful situation. The objective of this study was to assess the impact of IS and ES on clinical performance.A prospective randomized crossover study was undertaken with third-year medical students conducting two medical experiences with simulated patients. The effects of severity of the disease (IS) and the patient's aggressiveness (ES) were studied. A total of 109 students were assigned to four groups according to the presence of ES and IS. Subjective stress and anxiety responses were assessed before and after each experience. The students' clinical skills, diagnostic accuracy and argumentation were assessed as clinical performance measures. Sex and student-perceived cognitive difficulty of the task were considered as adjustment variables.Both types of stressors improved clinical performance. IS improved diagnostic accuracy (regression parameter β = 9.7, p = 0.004) and differential argumentation (β = 5.9, p = 0.02), whereas ES improved clinical examination (β = 12.3, p0.001) and communication skills (β = 15.4, p0.001). The student-perceived cognitive difficulty of the task was a strong deleterious factor on both stress and performance.In simulated consultation, extrinsic and intrinsic stressors both have a positive but different effect on clinical performance.

In this issue, Lyndon et al. [1] present the results of a systematic review on the relationship between academic assessment and psychological distress among medical students. One of their main findings is that different types of assessments are associated with subjective and physiological stress in medical students. As someone who has studied emotions, particularly stress, for 10 years, it would be easy for my response to be ‘of course!’ Medical training and practice are awash with emotional situations, from undergoing high stakes assessments, to the fear of making costly mistakes, to witnessing heartbreaking loss and death. However, this aspect of medical education has, for the most part, been ignored or merely superficially addressed in our study of how medical students learn and perform [2]. The Lyndon et al. paper [1] shines a light on an important and often neglected aspect of learning and performance. Research on how medical trainees learn, reason through clinical situations, or interact with patients has tended to focus on the knowledge and skills they require and how to develop them. However, there is overwhelming evidence from the psychological and neuroscience domains showing that emotions cannot be separated from cognitive functions [3]. We, as humans, are always in an emotional state of some kind. These emotions are instrumental in shaping how we attend to the world, what we remember from our experiences and how we make decisions. While there is growing interest in this topic in medical education, Lyndon et al. [1] highlight the nascent nature and disparity of the research to date on this topic. They are left, as is often the case for meta-analyses in medical education, with one sure conclusion: more research is needed. In our continued study of the impact of emotions, it is essential that research be guided by current theories, and that it builds on what is already known beyond medical education. As a construct, stress is highly complex. As an experience, however, it is powerfully familiar. As a result, we have many common sense beliefs about emotions. Furthermore, outdated theories, such as the Yerkes–Dodson law discussed by Lyndon et al. [1], maintain their appeal because of their simplicity and because they feel right. However, these common sense beliefs and theories do not capture the true complexity of the emotional response and the mechanisms by which they influence learning and performance. In contrast, current models of emotions, based on appraisal processes [3, 4], provide an elegant mechanism to explain stress responses: When faced with a situation (e.g. in-training examination) that can impede the achievement of a closely held goal (being top of class, becoming a doctor), a person makes an appraisal of the demands of the situation (how challenging is the exam) and of their resources to meet those demands (how much do I know? how well can I perform the skill?). If the resources are thought to meet the demands, then a positive state of eustress occurs and the individual mobilizes energy to the task (productive preparation). If, however, the demands are thought to outweigh the resources (I don’t know the Krebs cycle) or there is uncertainty (I don’t know what this instructor is looking for in my performance), then the person will feel distress. Thus, current models of stress, rather than fitting the curvilinear pattern of the Yerkes–Dodson law, resemble a more qualitative shift. This state of distress, as has been shown by a wealth of research, is accompanied by the activation of certain physiological systems (leading to the release of cortisol and alpha-amylase), and subjective experiences of fear, anxiety, agitation, etc. Both the physiological and the subjective responses influence attention, memory and decision-making processes [3]. If we are to truly understand the mechanisms of stress, and its impact on learning and performance, future research endeavours need to build on what is already known beyond the field of medical education. In addition to the need for more rigorous research on emotions and their impact on learning and performance, medical educators are tasked with a practical challenge. How do we deal with the fact that students are stressed by their academic and clinical environments? One approach could be to do nothing, to leave the onus on the individual to develop the necessary coping skills needed to become a health professional. The problem with taking this approach, which has essentially been our modus operandus for the past 30 years, is that not everyone will develop adaptive coping styles. In the health professions, the rates of posttraumatic stress, burnout, sick leave and absenteeism are high [5, 6]. Left to their own devices, many health professionals develop maladaptive ways to cope with the stressors of training and practice, to the detriment of their mental health and performance. An alternative is to select, in our admissions processes, those individuals who can handle the emotional load of medicine. An example of this approach is the recent interest in screening incoming medical students for their emotional intelligence [7]. There are several challenges with this approach, however [8]. The first is that constructs like emotional intelligence are currently of little value to educators. They are too general and they mean too many things to too many people. A second challenge is that we do not know the characteristics of those individuals who are resilient to the stressors of medical training and practice. Stress is a very situation-specific response. A person can get stressed by a verbal exam (due to being in the ‘hot seat’ or the ‘fish bowl’) and yet think nothing of a trauma resuscitation that would be quite gruesome to the average person. There do not appear to be a general set of stable characteristics that predict who will cope well with the emotional world of medicine. We can’t continue to neglect the emotional aspects of medical training, and it would be unethical to screen for resilience, because we don’t know what factors predict resilience to the stressors of medical training and practice. What we can—and must—do, as educators, is provide students with the skills required to maintain cognitive function during emotional events. This goal is achievable. Effective methods of emotional regulation, such as stress inoculation training and approaches that target situation reappraisal rather than emotional suppression, can reduce subjective and physiological stress and increase cognitive function and performance [9–12]. This is a promising area of future research for medical education. In summary, Lyndon et al. [1] highlight an important, and often neglected, area of medical education. They also show that research into the emotional aspects of medical training is sparse and the findings disparate. My hope is that their paper will serve to foster more research, building on what is already known outside of medicine. The ultimate goal is to better understand the emotional aspect of medical training and, as a result, to better prepare future health professionals.

CONCLUSIONS: Introduction of the Top Gun competition increased resident attendance at the MC-ACS meetings with positive survey feedback and could be considered as a strategy to increase local chapter involvement. In such competitive settings, there were no differences in performance among residents of different training levels, highlighting a potential role for team training and practice that improves junior performance. Laparoscopic tasks were responsible for differentiating the top teams.