Avital Sabrina Fischer

All Publications

• Occupational distress factors associated with suicidal ideation among physicians and comparison with other US workers. Academic medicine : journal of the Association of American Medical Colleges Fischer, A., Shanafelt, T. D., Dyrbye, L. N., West, C. P., Sinsky, C. A., Tutty, M., Wang, H., Carlasare, L. E., Trockel, M. T. 2026

  Abstract

  This study evaluates associations with suicidal ideation (SI) of impact of work on personal relationships (IWPR), self-valuation (SV), and imposter phenomenon and compares the SI point prevalence in physicians vs other workers.This study used American Medical Association Physician Professional Data to sample US physicians across different specialties between November 2020 and March 2021. Of 7,360 survey respondents, 6,497 (88.3%) completed the SI question. A probability-based sample included 2,508 nonphysician individuals from the US population employed at the time of survey administration, with 2,501 workers (99.7%) completing the SI item. Logistic regression was used to evaluate associations of occupational distress factors, including IWPR, SV, imposter phenomenon, and other factors, with SI before and after adjusting for depression and compare the risk of SI among physicians with other US workers.The study included 6,497 physicians and 2,501 workers in other fields. Adjusting for sex, age, relationship status, parenting status, and depression, each 1-point higher IWPR score (range, 0-10) was associated with 10% increased SI odds (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Adjusting for the same variables, each 1-point higher SV score (range, 0-10) was associated with 10% lower SI odds (OR, 0.90; 95% CI, 0.85-0.95). The association between imposter phenomenon scores (range, 4-20) and SI was not statistically significant (OR, 1.03; 95% CI, 0.99-1.08). The unadjusted 1-year SI point prevalence was 6.6% (95% CI, 6.0%-7.4%) in physicians vs 5.6% (95% CI, 4.7%-6.6%) among workers in other fields (P =  .09). In a multivariable model, workers in other fields with a bachelor's or master's degree had lower SI odds compared with physicians (OR, 0.64; 95% CI, 0.46-0.87).IWPR and low SV are associated with SI among physicians, independent of depression. Development and evaluation of interventions designed to mitigate these factors in physicians may be warranted.

  View details for DOI 10.1093/acamed/wvag179

  View details for PubMedID 42301925

• Impact of moral distress on burn-out: a cross-sectional survey of front-line family physicians during the initial wave of the COVID-19 pandemic. BMJ open Fischer, A. S., Fenning, R., Robb, J. M., Slater, A., Mai, U., Lam, T., De La Cruz, J. P., Billimek, J., Shapiro, J., Nguyen, T., Haq, C. 2025; 15 (2): e089980

  Abstract

  OBJECTIVES: Primary care clinicians are especially prone to burn-out. The primary objective of this study was to investigate factors contributing to burn-out and moral distress and their relationship among practising family physicians (FPs) in California early in the COVID-19 pandemic.DESIGN: Cross-sectional study, online survey evaluating burn-out, moral distress and associated factors.SETTING: California FPs between July and August 2020 practising in community health centres, hospital systems, private clinics and university systems were surveyed with a 22-item online questionnaire.PARTICIPANTS: FPs practising in California were eligible. The final sample included 218 physicians.PRIMARY AND SECONDARY OUTCOME MEASURES: The primary independent variable was frequency of moral distress and the primary outcome variable was worsening burn-out. Moderator variables included gender and employer support.RESULTS: FPs experiencing higher burn-out and moral distress were more likely to report concerns regarding personal COVID-19 risk and lack of personal protective equipment. Practising self-care and personal wellness were associated with decreased moral distress. Female physicians were 3.86-fold more likely to report worsening burn-out compared with male physicians. Employer support was associated with a 59% reduced burn-out risk and 54% reduction in frequent moral distress. Frequent moral distress was associated with a 3.12- fold higher burn-out risk. Gender moderated the relationship between moral distress and burn-out. Moral distress was associated with a 3.55-fold increase in burn-out risk among females.CONCLUSIONS: Female FPs experienced greater levels of moral distress and burn-out than male physicians. Moral distress was differentially associated with increased burn-out among female physicians. Employer support was a protective factor against moral distress and burn-out.

