Mickey Trockel

All Publications

• Impact of Work on Personal Relationships and Physician Well-being. Mayo Clinic proceedings Trockel, M. T., Dyrbye, L. N., West, C. P., Sinsky, C. A., Wang, H., Carlasare, L. E., Tutty, M., Shanafelt, T. D. 2024

  Abstract

  To assess the impact of work on personal relationships (IWPR) by specialty and demographic variables in a national sample of physicians, to assess the association between the IWPR and burnout, and to determine the effect of adjusting for IWPR on the risk of burnout associated with being a physician.Analysis was conducted of data from a representative sample of US physicians surveyed between November 20, 2020, and March 23, 2021, and from a probability-based sample of other US workers. IWPR and burnout were measured with published assessments.Of the 7360 physicians who responded to the survey, 6271 (85.2%) completed the IWPR assessment. In multivariable analysis, moderate or higher IWPR was associated with female sex (odds ratio [OR], 1.26; 95% CI, 1.11 to 1.43), married vs single (OR, 0.59; 95% CI, 0.48 to 0.71), and emergency medicine (OR, 1.93; 95% CI, 1.43 to 2.60) or physical and rehabilitative medicine (OR, 1.67; 95% CI, 1.12 to 2.50) vs internal medicine subspecialty. Physicians were more likely than workers in other fields (OR, 2.65; 95% CI, 2.33 to 3.02) to endorse the statement "In the past year, my job contributed to me feeling more isolated or detached from the people who are important to me" as at least moderately true. After adjustment for responses to this statement, work hours, and demographic characteristics, being a physician was not associated with the risk of burnout.IWPR is associated with burnout. Adjustment for IWPR eliminated the observed difference in burnout between physicians and workers in other fields. Interventions that identify and mitigate work practices that have a negative impact on physicians' personal relationships and interventions that support affected individual physicians are warranted.

  View details for DOI 10.1016/j.mayocp.2024.03.010

  View details for PubMedID 39230551

• Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians. JAMA network open Ligibel, J. A., Goularte, N., Berliner, J. I., Bird, S. B., Brazeau, C. M., Rowe, S. G., Stewart, M. T., Trockel, M. T. 2023; 6 (12): e2347894

  Abstract

  Importance: Physician turnover interrupts care delivery and creates health care system financial burden.Objective: To describe the prevalence of burnout, professional fulfillment, and intention to leave (ITL) among physicians at academic-affiliated health care systems and identify institutional and individual factors associated with ITL.Design, Setting, and Participants: This cross-sectional study administered a survey to 37 511 attending-level medical specialists at 15 academic medical institutions participating in the Healthcare Professional Well-Being Academic Consortium. Data were collected from October 2019 to July 2021. Statistical analysis was performed from May 2022 to March 2023.Exposures: Hypothesized institutional and individual determinants of occupational well-being.Main Outcomes and Measures: The main outcome was ITL, defined as having at least a moderate intention (a score of 2 on a 0-4 scale) to leave one's institution within the next 2 years. Additional outcomes included burnout and professional fulfillment, defined using published Professional Fulfillment Index cut points.Results: Of 18 719 academic physician survey respondents (8381 [44.8%] male; 2388 [12.8%] Asian, 10 599 [56.6%] White, 1039 [5.6%] other race, 4693 [25.1%] unknown race; 294 [1.6%] Hispanic or Latina/Latino/Latinx), 6903 of 18 217 (37.9%) met criteria for burnout and 7301 of 18 571 (39.3%) for professional fulfillment; 5177 of 15 890 (32.6%) reported moderate or greater ITL. Burnout, professional fulfillment, and ITL varied across specialties. After adjusting for demographics, each 1-point increase (range 0-10) in burnout was directly associated with ITL (odds ratio [OR], 1.52 [95% CI, 1.49-1.55])c, and each 1-point increase in professional fulfillment was inversely associated with ITL (OR, 0.64 [95% CI, 0.63-0.65]). After adjusting for demographics, burnout, and professional fulfillment, each 1-point increase (range 0-10) in supportive leadership behaviors (OR, 0.83 [95% CI, 0.82-0.84]), peer support (OR, 0.93 [95% CI, 0.91-0.95]), personal-organizational values alignment (OR, 0.81 [95% CI, 0.80-0.82]), perceived gratitude (OR, 0.95 [95% CI, 0.92-0.97]), COVID-19 organizational support (OR, 0.88 [95% CI, 0.85-0.91]), and electronic health record helpfulness (OR, 0.95 [95% CI, 0.93-0.97]) were inversely associated with ITL, whereas each 1-point increase (range 0-10) in depression (OR, 1.08 [95% CI, 1.05-1.10]) and negative impact of work on personal relationships (OR, 1.09 [1.07-1.11]) were directly associated with ITL.Conclusions and Relevance: In this cross-sectional study of academic physicians, 32.6% indicated moderate or higher ITL within 2 years. Burnout, lack of professional fulfillment, and other well-being factors were associated with ITL, suggesting the need for a comprehensive approach to reduce physician turnover.

  View details for DOI 10.1001/jamanetworkopen.2023.47894

  View details for PubMedID 38100103

• Assessment of Adverse Childhood Experiences, Adverse Professional Experiences, Depression, and Burnout in US Physicians. Mayo Clinic proceedings Trockel, M. T., West, C. P., Dyrbye, L. N., Sinsky, C. A., Tutty, M., Wang, H., Carlasare, L. E., Menon, N. K., Shanafelt, T. D. 2023; 98 (12): 1785-1796

  Abstract

  To assess associations of adverse childhood experiences (ACEs) and adverse occupational experiences (AOEs) with depression and burnout in US physicians.We performed a secondary analysis of data from a representative sample survey of US physicians conducted between November 20, 2020, and March 23, 2021, and from a probability-based sample of other US workers. The ACEs, AOEs, burnout, and depression were assessed using previously published measures.Analyses included data from 1125 of the 3671 physicians (30.6%) who received a mailed survey and 6235 of 90,000 physicians (6.9%) who received an electronic survey. The proportion of physicians age 29-65 who had lived with a family member with substance misuse during childhood (673 of 5039[13.4%]) was marginally lower (P <.001) than that of workers in other professions (448 of 2505 [17.9%]). The proportion of physicians age 29-65 who experienced childhood emotional abuse (823 of 5038 [16.3%]) was similar to that of workers in other professions (406 of 2508 [16.2%]). The average physician depression T-score was 49.60 (raw score ± SD, 6.48±3.15), similar to the normed US average. The AOEs were associated with mild to severe depression, including making a recent significant medical error (odds ratio [OR], 1.64; 95% CI, 1.33 to 2.02, P<.001), being named in a malpractice suit (OR, 1.30; 95% CI, 1.07 to 1.59, P=.008), and experiencing one or more coronavirus disease 2019-related AOEs (OR, 1.76; 95% CI, 1.56 to 1.99, P<.001). Having one or more ACEs was associated with mild to severe depression (OR, 1.58; 95% CI, 1.38 to 1.79, P<.001). The ACEs, coronavirus disease 2019-related AOEs, and medical errors were also associated with burnout.Assessing ACEs and AOEs and implementing selective primary prevention interventions may improve population health efforts to mitigate depression and burnout in physicians.

  View details for DOI 10.1016/j.mayocp.2023.03.021

  View details for PubMedID 38043996

• IMPACT: Evaluation of a Controlled Organizational Intervention Using Influential Peers to Promote Professional Fulfillment. Mayo Clinic proceedings Trockel, M. T., Menon, N. K., Makowski, M. S., Wen, L. Y., Roberts, R., Bohman, B. D., Shanafelt, T. D. 2022

  Abstract

  To determine the effects of a popular opinion leader (POL)-led organizational intervention targeting all physicians and advanced practice providers (APPs) working within clinic groups on professional fulfillment (primary outcome), gratitude, burnout, self-valuation, and turnover intent.All 20 Stanford University HealthCare Alliance clinics with ≥5 physicians-APPs were matched by size and baseline gratitude scores and randomly assigned to immediate or delayed intervention (control). Between July 10, 2018, and March 15, 2019, trained POLs and a physician-PhD study investigator facilitated 4 interactive breakfast or lunch workshops at intervention clinics, where colleagues were invited to discuss and experience one evidence-based practice (gratitude, mindfulness, cognitive, and behavioral strategies). Participants in both groups completed incentivized annual assessments of professional fulfillment, workplace gratitude, burnout, self-valuation, and intent to leave as part of ongoing organizational program evaluation.Eighty-four (75%) physicians-APPs at intervention clinics attended at least 1 workshop. Of all physicians-APPs, 236 of 251 (94%) completed assessments in 2018 and 254 of 263 (97%) in 2019. Of 264 physicians-APPs with 2018 or 2019 assessment data, 222 (84%) had completed 2017 assessments. Modal characteristics were 60% female, 46% White, 49% aged 40 to 59 years, 44% practicing family-internal medicine, 78% living with partners, and 53% with children. Change in professional fulfillment by 2019 relative to average 2017 to 2018 levels was more favorable (0.63 points; effect size = 0.35; P=.001) as were changes in gratitude and intent to leave among clinicians practicing at intervention clinics.Interventions led by respected physicians-APPs can achieve high participation rates and have potential to promote well-being among their colleagues.

  View details for DOI 10.1016/j.mayocp.2022.06.035

  View details for PubMedID 36464536

• Clinician Distress and Inappropriate Antibiotic Prescribing for Acute Respiratory Tract Infections: A Retrospective Cohort Study JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Brady, K. S., Barlam, T. F., Trockel, M. T., Ni, P., Sheldrick, R., Schneider, J. I., Rowe, S. G., Kazis, L. E. 2022; 48 (5): 287-297

  Abstract

  The National Academy of Medicine's 2019 consensus study on clinician burnout identified a need for research evaluating the impact of clinician distress on health care quality. This study examined the association between clinician distress and the inappropriate use of antibiotic prescriptions for acute respiratory tract infections (RTIs) in adult outpatients.A retrospective cohort study was conducted using electronic health record visit data linked to annual wellness surveys administered to all clinicians at Boston Medical Center from May 4 to June 20, 2017, and June 5 to July 6, 2018. Included were outpatient visits occurring in Family Medicine, General Internal Medicine, or the emergency department in which an acute RTI for an otherwise healthy adult was listed as a primary diagnosis. The study examined the association of clinician depression, anxiety, and burnout with the visit-level odds of a clinician inappropriately prescribing an antibiotic for an acute RTI.Out of the 2,187 visits eligible for inclusion, 1,668 visits were included in the final sample. Overall, 33.8% and 51.0% of clinicians reported depression/anxiety and burnout symptoms, respectively. Each 1 standard deviation increase in a clinician's composite depression and anxiety score was associated with a 28% increase (odds ratio = 1.28, 95% confidence interval = 1.02-1.61) in the adjusted odds of an inappropriate antibiotic prescription for an acute RTI. Clinician burnout had no significant association with inappropriate antibiotic prescribing for acute RTIs.These findings suggest that clinician depression and anxiety may be important indicators of health care quality in routine outpatient care.

  View details for DOI 10.1016/j.jcjq.2022.01.011

  View details for Web of Science ID 000805833000006

  View details for PubMedID 35489803

• Suicidal Ideation and Attitudes Regarding Help Seeking in US Physicians Relative to the US Working Population. Mayo Clinic proceedings Shanafelt, T. D., Dyrbye, L. N., West, C. P., Sinsky, C., Tutty, M., Carlasare, L. E., Wang, H., Trockel, M. 2021

  Abstract

  OBJECTIVE: To evaluate the prevalence of suicidal ideation (SI) and attitudes regarding help seeking among US physicians relative to the general US working population.PARTICIPANTS AND METHODS: A secondary analysis of a cross-sectional survey of US physicians and a probability-based sample of the US working population was conducted between October 12, 2017, and March 15, 2018. Among 30,456 invited physicians, 5197 (17.1%) completed the primary survey. Suicidal ideation in the last year, attitudes regarding help seeking, symptoms of depression, and burnout were assessed by standardized questions.RESULTS: Among the 4833 physicians who responded regarding SI, 316 (6.5%) reported having suicidal thoughts in the last 12 months. Most physicians (3527 [72.9%]) reported that they would seek professional help if they had a serious emotional problem. Physicians with SI were less likely to report that they would seek help (203/316 [64.2%]) than physicians without SI (3318/4517 [73.5%]; P=.001). On multivariable analysis, symptoms of depression (odds ratio [OR], 4.42; 95% CI, 1.89 to 11.52), emotional exhaustion (OR, 1.07 each 1-point increase; 95% CI, 1.03 to 1.11), and self-valuation (OR, 0.84 each 1-point increase; 95% CI, 0.70 to 0.99) were associated with SI. Among individuals aged 29 to 65 years, physicians were more likely than workers in other fields to report SI (7.1% vs 4.3%; P<.001), a finding that persisted on multivariable analysis.CONCLUSION: In this national study conducted before the COVID-19 pandemic, 1 in 15 US physicians had thoughts of taking their own life in the last year, which exceeded the prevalence of SI among US workers in other fields.

  View details for DOI 10.1016/j.mayocp.2021.01.033

  View details for PubMedID 34301399

• Self-valuation Challenges in the Culture andPractice of Medicine and Physician Well-being. Mayo Clinic proceedings Trockel, M., Sinsky, C., West, C. P., Dyrbye, L. N., Tutty, M., Carlasare, L., Wang, H., Shanafelt, T. 2021

  Abstract

  OBJECTIVE: To compare physicians with workers in other fields on measures of self-valuation (SV) and determine the effect of adjusting for SV on the relationship between being a physician and risk for burnout.PATIENTS AND METHODS: A random sample of physicians from the American Medical Association Physician Masterfile and a probability sample from the general US population were used. Data were collected for this cross-sectional study between October 12, 2017 and March 15, 2018. Burnout was indicated by a score of 27 or higher on Emotional Exhaustion or 10 or higher on Depersonalization, using the Maslach Burnout Inventory. Self-valuation was measured with Self-valuation Scale items.RESULTS: Physicians (248/832=29.8%) more than workers in other fields (1036/5182=20.0%) "often" or "always" felt more self-condemnation than self-encouragement to learn from the experience when they made a mistake. Physicians (435/832=52.3%) more than workers in other fields (771/5182=14.9%) "often" or "always" put off taking care of their own health due to time pressure. Physicians had greater odds of burnout before (odds ratio [OR], 1.51; 95% CI, 1.30 to 1.76) but not after adjusting for SV responses (OR, 0.93; 95% CI, 0.78 to 1.11). After adjustment for SV, work hours, sex, and age, physicians had lower odds of burnout than workers in other fields (OR, 0.82; 95% CI, 0.68 to 0.99).CONCLUSION: Self-valuation is lower in physicians compared with workers in other fields and adjusting for SV eliminated the association between being a physician and higher risk for burnout. Experimental design research is needed to determine whether the association of SV with burnout is causal and the degree to which SV is malleable to intervention at individual, organization, and professional culture levels.

  View details for DOI 10.1016/j.mayocp.2020.12.032

  View details for PubMedID 34210511

• Establishing Crosswalks Between Common Measures of Burnout in US Physicians. Journal of general internal medicine Brady, K. J., Ni, P., Carlasare, L., Shanafelt, T. D., Sinsky, C. A., Linzer, M., Stillman, M., Trockel, M. T. 2021

  Abstract

  BACKGROUND: Physician burnout is often assessed by healthcare organizations. Yet, scores from different burnout measures cannot currently be directly compared, limiting the interpretation of results across organizations or studies.OBJECTIVE: To link common measures of burnout to a single metric in psychometric analyses such that group-level scores from different assessments can be compared.DESIGN: Cross-sectional survey.SETTING: US practices.PARTICIPANTS: A total of 1355 physicians sampled from the American Medical Association Physician Masterfile.MAIN MEASURES: We linked the Stanford Professional Fulfillment Index (PFI) and Mini-Z Single-Item Burnout (MZSIB) scale to the Maslach Burnout Inventory (MBI) in item response theory (IRT) fixed-calibration and equipercentile analyses and created crosswalks mapping PFI and MZSIB scores to corresponding MBI scores. We evaluated the accuracy of the results by comparing physicians' actual MBI scores to those predicted by linking and described the closest cut-point equivalencies across scales linked to the same MBI subscale using the resulting crosswalks.KEY RESULTS: IRT linking produced the most accurate results and was used to create crosswalks mapping (1) PFI Work Exhaustion (PFI-WE) and MZSIB scores to MBI Emotional Exhaustion (MBI-EE) scores and (2) PFI Interpersonal Disengagement (PFI-ID) scores to MBI Depersonalization (MBI-DP) scores. The commonly used MBI-EE raw score cut-point of ≥27 corresponded most closely with respective PFI-WE and MZSIB raw score cut-points of ≥7 and ≥3. The commonly used MBI-DP raw score cut-point of ≥10 corresponded most closely with a PFI-ID raw score cut-point of ≥9.CONCLUSIONS: Our findings allow healthcare organizations using the PFI or MZSIB to compare group-level scores to historical, regional, or national MBI scores (and vice-versa).

  View details for DOI 10.1007/s11606-021-06661-4

  View details for PubMedID 33791938

• Assessment of the Association of Leadership Behaviors of Supervising Physicians With Personal-Organizational Values Alignment Among Staff Physicians. JAMA network open Shanafelt, T. D., Wang, H., Leonard, M., Hawn, M., McKenna, Q., Majzun, R., Minor, L., Trockel, M. 2021; 4 (2): e2035622

  Abstract

  Importance: Although misalignment of values between physicians and their organization is associated with increased risk of burnout, actionable organizational factors that contribute to perceived values alignment are poorly understood.Objective: To evaluate the association between the leadership behaviors of immediate supervisors and physicians' perception of personal-organizational values alignment.Design, Setting, and Participants: This survey study of faculty physicians and physician leaders at Stanford University School of Medicine was conducted from April 1 to May 13, 2019. The survey included assessments of perceived personal-organizational values alignment, professional fulfillment, and burnout. Physicians also evaluated the leadership behaviors of their immediate supervisor (eg, division chief) using a standardized assessment. Data analysis was performed from May to December 2020.Main Outcomes and Measures: Association between mean leadership behavior score (range, 0-10) of each supervisor and the mean personal-organizational values alignment scores (range, 0-12) for the physicians in their work unit.Results: Of 1924 physicians eligible to participate, 1285 (67%) returned surveys. Among these, 651 (51%) were women and 729 (57%) were aged 40 years or older. Among the 117 physician leaders evaluated, 66 (56%) had their leadership behavior independently evaluated by at least 5 physicians and were included in analyses. The mean (SD) personal-organizational values alignment score on the 0 to 12 scale was 6.19 (3.21). As the proportion of work effort devoted to clinical care increased, values alignment scores decreased. Personal-organizational values alignment scores demonstrated an inverse correlation with burnout (r=-0.39; P<.001) and a positive correlation with professional fulfillment (r=0.52; P<.001). The aggregate leader behavior score of the 66 leaders evaluated correlated with the mean values alignment score for physicians in their work unit (r=0.53; P<.001). Aggregate leader behavior score was associated with 21.6% of the variation in personal-organizational values alignment scores between work units. After adjusting for age, gender, academic rank, work hours, physician-leader gender concordance, and time devoted to clinical care, each 1-point increase in leadership score of immediate supervisor was associated with a 0.56-point (95% CI, 0.46-0.66; P<.001) increase in personal-organizational values alignment score.Conclusions and Relevance: This survey study's results suggest that physicians experience their organization through the prism of their work unit leader. Organizational efforts to improve values alignment should attend to the development of first-line physician leaders.

  View details for DOI 10.1001/jamanetworkopen.2020.35622

  View details for PubMedID 33560424

• Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. JAMA network open Trockel, M. T., Menon, N. K., Rowe, S. G., Stewart, M. T., Smith, R., Lu, M., Kim, P. K., Quinn, M. A., Lawrence, E., Marchalik, D., Farley, H., Normand, P., Felder, M., Dudley, J. C., Shanafelt, T. D. 2020; 3 (12): e2028111

  Abstract

  Importance: Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error.Objective: To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout.Design, Setting, and Participants: This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study.Exposures: Sleep-related impairment.Main Outcomes and Measures: Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection.Results: Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r=0.51; P<.001), work exhaustion (r=0.58; P<.001), and overall burnout (r=0.59; P<.001) were large. Sleep-related impairment correlation with professional fulfillment (r=-0.40; P<.001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively.Conclusions and Relevance: In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.