  View details for DOI 10.1136/bmjopen-2024-089980

  View details for PubMedID 39933805

• Supporting a Culture of Wellness: Examining the Utility of the Residency Program Community Well-Being Instrument in the Medical Training and Work Environment. Academic medicine : journal of the Association of American Medical Colleges Trockel, M., Fischer, A. 2023

  Abstract

  Physicians are experiencing symptoms of burnout at unprecedented rates. It is essential to assess programmatic factors contributing to physician burnout as actionable items for work climate improvement. Creation of an evidence base of strategies and methods to cultivate a culture of wellness requires iterative assessment, program development and implementation, and evaluation. To serve their function optimally, assessment tools need to be reliable, valid, and sensitive to change. In this Invited Commentary, the authors discuss Vermette and colleagues' report on the Residency Program Community Well-Being (RCWB) instrument. The authors examine the utility of the RCWB, a novel, validated tool that quantifies the subjective community well-being of an individual residency program and has 3 subscales that measure key aspects of interpersonal interactions among residents, with emphasis on those within the program leadership sphere of influence. The commentary authors recommend further validation of the RCWB, but acknowledge the instrument is a useful contribution to currently available measures in the domains of community well-being, workplace climate, and culture of wellness. Workplace interventions focused on community well-being or culture of wellness are particularly salient ethical and educational priorities for medical training programs. Prioritizing community well-being will help nurture trainees as an investment in the future of medical care, rather than an exploitable resource valued primarily for short-term work demands.

  View details for DOI 10.1097/ACM.0000000000005163

  View details for PubMedID 36745876

• Views from the trenches: California family physicians' challenges and resilience factors while providing patient care during the initial wave of COVID-19. Qualitative research in medicine & healthcare Fischer, A., Shapiro, J., Nguyen, T., Meckler, G., Lam, T., Mai, U., Fenning, R., De La Cruz, J. P., Haq, C. 2022; 6 (2): 10296

  Abstract

  This study examined challenges and factors promoting resilience among 20 California family physicians (FPs) during the first six months of the COVID-19 pandemic. A subset of academic, community, and resident FPs who responded to an online survey also participated in a semi-structured interview that explored concerns, moral distress, burnout, resource needs, support systems, coping strategies, and motivation to continue caring for patients. Thematic analysis was used to identify common themes in participant interviews. Interviewees demonstrated adaptability, resilience, and grit (i.e., commitment to completing a valued goal in the face of setbacks and adversity) despite challenges disrupting patient care, fears for family and self, and frustration due to the politicization of the pandemic. Factors promoting well-being and perseverance included professional and personal support, strong coping skills, and focusing on the meaning derived from practicing medicine. A service orientation that permeates family medicine philosophy and values motivated practitioners to continue to provide patient care while dealing with overwhelming personal and structural challenges. FPs drew strength from their internal coping skills, core family medicine values, and external support, notwithstanding demoralizing effects of mixed messages and politicization of the pandemic. FPs demonstrated resilience and grit in the face of challenges created by the COVID-19 pandemic. Ensuring adequate resources to promote a physically and psychologically healthy workforce while increasing access to care for all patients is crucial to prepare for the next healthcare crisis.

  View details for DOI 10.4081/qrmh.2022.10296

  View details for PubMedID 37440773

• Selective serotonin reuptake inhibitors associated with increased mortality risk in breast cancer patients in Northern Israel. International journal of epidemiology Fischer, A., Rennert, H. S., Rennert, G. 2022

  Abstract

  Approximately one in six women in the USA takes antidepressants and a third use selective serotonin reuptake inhibitors (SSRIs) after breast cancer diagnosis. Recent investigation demonstrated serotonin receptor (5-HTR2B) expression in the breast and serotonin production as an indicator of poor breast cancer prognosis. This study investigates the association between SSRI use at different time intervals relative to breast cancer diagnosis on survival.A population-based sample of 6959 consecutive, newly diagnosed breast cancer cases in Northern Israel was included. Patients were recruited from January 2000 and followed up through March 2020. Participants completed risk factor questionnaires regarding medical, reproductive and family history, medication use and health habits. Full prescription data were available through the Israeli national Clalit medical database. Multivariate Cox proportional hazard models were used to determine survival based on time of SSRI use.Use of SSRIs in the 5 years prior to breast cancer diagnosis was associated with a 66% increase in overall mortality (HRadj = 1.66; CI: 1.05-2.63). SSRI use that initiated after breast cancer diagnosis was associated with an 81% increase in mortality (HRadj = 1.81; CI: 1.58-2.06). Use of SSRIs in the 5 years post-diagnosis was associated with a dose-response increase (P < 0.001) in long-term mortality (>5 years). Heavy SSRI use (≥24 prescription fills) after diagnosis was associated with nearly doubling in mortality (HR = 1.99; CI: 1.39-2.83).SSRI use prior to and after breast cancer diagnosis is associated with increased mortality in breast cancer patients. Additional research is needed to better understand mechanisms mediating this association.