  View details for DOI 10.1001/jamanetworkopen.2020.28111

  View details for PubMedID 33284339

• Association of Physician Burnout With Suicidal Ideation and Medical Errors. JAMA network open Menon, N. K., Shanafelt, T. D., Sinsky, C. A., Linzer, M., Carlasare, L., Brady, K. J., Stillman, M. J., Trockel, M. T. 2020; 3 (12): e2028780

  Abstract

  Importance: Addressing physician suicide requires understanding its association with possible risk factors such as burnout and depression.Objective: To assess the association between burnout and suicidal ideation after adjusting for depression and the association of burnout and depression with self-reported medical errors.Design, Setting, and Participants: This cross-sectional study was conducted from November 12, 2018, to February 15, 2019. Attending and postgraduate trainee physicians randomly sampled from the American Medical Association Physician Masterfile were emailed invitations to complete an online survey in waves until a convenience sample of more than 1200 practicing physicians agreed to participate.Main Outcomes and Measures: The primary outcome was the association of burnout with suicidal ideation after adjustment for depression. The secondary outcome was the association of burnout and depression with self-reported medical errors. Burnout, depression, suicidal ideation, and medical errors were measured using subscales of the Stanford Professional Fulfillment Index, Maslach Burnout Inventory-Human Services Survey for Medical Personnel, and Mini-Z burnout survey and the Patient-Reported Outcomes Measurement Information System depression Short Form. Associations were evaluated using multivariable regression models.Results: Of the 1354 respondents, 893 (66.0%) were White, 1268 (93.6%) were non-Hispanic, 762 (56.3%) were men, 912 (67.4%) were non-primary care physicians, 934 (69.0%) were attending physicians, and 824 (60.9%) were younger than 45 years. Each SD-unit increase in burnout was associated with 85% increased odds of suicidal ideation (odds ratio [OR], 1.85; 95% CI, 1.47-2.31). After adjusting for depression, there was no longer an association (OR, 0.85; 95% CI, 0.63-1.17). In the adjusted model, each SD-unit increase in depression was associated with 202% increased odds of suicidal ideation (OR, 3.02; 95% CI, 2.30-3.95). In the adjusted model for self-reported medical errors, each SD-unit increase in burnout was associated with an increase in self-reported medical errors (OR, 1.48; 95% CI, 1.28-1.71), whereas depression was not associated with self-reported medical errors (OR, 1.01; 95% CI, 0.88-1.16).Conclusions and Relevance: The results of this cross-sectional study suggest that depression but not physician burnout is directly associated with suicidal ideation. Burnout was associated with self-reported medical errors. Future investigation might examine whether burnout represents an upstream intervention target to prevent suicidal ideation by preventing depression.

  View details for DOI 10.1001/jamanetworkopen.2020.28780

  View details for PubMedID 33295977

• Advancing Physician Well-Being: A Population Health Framework. Mayo Clinic proceedings Trockel, M., Corcoran, D., Minor, L. B., Shanafelt, T. D. 2020

  View details for DOI 10.1016/j.mayocp.2020.02.014

  View details for PubMedID 32499127

• Association of Burnout, Professional Fulfillment, and Self-care Practices of Physician Leaders With Their Independently Rated Leadership Effectiveness. JAMA network open Shanafelt, T. D., Makowski, M. S., Wang, H. n., Bohman, B. n., Leonard, M. n., Harrington, R. A., Minor, L. n., Trockel, M. n. 2020; 3 (6): e207961

  Abstract

  Although leadership behavior of physician supervisors is associated with the occupational well-being of the physicians they supervise, the factors associated with leadership behaviors are poorly understood.To evaluate the associations between burnout, professional fulfillment, and self-care practices of physician leaders and their independently assessed leadership behavior scores.This survey study of physicians and physician leaders at Stanford University School of Medicine (n = 1924) was conducted from April 1 to May 13, 2019. The survey included assessments of professional fulfillment, self-valuation, sleep-related impairment, and burnout. Physicians also rated the leadership behaviors of their immediate physician supervisors using a standardized assessment. Leaders' personal well-being metrics were paired with their leadership behavior scores as rated by the physicians they supervised. All assessment scores were converted to a standardized scale (range, 0-10). Data were analyzed from October 20, 2019, to March 10, 2020.Association between leaders' own well-being scores and their independently assessed leadership behavior.Of 1924 physicians invited to participate, 1285 (66.8%) returned surveys, including 67 of 117 physician leaders (57.3%). Among these respondents, 651 (50.7%) were women and 729 (56.7%) were 40 years or older. Among the 67 leaders, 57 (85.1%) had their leadership behaviors evaluated by at least 5 physicians (median, 11 [interquartile range, 9-15]) they supervised. Overall, 9.8% of the variation in leaders' aggregate leadership behavior scores was associated with their own degree of burnout. In models adjusted for age and sex, each 1-point increase in burnout score of the leaders was associated with a 0.19-point decrement in leadership behavior score (β = -0.19; 95% CI, -0.35 to -0.03; P = .02), whereas each 1-point increase in their professional fulfillment and self-valuation scores was associated with a 0.13-point (β = 0.13; 95% CI, 0.01-0.26; P = .03) and 0.15-point (β = 0.15; 95% CI, 0.02-0.29; P = .03) increase in leadership behavior score, respectively. Each 1-point increase in leaders' sleep-related impairment was associated with a 0.15-point increment in sleep-related impairment among those they supervised (β = 0.15; 95% CI, 0.02-0.29; P = .03). The associations between leaders' well-being scores in other dimensions and the corresponding well-being measures of those they supervised were not significant.In this survey study, burnout, professional fulfillment, and self-care practices of physician leaders were associated with their independently assessed leadership effectiveness. Training, skill building, and support to improve leader well-being should be considered a dimension of leadership development rather than simply a dimension of self-care.

  View details for DOI 10.1001/jamanetworkopen.2020.7961

  View details for PubMedID 32543700

• Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA Shanafelt, T. n., Ripp, J. n., Trockel, M. n. 2020

  View details for DOI 10.1001/jama.2020.5893

  View details for PubMedID 32259193

• Self-valuation: Attending to the Most Important Instrument in the Practice of Medicine. Mayo Clinic proceedings Trockel, M. T., Hamidi, M. S., Menon, N. K., Rowe, S. G., Dudley, J. C., Stewart, M. T., Geisler, C. Z., Bohman, B. D., Shanafelt, T. D. 2019

  Abstract

  OBJECTIVE: To measure self-valuation, involving constructive prioritization of personal well-being and a growth mindset perspective that seeks to learn and improve as the primary response to errors, in physicians and evaluate its relationship with burnout and sleep-related impairment.METHODS: We analyzed cross-sectional survey data collected between July 1, 2016, and October 31, 2017, from 5 academic medical centers in the United States. All faculty and medical-staff physicians at participating organizations were invited to participate. The self-valuation scale included 4 items measured on a 5-point (0-4) Likert scale (summative score range, 0-16). The self-valuation scale was developed and pilot tested in a sample of 250 physicians before inclusion in the multisite wellness survey, which also included validated measures of burnout and sleep-related impairment.RESULTS: Of the 6189 physicians invited to participate, 3899 responded (response rate, 63.0%). Each 1-point score increase in self-valuation was associated with-1.10 point lower burnout score (95% CI,-1.16 to-1.05; standardized beta=-0.53; P<.001) and 0.81 point lower sleep-related impairment score (95% CI,-0.85 to-0.76; standardized beta=-0.47; P<.001), adjusting for sex and medical specialty. Women had lower self-valuation (Cohen d=0.30) and higher burnout (Cohen d=0.22) than men. Lower self-valuation scores in women accounted for most of the sex difference in burnout.CONCLUSION: Low self-valuation among physicians is associated with burnout and sleep-related impairment. Further research is warranted to develop and test interventions that increase self-valuation as a mechanism to improve physician well-being.

  View details for DOI 10.1016/j.mayocp.2019.04.040

  View details for PubMedID 31543254

• Selecting physician well-being measures to assess health system performance and screen for distress: Conceptual and methodological considerations. Current problems in pediatric and adolescent health care Brady, K. J., Kazis, L. E., Sheldrick, R. C., Ni, P. n., Trockel, M. T. 2019: 100662

  Abstract

  Following national calls to address burnout among U.S. physicians, healthcare systems across the nation are integrating measures of physician well-being into institutional assessments. In this paper, we review important conceptual and methodological considerations for selecting self-reported physician well-being measures to monitor health system performance and to screen individual physicians for symptoms of distress. First, we discuss the importance of selecting any given measure of physician well-being based on the degree to which evidence supports the validity of the measure within the context of its intended use. Second, we present a conceptual model explaining the relationship between physician well-being and the larger healthcare context, to assist health systems in identifying the intended goals of physician well-being assessment. Well-being assessments are metrics of individual-level physician wellness/distress and may be indicators of system-level performance. We highlight proposed roles of physician well-being as a performance metric (i.e., as a downstream effect of the medical practice environment, as a predictor of health system outcomes, and as a mediator of the practice environment's effect on health system outcomes). Using this framework, we review the evidence supporting the validity of four of the most commonly used measures of well-being in U.S. physicians, identify gaps in the literature, and present practical recommendations for healthcare organizations' selection of appropriate measurement tools. We conclude by offering directions for future research to advance the measurement of physician well-being outcomes.

  View details for DOI 10.1016/j.cppeds.2019.100662

  View details for PubMedID 31562054

• Estimating institutional physician turnover attributable to self-reported burnout and associated financial burden: a case study. BMC health services research Hamidi, M. S., Bohman, B., Sandborg, C., Smith-Coggins, R., de Vries, P., Albert, M. S., Murphy, M. L., Welle, D., Trockel, M. T. 2018; 18 (1): 851

  Abstract

  BACKGROUND: Awareness of the economic cost of physician attrition due to burnout in academic medical centers may help motivate organizational level efforts to improve physician wellbeing and reduce turnover. Our objectives are: 1) to use a recent longitudinal data as a case example to examine the associations between physician self-reported burnout, intent to leave (ITL) and actual turnover within two years, and 2) to estimate the cost of physician turnover attributable to burnout.METHODS: We used de-identified data from 472 physicians who completed a quality improvement survey conducted in 2013 at two Stanford University affiliated hospitals to assess physician wellness. To maintain the confidentially of survey responders, potentially identifiable demographic variables were not used in this analysis. A third party custodian of the data compiled turnover data in 2015 using medical staff roster. We used logistic regression to adjust for potentially confounding factors.RESULTS: At baseline, 26% of physicians reported experiencing burnout and 28% reported ITL within the next 2years. Two years later, 13% of surveyed physicians had actually left. Those who reported ITL were more than three times as likely to have left. Physicians who reported experiencing burnout were more than twice as likely to have left the institution within the two-year period (Relative Risk (RR)=2.1; 95% CI=1.3-3.3). After adjusting for surgical specialty, work hour categories, sleep-related impairment, anxiety, and depression in a logistic regression model, physicians who experienced burnout in 2013 had 168% higher odds (Odds Ratio=2.68, 95% CI: 1.34-5.38) of leaving Stanford by 2015 compared to those who did not experience burnout. The estimated two-year recruitment cost incurred due to departure attributable to burnout was between $15,544,000 and $55,506,000. Risk of ITL attributable to burnout was 3.7 times risk of actual turnover attributable to burnout.CONCLUSIONS: Institutions interested in the economic cost of turnover attributable to burnout can readily calculate this parameter using survey data linked to a subsequent indicator of departure from the institution. ITL data in cross-sectional studies can also be used with an adjustment factor to correct for overestimation of risk of intent to leave attributable to burnout.

  View details for PubMedID 30477483

• A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry Trockel, M. n., Bohman, B. n., Lesure, E. n., Hamidi, M. S., Welle, D. n., Roberts, L. n., Shanafelt, T. n. 2017

  Abstract

  The objective of this study was to evaluate the performance of the Professional Fulfillment Index (PFI), a 16-item instrument to assess physicians' professional fulfillment and burnout, designed for sensitivity to change attributable to interventions or other factors affecting physician well-being.A sample of 250 physicians completed the PFI, a measure of self-reported medical errors, and previously validated measures including the Maslach Burnout Inventory (MBI), a one-item burnout measure, the World Health Organization's abbreviated quality of life assessment (WHOQOL-BREF), and PROMIS short-form depression, anxiety, and sleep-related impairment scales. Between 2 and 3 weeks later, 227 (91%) repeated the PFI and the sleep-related impairment scale.Principal components analysis justified PFI subscales for professional fulfillment, work exhaustion, and interpersonal disengagement. Test-retest reliability estimates were 0.82 for professional fulfillment (α = 0.91), 0.80 for work exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall burnout (α = 0.92). PFI burnout measures correlated highly (r ≥ 0.50) with their closest related MBI equivalents. Cohen's d effect size differences in self-reported medical errors for high versus low burnout classified using the PFI and the MBI were 0.55 and 0.44, respectively. PFI scales correlated in expected directions with sleep-related impairment, depression, anxiety, and WHOQOL-BREF scores. PFI scales demonstrated sufficient sensitivity to detect expected effects of a two-point (range 8-40) change in sleep-related impairment.PFI scales have good performance characteristics including sensitivity to change and offer a novel contribution by assessing professional fulfillment in addition to burnout.

  View details for PubMedID 29196982

• Effects of Cognitive Behavioral Therapy for Insomnia on Suicidal Ideation in Veterans SLEEP Trockel, M., Karlin, B. E., Taylor, C. B., Brown, G. K., Manber, R. 2015; 38 (2): 259-265

  Abstract

  To examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on suicidal ideation among Veterans with insomnia.Longitudinal data collected in the course of an uncontrolled evaluation of a large-scale CBT-I training program.Outpatient and residential treatment facilities.Four hundred five Veterans presenting for treatment of insomnia.Cognitive behavioral therapy for insomnia (CBT-I).At baseline, 32% of patients, compared with 21% at final assessment, endorsed some level of suicidal ideation [χ(2)(df = 1) = 125; P < 0.001]. After adjusting for demographic variables and baseline insomnia severity, each 7-point decrease in Insomnia Severity Index (ISI) score achieved during CBT-I treatment was associated with a 65% (OR = 0.35; 95% CI = 0.24 to 0.52) reduction in odds of suicidal ideation. The effect of change in insomnia severity on change in depression severity was also significant. After controlling for change in depression severity and other variables in the model, the effect of change in insomnia severity on change in suicidal ideation remained significant.This evaluation of the largest dissemination of CBT-I in the United States found a clinically meaningful reduction in suicidal ideation among Veterans receiving CBT-I. The mechanisms by which effective treatment of insomnia with CBT-I reduces suicide risk are unknown and warrant investigation. The current results may have significant public health implications for preventing suicide among Veterans.

  View details for DOI 10.5665/sleep.4410

  View details for Web of Science ID 000348757800014

  View details for PubMedID 25515115

  View details for PubMedCentralID PMC4288607

• Cognitive Behavioral Therapy for insomnia with veterans: Evaluation of effectiveness and correlates of treatment outcomes. Behaviour research and therapy Trockel, M., Karlin, B. E., Taylor, C. B., Manber, R. 2014; 53: 41-46

  Abstract

  This paper examines the effectiveness of Cognitive Behavioral Therapy for insomnia (CBT-I) in Veterans and the effects of two process measures on CBT-I outcomes: 1) therapist ratings of patient adherence and 2) patient ratings of therapeutic alliance. Data are from 316 therapists in the Department of Veterans Affairs CBT-I Training Program and 696 patients receiving CBT-I from therapists undergoing training. Mixed effects model results indicate Insomnia Severity Index scores decreased from 20.7 at baseline to 10.9 (d = 2.3) during a typical course of CBT-I. Patients with highest tercile compared to those with lowest tercile adherence achieved, on average, 4.1 points greater reduction in ISI scores (d = 0.95). The effect of therapeutic alliance on change in insomnia severity was not significant after adjusting for adherence to CBT-I. These results support the effectiveness and feasibility of large-scale training in and implementation of CBT-I and indicate that greater focus on patient adherence may lead to enhanced outcomes. The current findings suggest that CBT-I therapists and training programs place greater emphasis on attending to and increasing patient adherence.

  View details for DOI 10.1016/j.brat.2013.11.006

  View details for PubMedID 24412462

• An E-mail Delivered CBT for Sleep-Health Program for College Students: Effects on Sleep Quality and Depression Symptoms JOURNAL OF CLINICAL SLEEP MEDICINE Trockel, M., Manber, R., Chang, V., Thurston, A., Taylor, C. B. 2011; 7 (3): 273-278

  View details for DOI 10.5664/JCSM.1072

  View details for Web of Science ID 000292923600024

• Smoking Behavior Postmvocardial Infarction Among ENRICHD Trial Participants: Cognitive Behavior Therapy Intervention for Depression and Low Perceived Social Support Compared With Care as Usual PSYCHOSOMATIC MEDICINE Trockel, M., Burg, M., Jaffe, A., Barbour, K., Taylor, C. B. 2008; 70 (8): 875-882

  Abstract

  Patients with cardiovascular disease who stop smoking lower their risk of subsequent morbidity and mortality. However, patients who have suffered a myocardial infarction (MI) are more likely to be depressed than the general population, which may make smoking cessation more difficult. Poor social support may also make smoking cessation more difficult for some patients. This study examines the effect of cognitive behavior therapy (CBT) for depression, low perceived social support or both on smoking behavior in post-MI patients.Participants were 1233 patients with a history of smoking enrolled in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) trial who provided 7-day point-prevalence smoking behavior information at baseline and at two or more follow-up assessments. The ENRICHD trial enrolled post-MI patients with depression, low perceived social support or both. Participants were randomly assigned to either CBT intervention or usual care. We used mixed effects models to accommodate data from multiple smoking point-prevalence measures for each individual participant.CBT did not significantly reduce post-MI smoking across all intervention patients with a history of smoking. However, CBT did reduce post-MI smoking among the subgroup of depressed patients with adequate perceived social support (OR, 0.68; 95% CI, 0.47-0.98).CBT for depression without more specific attention to smoking cessation may have little overall value as a strategy for helping post-MI patients refrain from smoking. However, use of CBT to treat depression may have the gratuitous benefit of reducing smoking among some post-MI patients.

  View details for DOI 10.1097/PSY.0b013e3181842897

  View details for Web of Science ID 000260401100006

  View details for PubMedID 18842753

• When the party for some becomes a problem for others: The effect of perceived secondhand consequences of drinking behavior on drinking norms JOURNAL OF PSYCHOLOGY Trockel, M., Wall, A., Williams, S. S., Reis, J. 2008; 142 (1): 57-69

  Abstract

  The authors examined the influence of fraternity men's expectancies regarding secondhand consequences of excessive drinking behavior on normative standards regarding alcohol use and consumption levels. Participants were 381 men from 26 chapters of 2 national fraternities. One organization participated in a brief intervention involving discussion of secondhand consequences of excessive drinking. Immediate influence of the intervention on perceived secondhand consequences of alcohol use was assessed using a posttest-only, randomized groups design. Results supported a hypothesized measurement model with 1 overall secondhand consequence expectancy construct and 4 subfactors: (a) Noise Disruptive of Sleep and Study, (b) Violence, (c) Sexual Assault, and (d) Property Damage. Cross-sectional analysis at the chapter and individual levels demonstrated that secondhand expectancies had an indirect effect on alcohol consumption, mediated by personal consumption standards for limiting alcohol consumption. The intervention had an effect on secondhand expectancies. Findings suggest that interventions with intact groups can increase secondhand expectancies regarding excessive drinking and may lead to a reduction in excessive alcohol consumption.

  View details for Web of Science ID 000253432400004

  View details for PubMedID 18350844

• Comment on study by Hagan et al.: The Single-Item Burnout Question. Journal of general internal medicine Trockel, M. T., West, C. P., Shanafelt, T. D. 2024

  View details for DOI 10.1007/s11606-024-09016-x

  View details for PubMedID 39261339

  View details for PubMedCentralID 10724765

• Associations Between Organizational Support, Burnout, and Professional Fulfillment Among US Physicians During the First Year of the COVID-19 Pandemic. Journal of healthcare management / American College of Healthcare Executives Carlasare, L. E., Wang, H., West, C. P., Trockel, M., Dyrbye, L. N., Tutty, M., Sinsky, C., Shanafelt, T. D. 2024; 69 (5): 368-386

  Abstract

  This research aimed to evaluate variations in perceived organizational support among physicians during the first year of the COVID-19 pandemic and the associations between perceived organizational support, physician burnout, and professional fulfillment.Between November 20, 2020, and March 23, 2021, 1,162 of 3,671 physicians (31.7%) responded to the study survey by mail, and 6,348 of 90,000 (7.1%) responded to an online version. Burnout was assessed using the Maslach Burnout Inventory, and perceived organizational support was assessed by questions developed and previously tested by the Stanford Medicine WellMD Center. Professional fulfillment was measured using the Stanford Professional Fulfillment Index.Responses to organizational support questions were received from 5,933 physicians. The mean organizational support score (OSS) for male physicians was higher than the mean OSS for female physicians (5.99 vs. 5.41, respectively, on a 0-10 scale, higher score favorable; p < .001). On multivariable analysis controlling for demographic and professional factors, female physicians (odds ratio [OR] 0.66; 95% CI: 0.55-0.78) and physicians with children under 18 years of age (OR 0.72; 95% CI: 0.56-0.91) had lower odds of an OSS in the top quartile (i.e., a high OSS score). Specialty was also associated with perceived OSS in mean-variance analysis, with some specialties (e.g., pathology and dermatology) more likely to perceive significant organizational support relative to the reference specialty (i.e., internal medicine subspecialty) and others (e.g., anesthesiology and emergency medicine) less likely to perceive support. Physicians who worked more hours per week (OR for each additional hour/week 0.99; 95% CI: 0.99-1.00) were less likely to have an OSS in the top quartile. On multivariable analysis, adjusting for personal and professional factors, each one-point increase in OSS was associated with 21% lower odds of burnout (OR 0.79; 95% CI: 0.77-0.81) and 32% higher odds of professional fulfillment (OR 1.32; 95% CI: 1.28-1.36).Perceived organizational support of physicians during the COVID-19 pandemic was associated with a lower risk of burnout and a higher likelihood of professional fulfillment. Women physicians, physicians with children under 18 years of age, physicians in certain specialties, and physicians working more hours reported lower perceived organizational support. These gaps must be addressed in conjunction with broad efforts to improve organizational support.