  View details for DOI 10.1093/ije/dyac004

  View details for PubMedID 35134960

• Selective Serotonin Reuptake Inhibitors and Tardive Dyskinesia: A Case Report of Escitalopram Use in a Cardiac and Liver Transplant Patient. Journal of clinical psychopharmacology Fischer, A., Connor, A. T., Machenzie, K. M., Shaw, R. J. 2020; 40 (6): 626–27

  View details for DOI 10.1097/JCP.0000000000001285

  View details for PubMedID 33136924

• Negative Valence Life Events Promote Breast Cancer Development. Clinical breast cancer Fischer, A., Ziogas, A., Anton-Culver, H. 2018; 18 (4): e521-e528

  Abstract

  The influence of stress on breast cancer risk remains unknown. The goal of the present study was to determine the effect of stress in the form of salient positive and negative valence life events (LEs) on primary invasive breast cancer risk. We hypothesized that salient negative LEs would increase breast cancer risk and salient positive LEs would attenuate this increased risk.We used a case-control design with 664 cases identified through the Cancer Surveillance Program of Orange County and 203 population-based controls. Participants completed a risk factor questionnaire, which included a LE section. Fourteen salient LEs of positive or negative valence were used to quantify stress exposure. A baseline model was constructed, and odds ratios (ORs) were calculated using multivariate unconditional logistic regression.Negative LEs were associated with increased breast cancer risk. The OR for ≥ 4 negative LEs showed a 2.81-fold increase in breast cancer risk (OR, 2.81; 95% confidence interval [CI], 1.47-5.36). A significant dose-response relationship between lifetime negative valence LEs and breast cancer risk was found. Previous personal illness increased breast cancer risk by 3.6-fold (OR, 3.60; 95% CI, 2.50-5.20). In contrast, abortion was associated with a 45% decrease in breast cancer risk (OR, 0.55; 95% CI, 0.34-0.89). Salient positive LEs did not have a significant effect on breast cancer risk. However, they seemed to buffer the adverse effect of salient negative LEs on breast cancer risk.The findings from the present study support the role of salient negative LEs in promoting breast cancer development, with a possible buffering effect of salient positive LEs.

  View details for DOI 10.1016/j.clbc.2017.10.017

  View details for PubMedID 29170032

  View details for PubMedCentralID PMC6541225

• Perception matters: Stressful life events increase breast cancer risk. Journal of psychosomatic research Fischer, A., Ziogas, A., Anton-Culver, H. 2018; 110: 46-53

  Abstract

  The relationship between psychological stress and breast cancer risk is unclear. The present study sought to understand how stressfulness appraisal of salient Life Events (LEs) influences breast cancer risk.A case-control design was used and included 664 female cases identified through the Cancer Surveillance Program of Orange County, CA and 203 female population-based controls. A LE questionnaire determined if events occurred prior to breast cancer diagnosis and if these events were considered to be stressful or not. Multivariate unconditional logistic regression was used to calculate ORs while adjusting for known breast cancer covariates.Cumulative adverse LEs perceived as stressful were associated with increased breast cancer risk in a dose response fashion (OR = 1.63, 95% CI = 1.00-2.66, Ptrend = 0.045). Conversely, events perceived as non-stressful did not have a significant impact on breast cancer risk. Previous personal illness was directly related to increased breast cancer risk, whether perceived as stressful (OR = 2.84, 95% CI = 1.96-4.11) or non-stressful (OR = 3.47, 95% CI = 1.34-8.94). Abortion and relocation were observed to have a protective effect on breast cancer risk only when reported as stressful (OR = 0.54, 95% CI = 0.32-0.92; OR = 0.63, 95% CI = 0.43-0.93, respectively). Pre/Peri-menopausal women who were nulliparous or who had their first child at ≥30 years of age were especially prone to the effects of appraised stress on increased breast cancer risk.This study underscores the importance of stressfulness appraisal when determining the effect of major LEs on breast cancer risk. Our results support incorporating assessments of perceived stressfulness in future epidemiological investigation of this topic.

  View details for DOI 10.1016/j.jpsychores.2018.03.010

  View details for PubMedID 29764605

  View details for PubMedCentralID PMC7793611