  View details for DOI 10.1097/JHM-D-23-00124

  View details for PubMedID 39240266

• An examination of the vacation behaviors of United States emergency physicians. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Lu, D. W., Courtney, D. M., Sinsky, C. A., Wang, H., Trockel, M. T., Dyrbye, L. N., Carlasare, L. E., West, C. P., Shanafelt, T. D. 2024

  View details for DOI 10.1111/acem.15005

  View details for PubMedID 39215456

• Characteristics and Habits of Psychiatrists and Neurologists With High Occupational Well-Being: A Mixed Methods Study. Mayo Clinic proceedings. Innovations, quality & outcomes Amano, A., Menon, N. K., Bissonnette, S., Sullivan, A. B., Frost, N., Mekile, Z., Wang, H., Shanafelt, T. D., Trockel, M. T. 2024; 8 (4): 329-342

  Abstract

  To identify the characteristics that distinguish occupationally well outliers (OWO), a subset of academic psychiatrists and neurologists with consistently high professional fulfillment and low burnout, from their counterparts with lower levels of occupational well-being.Participants included faculty physicians practicing psychiatry and neurology in academic medical centers affiliated with the Professional Well-being Academic Consortium. In this prospective, longitudinal study, a mixed qualitative and quantitative approach was used. Quantitative measures were administered to physicians in a longitudinal occupational well-being survey sponsored by the academic organizations where they work. Four organizations participated in the qualitative study. Psychiatrists and neurologists at these organizations who competed survey measures at 2 consecutive time points between 2019 and 2021 were invited to participate in an interview.Of 410 (213 psychiatrists and 197 neurologists) who completed professional fulfillment and burnout measures at 2 time points, 84 (20.5%) met OWO criteria. Occupationally well outliers psychiatrists and neurologists had more favorable scores on hypothesized determinants of well-being (values alignment, perceived gratitude, supportive leadership, peer support, and control of schedule). Ultimately, 31 psychiatrists (25% of 124 invited) and 33 neurologists (18.5% of 178 invited) agreed to participate in an interview. Qualitatively, OWO physicians differed from all others in 3 thematic domains: development of life grounded in priorities, ability to shape day-to-day work context, and professional relationships that provide joy and support.A multilevel approach is necessary to promote optimal occupational well-being, targeting individual-level factors, organizational-level factors, and broader system-level factors.

  View details for DOI 10.1016/j.mayocpiqo.2024.04.005

  View details for PubMedID 38974531

  View details for PubMedCentralID PMC11223072

• A qualitative study of strategies to improve occupational well-being in physical medicine and rehabilitation physicians. PM & R : the journal of injury, function, and rehabilitation Amano, A., Makowski, M. S., Trockel, M. T., Menon, N. K., Wang, H., Sliwa, J., Weinstein, S., Kinney, C., Paganoni, S., Verduzco-Gutierrez, M., Kennedy, D. J., Knowlton, T., Stautzenbach, T., Shanafelt, T. D. 2024

  Abstract

  Physiatry is a specialty with high rates of burnout. Although organizational strategies to combat burnout are key, it is also important to understand strategies that individual physiatrists can use to address burnout.To identify changes that resulted in improvement of occupational well-being of physiatrists over a 6- to 9-month period.We employed two quantitative surveys spaced 6 to 9 months apart to identify physiatrists who experienced meaningful improvement in occupational burnout and/or professional fulfillment between the two survey timepoints. These physiatrists were subsequently recruited to participate in a qualitative study using semi-structured interviews to identify changes that respondents felt contributed to improvements in burnout and professional fulfillment.Online surveys and interviews.Physiatrists in the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Membership Masterfile.Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index.One hundred twelve physiatrists responded to the baseline and follow-up surveys. Of these, 35 were eligible for interviews based on improvements in the Stanford Professional Fulfillment Index, and 23 (64%) agreed to participate. Themes from the qualitative interviews highlighted the importance of personal lifestyle choices, approaches to improve professional satisfaction, and strategies to foster work-life harmony. Personal lifestyle strategies included investing in wellness and mental health. Efforts to improve professional satisfaction included decreasing work intensity, prioritizing meaningful aspects of work, and building relationships with colleagues. Fostering work-life harmony also included making trade-offs in both domains, setting boundaries at work, setting expectations at home, and overcoming personal challenges.Our findings illustrate that, in addition to organizational strategies demonstrated to be effective, there are actions that individual physiatrists can take to recover from burnout and foster professional fulfillment.

  View details for DOI 10.1002/pmrj.13189

  View details for PubMedID 38837667

• A qualitative study of strategies to improve occupational well-being in physical medicine and rehabilitation physicians. American journal of physical medicine & rehabilitation Amano, A., Makowski, M. S., Trockel, M. T., Menon, N. K., Wang, H., Sliwa, J., Weinstein, S., Kinney, C., Paganoni, S., Verduzco-Gutierrez, M., Kennedy, D. J., Knowlton, T., Stautzenbach, T., Shanafelt, T. D. 2024

  Abstract

  Physiatry is a specialty with high rates of burnout. Although organizational strategies to combat burnout are key, it is also important to understand strategies that individual physiatrists can use to address burnout.To identify changes that resulted in improvement of occupational well-being of physiatrists over a 6- to 9-month period.We employed two quantitative surveys spaced 6 to 9 months apart to identify physiatrists who experienced meaningful improvement in occupational burnout and/or professional fulfillment between the two survey timepoints. These physiatrists were subsequently recruited to participate in a qualitative study using semi-structured interviews to identify changes that respondents felt contributed to improvements in burnout and professional fulfillment.Setting: Online surveys and interviews.Participants: Physiatrists in the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Membership Masterfile.Main Outcome Measure: Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index.One hundred twelve physiatrists responded to the baseline and follow-up surveys. Of these, 35 were eligible for interviews based on improvements in the Stanford Professional Fulfillment Index, and 23 (64%) agreed to participate. Themes from the qualitative interviews highlighted the importance of personal lifestyle choices, approaches to improve professional satisfaction, and strategies to foster work-life harmony. Personal lifestyle strategies included investing in wellness and mental health. Efforts to improve professional satisfaction included decreasing work intensity, prioritizing meaningful aspects of work, and building relationships with colleagues. Fostering work-life harmony also included making trade-offs in both domains, setting boundaries at work, setting expectations at home, and overcoming personal challenges.Our findings illustrate that, in addition to organizational strategies demonstrated to be effective, there are actions that individual physiatrists can take to recover from burnout and foster professional fulfillment.

  View details for DOI 10.1097/PHM.0000000000002555

  View details for PubMedID 38838100

• Teamwork Climate, Safety Climate, and Physician Burnout: A National, Cross-Sectional Study JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Rotenstein, L., Wang, H., West, C. P., Dyrbye, L. N., Trockel, M., Sinsky, C., Shanafelt, T. 2024; 50 (6): 458-462

  View details for DOI 10.1016/j.jcjq.2024.03.007

  View details for Web of Science ID 001263464000001

  View details for PubMedID 38653613

• Evaluation of Work-Life Integration, Social Isolation, and the Impact of Work on Personal Relationships Among Healthcare CEOs and Administrative Leaders. Journal of healthcare management / American College of Healthcare Executives Shanafelt, T., Trockel, M., Mayer, T., Wang, H., Athey, L. 2024; 69 (2): 99-117

  Abstract

  The objective of this study was to evaluate satisfaction with work-life integration (WLI), social isolation, and the impact of work on personal relationships (IWPR) among senior healthcare operational leaders.Between June 7 and June 30, 2021, we performed a national survey of CEOs and other senior healthcare operational leaders in the United States to evaluate their personal work experience. Satisfaction with WLI, social isolation, and IWPR were assessed using standardized instruments. Burnout and professional fulfillment were also assessed using standardized scales.The mean IWPR score on the 0-10 scale was 4.39 (standard deviation was 2.36; higher scores were unfavorable). On multivariable analysis to identify demographic and professional factors associated with the IWPR score, each additional hour worked per week decreased the likelihood of a favorable IWPR score. The IWPR, feeling isolated, and satisfaction with WLI were independently associated with burnout after adjusting for other personal and professional factors. On multivariable analysis, healthcare administrators were more likely than U.S. workers in other fields to indicate work had adversely impacted personal relationships in response to the item "In the past year, my job has contributed to me feeling more isolated and detached from the people who are most important to me."Experiencing an adverse IWPR is common among U.S. healthcare administrators, who are more likely than the general U.S. working population to indicate their job contributes to isolation and detachment from the people most important to them. Problems with WLI, isolation, and an adverse IWPR are associated with increased burnout and lower professional fulfillment. Intentional efforts by both organizations and administrative leaders are necessary to address the work characteristics and professional norms that erode WLI and result in work adversely impacting personal relationships.

  View details for DOI 10.1097/JHM-D-23-00134

  View details for PubMedID 38467024

• Vacation Days Taken, Work During Vacation, and Burnout Among US Physicians. JAMA network open Sinsky, C. A., Trockel, M. T., Dyrbye, L. N., Wang, H., Carlasare, L. E., West, C. P., Shanafelt, T. D. 2024; 7 (1): e2351635

  Abstract

  Vacation has been shown to be an important restorative activity in the general population; less is known about physicians' vacation behaviors and their association with burnout and professional fulfillment.To examine the number of vacation days taken per year and the magnitude of physician work while on vacation and their association with physician burnout and professional fulfillment, by individual and organizational characteristics.This cross-sectional survey of US physicians was conducted between November 20, 2020, and March 23, 2021. Data analysis was performed from March to July 2023.Burnout was measured using the Maslach Burnout Index, and professional fulfillment was measured using the Stanford Professional Fulfillment Index. Number of vacation days taken in the last year, time spent working on patient care and other professional tasks per typical vacation day (ie, work on vacation), electronic health record (EHR) inbox coverage while on vacation, barriers to taking vacation, and standard demographics were collected.Among 3024 respondents, 1790 of 3004 (59.6%), took 15 or fewer days of vacation in the last year, with 597 of 3004 (19.9%) taking 5 or fewer days. The majority, 2104 respondents (70.4%), performed patient care-related tasks on vacation, with 988 of 2988 (33.1%) working 30 minutes or more on a typical vacation day. Less than one-half of physicians (1468 of 2991 physicians [49.1%]) reported having full EHR inbox coverage while on vacation. On multivariable analysis adjusting for personal and professional factors, concern about finding someone to cover clinical responsibilities (odds ratio [OR], 0.48 [95% CI, 0.35-0.65] for quite a bit; OR, 0.30 [95% CI, 0.21-0.43] for very much) and financial concerns (OR, 0.49 [95% CI, 0.36-0.66] for quite a bit; OR, 0.38 [95% CI, 0.27-0.54] for very much) were associated with decreased likelihood of taking more than 3 weeks of vacation per year. Taking more than 3 weeks of vacation per year (OR, 0.66 [95% CI, 0.45-0.98] for 16-20 days; OR, 0.59 [95% CI, 0.40-0.86] for >20 days vs none) and having full EHR inbox coverage while on vacation (OR, 0.74; 95% CI, 0.63-0.88) were associated with lower rates of burnout on multivariable analysis, whereas spending 30 minutes or longer per vacation day on patient-related work (OR, 1.58; 95% CI, 1.22-2.04 for 30-60 minutes; OR, 1.97; 95% CI, 1.41-2.77 for 60-90 minutes; OR, 1.92; 95% CI, 1.36-2.73 for >90 minutes) was associated with higher rates of burnout.In this cross-sectional study of 3024 physicians, the number of vacation days taken and performing patient-related work while on vacation were associated with physician burnout. System-level efforts to ensure physicians take adequate vacation and have coverage for clinical responsibilities, including EHR inbox, may reduce physician burnout.

  View details for DOI 10.1001/jamanetworkopen.2023.51635

  View details for PubMedID 38214928

• Career Plans of US Physicians After the First 2 Years of the COVID-19 Pandemic. Mayo Clinic proceedings Shanafelt, T. D., Dyrbye, L. N., West, C. P., Trockel, M., Tutty, M., Wang, H., Carlasare, L. E., Sinsky, C. A. 2023; 98 (11): 1629-1640

  Abstract

  OBJECTIVE: To assess the career plans of US physicians at the end of 2021 relative to 2011 and2014.METHODS: Physicians in the United States were surveyed from December 9, 2021, to January 24, 2022, using methods similar to prior studies in 2011 and 2014. Responding physicians in active practice (n=1884) were included in the analysis. At all time-points, physicians indicated the likelihood they would (1) reduce clinical work hours in the next 12 months and (2) leave their current practice within 24 months.RESULTS: In 2021, 542 of 1344 (40.3%) indicated that it was "likely" or "definite" they would reduce clinical work hours in the next 12 months compared with 1120 of 6950 (16.1%) and 1275 of 6452 (19.8%) in 2011 and 2014. In 2021, 466 of 1817 (25.6%) indicated it was "likely" or "definite" they would leave their current practice in the next 24 months compared with 1284 of 6975 (18.4%) and 1726 of 6496 (26.6%) in 2011 and 2014. On multivariable analysis pooling responders from 2011, 2014, and 2021, physicians who responded in 2021 had higher odds of reporting intent to reduce clinical work hours compared with those who responded in 2014 (OR, 3.12; 95% CI, 2.73 to 3.57), whereas those responding in 2011 had lower odds relative to 2014 (OR, 0.81; 95% CI, 0.74 to 0.89).CONCLUSION: Roughly two of every five US physicians intend to reduce their clinical work hours in the next year, more than double previous rates. These findings have potentially profound implications for the adequacy of a US physician workforce already facing substantial shortages.

  View details for DOI 10.1016/j.mayocp.2023.07.006

  View details for PubMedID 37923521

• Politicization of Medical Care, Burnout, and Professionally Conflicting Emotions Among Physicians During COVID-19. Mayo Clinic proceedings Sinsky, C. A., Trockel, M., Carlasare, L. E., West, C. P., Wang, H., Tutty, M., Dyrbye, L. N., Shanafelt, T. D. 2023; 98 (11): 1613-1628

  Abstract

  OBJECTIVE: To evaluate the association of politicization of medical care with burnout, professional fulfillment, and professionally conflicting emotions (eg, less empathy, compassion; more anger, frustration, resentment).PARTICIPANTS AND METHODS: Physicians in select specialties were surveyed between December 2021 and January 2022 using methods similar to our prior studies, with additional assessment of politicization of medical care; moral distress; and having had to compromise professional integrity, workload, and professionally conflicting emotions.RESULTS: In a sample of 2780 physicians in emergency medicine, critical care, noncritical care hospital medicine, and ambulatory care, stress related to politicization of medical care was reported by 91.8% of physicians. On multivariable analysis, compromised integrity (odds ratio [OR], 3.64; 95% CI, 2.31 to 5.98), moral distress (OR, 2.82; 95% CI, 2.16 to 3.68), and feeling more exhausted taking care of patients with coronavirus disease 2019 (COVID-19) (OR, 3.46; 95% CI, 2.63 to 4.54) were associated with burnout. Compromised integrity, moral distress, and feeling more exhausted taking care of patients with COVID-19 were also statistically significantly associated with lower odds of professional fulfillment and professionally conflicting emotions. Stress related to conversations about non-approved COVID-19 therapies (OR, 1.74; 95% CI, 1.08 to 2.89), patient resistance to mask wearing (OR, 1.84; 95% CI, 1.35 to 2.55), and working more hours due to COVID (OR, 0.66; 95% CI, 0.49 to 0.89) were associated with professionally conflicting emotions.CONCLUSION: Most physicians experienced intrusion of politics into medical care during the pandemic. These experiences are associated with professionally conflicting emotions, including less compassion and empathy, greater frustration, and resentment. COVID-19-related moral distress and compromised integrity were also associated with less professional fulfillment and greater occupational burnout.

  View details for DOI 10.1016/j.mayocp.2023.07.007

  View details for PubMedID 37923520

• Designing and Building a Portfolio of Individual Support Resources for Physicians. Academic medicine : journal of the Association of American Medical Colleges Brazeau, C. M., Trockel, M. T., Swensen, S. J., Shanafelt, T. D. 2023

  Abstract

  As health care organizations in the United States move toward recovery from the COVID-19 pandemic, physicians and clinical faculty are experiencing occupational burnout and various manifestations of distress. To mitigate these challenges, health care organizations must optimize the work environment and provide support for individual clinicians using a variety of approaches, including mentoring, group-based peer support, individual peer support, coaching, and psychotherapy. While often conflated, each of these approaches offers distinct benefits. Mentoring is a longitudinal one-on-one relationship, typically focused on career development, usually with an experienced professional guiding a junior professional. Group-based peer support involves regular, longitudinal meetings of health professionals to discuss meaningful topics, provide mutual support to one another, and foster community. Individual peer support involves training peers to provide timely 1-on-1 support for a distressed colleague dealing with adverse clinical events or other professional challenges. Coaching involves a certified professional helping an individual identify their values and priorities and consider changes that would allow them to adhere to these more fully, and providing longitudinal support that fosters accountability for action. Individual psychotherapy is a longitudinal, short- or long-term professional relationship during which specific therapeutic interventions are delivered by a licensed mental health professional. When distress is severe, this is the best approach. Although some overlap exists, these approaches are distinct and complementary. Individuals may use different methods at different career stages and for different challenges. Organizations seeking to address a specific need should consider which approach is most suitable. Over time, a portfolio of offerings is typically needed to holistically address the diverse needs of clinicians. A stepped care model using a population health approach may be a cost-effective way to promote mental health and prevent occupational distress and general psychiatric symptoms.

  View details for DOI 10.1097/ACM.0000000000005276

  View details for PubMedID 37220390

• At-Risk Work Hours Among U.S. Physicians and Other U.S. Workers. American journal of preventive medicine Shanafelt, T. D., West, C. P., Sinsky, C. A., Trockel, M. T., Tutty, M. A., Wang, H., Carlasare, L. E., Dyrbye, L. N. 2023

  Abstract

  Systematic reviews by the WHO have shown an increased risk of morbidity and mortality related to ischemic heart disease and stroke among individuals working an average of ≥55 hours/week.A cross-sectional survey of U.S. physicians and a probability-based sample of the general U.S. working population (n=2,508) was conducted between November 20, 2020, and February 16, 2021 (data analyzed in 2022). Among 3,617 physicians who received a mailed survey, 1,162 (31.7%) responded; among 90,000 physicians who received an electronic survey, 6,348 (7.1%) responded. Mean weekly work hours were assessed.The mean reported weekly work hours for physicians and U.S. workers in other fields were 50.8 hours and 40.7 hours, respectively (p<0.001). Less than 10% of U.S. workers in other fields (9.2%) reported working ≥55 hours/week compared with 40.7% of physicians. Although work hours decreased among physicians working less than full time, the decrease in work hours was smaller than the reported reduction in professional work effort. Specifically, for physicians who worked between half-time and full-time (i.e., full-time equivalent=50%-99%), work hours decreased by approximately 14% for each 20% reduction in full-time equivalent. On multivariable analysis of physicians and workers in other fields adjusting for age, gender, relationship status, and level of education, individuals with a professional/doctorate degree other than an MD/DO (OR=3.74; 95% CI=2.28, 6.09) and physicians (OR=8.62; 95% CI=6.44, 11.80) were more likely to work ≥55 hours/week.A substantial proportion of physicians have work hours previously shown to be associated with adverse personal health outcomes.

  View details for DOI 10.1016/j.amepre.2023.03.020

  View details for PubMedID 37178097

• Occupational Characteristics Associated With Professional Fulfillment and Burnout Among US Physiatrists. American journal of physical medicine & rehabilitation Makowski, M. S., Trockel, M., Paganoni, S., Weinstein, S., Verduzco-Gutierrez, M., Kinney, C., Kennedy, D. J., Sliwa, J., Wang, H., Knowlton, T., Stautzenbach, T., Shanafelt, T. D. 2023; 102 (5): 379-388

  Abstract

  Multiple national studies suggest that among physicians, physiatrists are at increased risk for occupational burnout.The aim of the study is to identify characteristics of the work environment associated with professional fulfillment and burnout among US physiatrists.Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists.Online interviews, focus groups, and survey were conducted.The participants are physiatrists in the American Academy of Physical Medicine and Rehabilitation Membership Masterfile.Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index.Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items, Cronbach α = 0.86); integration of physiatry into patient care (3 items, Cronbach α = 0.71); personal-organizational values alignment (3 items, Cronbach α = 0.90); meaningfulness of physiatrist clinical work (6 items, Cronbach α = 0.90); teamwork and collaboration (3 items, Cronbach α = 0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.4%) returned surveys (median age, 52 yrs; 46.1% women). Overall, 42.6% (336 of 788) experienced burnout and 30.6% (244 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (odds ratio = 1.96; 95% confidence interval = 1.45-2.69), integration of physiatry into patient care (odds ratio = 1.77; 95% confidence interval = 1.32-2.38), personal-organizational values alignment (odds ratio = 1.92; 95% confidence interval = 1.48-2.52), meaningfulness of physiatrist clinical work (odds ratio = 2.79; 95% confidence interval = 1.71-4.71), and teamwork and collaboration score (odds ratio = 2.11; 95% confidence interval = 1.48-3.03) was independently associated with higher likelihood of professional fulfillment.Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in US physiatrists. Variation in these domains by practice setting and subspecialty suggests that tailored approaches are needed to promote professional fulfillment and reduce burnout among US physiatrists.

  View details for DOI 10.1097/PHM.0000000000002216

  View details for PubMedID 37076955

• Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial. JMIR mental health Vollert, B., Müller, L., Jacobi, C., Trockel, M., Beintner, I. 2023; 10: e39052

  Abstract

  A growing body of evidence for digital interventions to improve sleep shows promising effects. The interventions investigated so far have been primarily web-based; however, app-based interventions may reach a wider audience and be more suitable for daily use.This study aims to evaluate the intervention effects, adherence, and acceptance of an unguided app-based intervention for individuals who wish to improve their sleep.In a randomized controlled trial, we evaluated the effects of an app-based short intervention (Refresh) to improve sleep compared with a waitlist condition. Refresh is an 8-week unguided intervention covering the principles of cognitive behavioral therapy for insomnia (CBT-I) and including a sleep diary. The primary outcome was sleep quality (insomnia symptoms) as self-assessed by the Regensburg Insomnia Scale (RIS). The secondary outcomes were depression (9-item Patient Health Questionnaire [PHQ-9] score) and perceived insomnia-related impairment.We included 371 participants, of which 245 reported poor sleep at baseline. About 1 in 3 participants who were allocated to the intervention group never accessed the intervention. Active participants completed on average 4 out of 8 chapters. Retention rates were 67.4% (n=250) at postassessment and 57.7% (n=214) at the 6-month follow-up. At postintervention, insomnia symptoms in the intervention group had improved more than those in the waitlist group, with a small effect (d=0.26) in the whole sample and a medium effect (d=0.45) in the subgroup with poor sleep. Effects in the intervention group were maintained at follow-up. Perceived insomnia-related impairment also improved from pre- to postassessment. No significant intervention effect on depression was detected. Working alliance and acceptance were moderate to good.An app-based, unguided intervention is a feasible and effective option to scale-up CBT-I-based treatment, but intervention uptake and adherence need to be carefully addressed.ISRCTN Registry ISRCTN53553517; https://www.isrctn.com/ISRCTN53553517.

  View details for DOI 10.2196/39052

  View details for PubMedID 36943337

• Occupational Characteristics Associated with Professional Fulfillment and Burnout Among U.S. Physiatrists. PM & R : the journal of injury, function, and rehabilitation Makowski, M. S., Trockel, M., Paganoni, S., Weinstein, S., Verduzco-Guiterrez, M., Kinney, C., Kennedy, D. J., Sliwa, J., Wang, H., Knowlton, T., Stautzenbach, T., Shanafelt, T. 2023

  Abstract

  Multiple national studies suggest that, among physicians, physiatrists are at increased risk for occupational burnout.Identify characteristics of the work environment associated with professional fulfillment and burnout among U.S. physiatrists.Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists.Online interviews, focus groups, and survey PARTICIPANTS: physiatrists in the AAPM&R Membership Masterfile MAIN OUTCOME MEASURES: Burnout and professional fulfillment assessed using the Stanford Professional Fulfillment Index RESULTS: Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items; Cronbach's alpha=0.86); integration of physiatry into patient care (3 items; Cronbach's alpha=0.71); personal-organizational values alignment (3 items; Cronbach's alpha=0.90); meaningfulness of physiatrist clinical work (6 items; Cronbach's alpha=0.90); teamwork and collaboration (3 items; Cronbach's alpha=0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.3%) returned surveys (median age 52 years; 46.1% women). Overall, 42.6% (336 or 788) experienced burnout and 30.6% (224 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (OR=2.00; 95%CI=1.45-2.69), integration of physiatry into patient care (OR=1.77; 95%CI=1.32-2.38), personal-organizational-values alignment (OR=1.92; 95%CI=1.48-2.52), meaningfulness of physiatrist clinical work (OR=2.79; 95%CI=1.71-4.71) and teamwork and collaboration score (OR=2.11; 95%CI=1.48-3.03) was independently associated with higher likelihood of professional fulfillment.Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in U.S. physiatrists. Variation in these domains by practice setting and sub-specialty suggests tailored approaches are needed to promote professional fulfillment and reduce burnout among US physiatrists.

  View details for DOI 10.1002/pmrj.12961

  View details for PubMedID 36794660

• 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

• Moderators and Mediators of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders: Informing Future Design Efforts JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Graham, A. K., Fitzsimmons-Craft, E. E., Sadeh-Sharvit, S., Balantekin, K. N., Eichen, D. M., Firebaugh, M., Goel, N. J., Monterubio, G. E., Karam, A. M., Flatt, R. E., Jo, B., Jacobi, C., Wilfley, D. E., Taylor, C., Trockel, M. 2023

  Abstract

  The Student Bodies-Eating Disorders intervention (SB-ED), a digital cognitive behavior therapy-guided self-help intervention for college women with an eating disorder, is effective for reducing eating disorder psychopathology. The purpose of this study was to evaluate moderators and mediators of the SB-ED intervention. To our knowledge, this is the first evaluation of clinical mediators of a digital intervention for women with eating disorders.This is an exploratory secondary analysis of a cluster randomized trial comparing the SB-ED intervention to referral to usual care among 690 women at 27 United States colleges. Moderators included body mass index (BMI), race, ethnicity, weight/shape concerns, eating disorder impairment, thin ideal internalization, depression, anxiety, and motivation for treatment, assessed at baseline. Thin ideal internalization and depressive symptoms were tested as predictors at postintervention and mediators at 2-year follow-up. Outcome was change in global eating disorder psychopathology.BMI moderated the effect of the intervention at follow-up (but not posttreatment), with individuals with a lower BMI experiencing more continued improvements in eating disorder psychopathology following the intervention than individuals with a higher BMI. Thin ideal internalization mediated the effect of the intervention at follow-up, and depression partially mediated the effect of the intervention at follow-up.Results of the mediator analyses suggest that helping college women reduce inflated internalization of the thin ideal and improve depressive symptoms leads to improvements in eating disorder psychopathology. Results also suggest opportunities to optimize the intervention so individuals across the BMI spectrum experience ongoing improvements over time. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

  View details for DOI 10.1037/ccp0000786

  View details for Web of Science ID 000912082400001

  View details for PubMedID 36634022

• Organization-Wide Approaches to Foster Effective Unit-Level Efforts to Improve Clinician Well-Being. Mayo Clinic proceedings Shanafelt, T. D., Larson, D., Bohman, B., Roberts, R., Trockel, M., Weinlander, E., Springer, J., Wang, H., Stolz, S., Murphy, D. 2023; 98 (1): 163-180

  Abstract

  Health care delivery organizations are positioned to have a tremendous impact on addressing the variables in the practice environment that contribute to occupational distress and that, when optimized, can promote clinician well-being. Many organizations are committed to this work and have clarity on how to address general, system-wide issues and provide resources for individual clinicians. While such top of the organization elements are essential for success, many of the specific improvement efforts that are necessary must address local challenges at the work unit level (department, division, hospital ward, clinic). Uncertainty of how to address variability and the unique needs of different work units is a barrier to effective action for many health care delivery systems. Overcoming this challenge requires organizations to recognize that unit-specific improvement efforts require a system-level approach. In this manuscript, we outline 7 steps for organizations to consider as they establish the infrastructure to improve professional well-being and provide a description of application and evidence of efficacy from a large academic medical center. Such unit-level efforts to address the unique needs of each specialty and occupation at the work unit level have the ability to address many of the day-to-day issues that drive clinician well-being. An enterprise approach is necessary to systematically advance such unit-level action.

  View details for DOI 10.1016/j.mayocp.2022.10.031

  View details for PubMedID 36603944

• Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic. Mayo Clinic proceedings Shanafelt, T. D., West, C. P., Dyrbye, L. N., Trockel, M., Tutty, M., Wang, H., Carlasare, L. E., Sinsky, C. 2022

  Abstract

  OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) in US physicians at the end of 2021, roughly 21 months into the COVID-19 pandemic, with comparison to 2020, 2017, 2014, and2011.METHODS: Between December 9, 2021, and January 24, 2022, we surveyed US physicians using methods similar to those of our prior studies. Burnout, WLI, depression, and professional fulfillment were assessed with standard instruments.RESULTS: There were 2440 physicians who participated in the 2021 survey. Mean emotional exhaustion and depersonalization scores were higher in 2021 than those observed in 2020, 2017, 2014, and 2011 (all P<.001). Mean emotional exhaustion scores increased 38.6% (2020 mean, 21.0; 2021 mean, 29.1; P<.001), whereas mean depersonalization scores increased 60.7% (2020 mean, 6.1; 2021 mean, 9.8; P<.001). Overall, 62.8% of physicians had at least 1 manifestation of burnout in 2021 compared with 38.2% in 2020, 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Although these trends were consistent across nearly all specialties, substantial variability by specialty was observed. Satisfaction with WLI declined from 46.1% in 2020 to 30.2% in 2021 (P<.001). Mean scores for depression increased 6.1% (2020 mean, 49.54; 2021 mean, 52.59; P<.001).CONCLUSION: A dramatic increase in burnout and decrease in satisfaction with WLI occurred in US physicians between 2020 and 2021. Differences in mean depression scores were modest, suggesting that the increase in physician distress was overwhelmingly work related. Given the association of physician burnout with quality of care, turnover, and reductions in work effort, these findings have profound implications for the US health care system.

  View details for DOI 10.1016/j.mayocp.2022.09.002

  View details for PubMedID 36229269

• Imposter Phenomenon in US Physicians Relative to the US Working Population. Mayo Clinic proceedings Shanafelt, T. D., Dyrbye, L. N., Sinsky, C., Trockel, M., Makowski, M. S., Tutty, M., Wang, H., Carlasare, L. E., West, C. P. 2022

  Abstract

  OBJECTIVE: To determine the prevalence of imposter phenomenon (IP) experiences among physicians and evaluate their relationship to personal and professional characteristics, professional fulfillment, burnout, and suicidal ideation.PARTICIPANTS AND METHODS: Between November 20, 2020, and February 16, 2021, we surveyed US physicians and a probability-based sample of the US working population. Imposter phenomenon was measured using a 4-item version of the Clance Imposter Phenomenon Scale. Burnout and professional fulfillment were measured using standardized instruments.RESULTS: Among the 3237 physician responders invited to complete the subsurvey including the IP scale, 3116 completed the IP questions. Between 4% (133) and 10% (308) of the 3116 physicians endorsed each of the 4 IP items as a "very true" characterization of their experience. Relative to those with a low IP score, the odds ratio for burnout among those with moderate, frequent, and intense IP was 1.28 (95% CI, 1.04 to 1.58), 1.79 (95% CI, 1.38 to 2.32), and 2.13 (95% CI, 1.43 to 3.19), respectively. A similar association between IP and suicidal ideation was observed. On multivariable analysis, physicians endorsed greater intensity of IP than workers in other fields in response to the item, "I am disappointed at times in my present accomplishments and think I should have accomplished more."CONCLUSION: Imposter phenomenon experiences are common among US physicians, and physicians have more frequent experiences of disappointment in accomplishments than workers in other fields. Imposter phenomenon experiences are associated with increased burnout and suicidal ideation and lower professional fulfillment. Systematic efforts to address the professional norms and perfectionistic attitudes that contribute to this phenomenon are necessary.

  View details for DOI 10.1016/j.mayocp.2022.06.021

  View details for PubMedID 36116974

• Assessing Professional Fulfillment and Burnout Among CEOs and Other Healthcare Administrative Leaders in the United States. Journal of healthcare management / American College of Healthcare Executives Shanafelt, T., Trockel, M., Wang, H., Mayer, T., Athey, L. 2022

  Abstract

  GOAL: The objective of this study was to evaluate the prevalence of burnout and professional fulfillment among healthcare administrative leaders and examine the association between burnout and professional fulfillment and personal and professional characteristics.METHODS: Between June 7 and June 30, 2021, we performed a national survey of CEOs and other senior operational leaders to evaluate their personal work experience. Burnout and professional fulfillment-as well as a sleep-related impairment and self-valuation-were assessed using standardized instruments.PRINCIPLE FINDINGS: Of the 5,994 members of the American College of Healthcare Executives who were sent an invitation to participate, 1,269 (21.2%), including 279 CEOs, submitted usable responses. The mean overall burnout score was 2.71 (range: 0-10), and 33% of participants had burnout scores that fell in the high range (unfavorable). Mean professional fulfillment score was 7.29 (range: 0-10), with 56.6% scoring in the high range (favorable). Burnout and professional fulfillment scores varied by role. On multivariable analysis, sleep-related impairment (OR for each 1-point increase = 1.29, 95% CI [1.19-1.41]; p < .001) and self-valuation (OR for each 1-point increase = 0.63, 95% CI [0.57-0.68]; p < .001) were independently associated with burnout after adjusting for all other variables.APPLICATIONS TO PRACTICE: Results of this study suggest that healthcare leaders had lower burnout and professional fulfillment scores than clinicians. Nonetheless, one-third of healthcare leaders had burnout scores that fell in the high range. At the individual level, sleep health and self-valuation appear to reduce risk of burnout and promote professional fulfillment.

  View details for DOI 10.1097/JHM-D-22-00012

  View details for PubMedID 35984407

• Mistreatment Experiences, Protective Workplace Systems, and Occupational Distress in Physicians. JAMA network open Rowe, S. G., Stewart, M. T., Van Horne, S., Pierre, C., Wang, H., Manukyan, M., Bair-Merritt, M., Lee-Parritz, A., Rowe, M. P., Shanafelt, T., Trockel, M. 2022; 5 (5): e2210768

  Abstract

  Importance: Reducing physician occupational distress requires understanding workplace mistreatment, its relationship to occupational well-being, and how mistreatment differentially impacts physicians of diverse identities.Objectives: To assess the prevalence and sources of mistreatment among physicians and associations between mistreatment, occupational well-being, and physicians' perceptions of protective workplace systems.Design, Setting, and Participants: This survey study was administered in September and October 2020 to physicians at a large academic medical center. Statistical analysis was performed from May 2021 to February 2022.Main Outcomes and Measures: Primary measures were the Professional Fulfillment Index, a measure of intent to leave, and the Mistreatment, Protection, and Respect Measure (MPR). Main outcomes were the prevalence and sources of mistreatment. Secondary outcomes were the associations of mistreatment and perceptions of protective workplace systems with occupational well-being.Results: Of 1909 medical staff invited, 1505 (78.8%) completed the survey. Among respondents, 735 (48.8%) were women, 627 (47.1%) were men, and 143 (9.5%) did not share gender identity or chose "other"; 12 (0.8%) identified as African American or Black, 392 (26%) as Asian, 10 (0.7%) as multiracial, 736 (48.9%) as White, 63 (4.2%) as other, and 292 (19.4%) did not share race or ethnicity. Of the 1397 respondents who answered mistreatment questions, 327 (23.4%) reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, reported by 232 physicians (16.6%). Women were more than twice as likely as men to experience mistreatment (31% [224 women] vs 15% [92 men]). On a scale of 0 to 10, mistreatment was associated with a 1.13 point increase in burnout (95% CI, 0.89 to 1.36), a 0.99-point decrease in professional fulfillment (95% CI, -1.24 to -0.73), and 129% higher odds of moderate or greater intent to leave (odds ratio, 2.29; 95% CI, 1.75 to 2.99). When compared with a perception that protective workplace systems are in place "to a very great extent," a perception that there are no protective workplace systems was associated with a 2.41-point increase in burnout (95% CI, 1.80 to 3.02), a 2.81-point lower professional fulfillment score (95% CI, -3.44 to -2.18), and 711% higher odds of intending to leave (odds ratio, 8.11; 95% CI, 3.67 to 18.35).Conclusions and Relevance: This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that health care organizations should prioritize reducing workplace mistreatment.

  View details for DOI 10.1001/jamanetworkopen.2022.10768

  View details for PubMedID 35522279

• Physicians' Experiences With Mistreatment and Discrimination by Patients, Families, and Visitors and Association With Burnout. JAMA network open Dyrbye, L. N., West, C. P., Sinsky, C. A., Trockel, M., Tutty, M., Satele, D., Carlasare, L., Shanafelt, T. 2022; 5 (5): e2213080

  Abstract

  Importance: Burnout is common among physicians and is associated with suboptimal patient outcomes. Little is known about how experiences with patients, families, and visitors differ by physician characteristics or contribute to the risk of burnout.Objective: To examine the occurrence of mistreatment and discrimination by patients, families, and visitors by physician characteristics and the association between such interactions and experiencing burnout.Design, Setting, and Participants: This cross-sectional survey was conducted from November 20, 2020, to March 23, 2021, among US physicians.Exposures: Mistreatment and discrimination were measured using items adapted from the Association of American Medical College's Graduation Questionnaire with an additional item querying respondents about refusal of care because of the physicians' personal attributes; higher score indicated greater exposure to mistreatment and discrimination.Main Outcomes and Measures: Burnout as measured by the Maslach Burnout Inventory.Results: Of 6512 responding physicians, 2450 (39.4%) were female, and 369 (7.2%) were Hispanic; 681 (13.3%) were non-Hispanic Asian, Native Hawaiian, or Pacific Islander; and 3633 (70.5%) were non-Hispanic White individuals. Being subjected to racially or ethnically offensive remarks (1849 [29.4%]), offensive sexist remarks (1810 [28.7%]), or unwanted sexual advances (1291 [20.5%]) by patients, families, or visitors at least once in the previous year were common experiences. Approximately 1 in 5 physicians (1359 [21.6%]) had experienced a patient or their family refusing to allow them to provide care because of the physician's personal attributes at least once in the previous year. On multivariable analyses, female physicians (OR, 2.33; 95% CI, 2.02-2.69) and ethnic and racial minority physicians (eg, Black or African American: OR, 1.59; 95% CI, 1.13-2.23) were more likely to report mistreatment or discrimination in the previous year. Experience of mistreatment or discrimination was independently associated with higher odds of burnout (vs score of 0 [no mistreatment], score of 1: OR, 1.27; 95% CI, 1.04-1.55; score of 2: OR, 1.70; 95% CI, 1.38-2.08; score of 3: OR, 2.20; 95% CI, 1.89-2.57). There was no difference in the odds of burnout by gender after controlling for experiencing mistreatment and discrimination score and other demographic factors, specialty, practice setting, work hours, and frequency of overnight call.Conclusions and Relevance: In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct.

  View details for DOI 10.1001/jamanetworkopen.2022.13080

  View details for PubMedID 35587344

• Validity Evidence of Brazilian Portuguese Version of the Professional Fulfillment Index. American journal of health promotion : AJHP Silva-Junior, J. S., Niituma Ogata, A. J., Scarpellini, B. C., Arantes da Cunha, A., Trockel, M., Demarch, R. B. 2022: 8901171221086945

  Abstract

  PURPOSE: The questionnaire "Professional Fulfillment Index" (PFI) was validated to assess emotional exhaustion, interpersonal disengagement, and professional achievement among physicians. This study presents the process of cross-cultural adaptation of the PFI to the Brazilian context.DESIGN: Analytical cross-sectional study carried out between July and October 2020. Settings: For conceptual equivalence, a panel of experts was constituted who conducted analyzes on the translation and back-translation processes from English to Brazilian Portuguese.SUBJECTS: For the operational equivalence, 432 physicians in the field of Occupational Medicine were invited.MEASURES: They answered the PFI in an online platform. Analysis: Both exploratory and confirmatory factor analysis were performed to seek evidence of the hypothesized structure of PFI item responses. Reliability was assessed using three indicators.RESULTS: The Brazilian version can be considered similar to the original. Most of participants were female (57.6%) and mean age 49.6years-SD 14.0. The mean time since graduation was 18.5years-SD 9.67. Most of them had a full-time job (88.0%) and were trained through post-graduation courses 83.8%. The most frequent job task was to perform workers clinical evaluations (84.9%). Exploratory and confirmatory analyzes showed the adequacy of the items in measuring the instrument's construct, with stability for use in other populations and samples.CONCLUSION: The PFI was developed to evaluate positive and negative aspects of physicians' role and performance. The process described in this article was the first cross-cultural adaptation of the questionnaire. The PFI can help in mapping potential risk situations for negative impacts on physicians' occupational well-being and performance at work, in order to propose interventions that reduce exhaustion and expand professional fulfillment.

  View details for DOI 10.1177/08901171221086945

  View details for PubMedID 35417258

• Predictors of dropout in university students participating in an 8-week e-mail-based cognitive-behavioral therapy for insomnia intervention. Sleep & breathing = Schlaf & Atmung Nam, H., Chang, J., Trockel, M., Okajima, I., Yang, C., Chan, N. Y., Li, S., Suh, S. 2022

  Abstract

  PURPOSE: We conducted an exploratory study to identify risk factors of dropout in an 8-week e-mail-based cognitive-behavioral therapy for insomnia (REFRESH) to improve sleep among university students with insomnia symptoms.METHODS: University and graduate students in Hong Kong and Korea who scored higher than 10 on the Insomnia Severity Index participated in REFRESH.RESULTS: Of 158 participants from Hong Kong (n = 43) and Korea (n = 115), 90 (57%) did not complete all 7 sessions, while 52 of 90 (57.8%) dropped out prior to the fourth session. ROC analysis was conducted on the entire sample of 158 participants with intervention completion vs. dropout (non-completion) as the outcome variable. Predictors of dropout were wake time after sleep onset (WASO)<7.1min on the weekly sleep diary and expectations for sleep (a subscale of dysfunctional beliefs and attitudes about sleep; DBAS)<18 at baseline.CONCLUSIONS: These findings indicate that shorter WASO and less expectations for sleep at baseline were associated with risk of dropout from e-mail delivered self-help CBT-I-based intervention. Our results highlight the importance of identifying and tailoring treatment formats to students based on their presenting sleep characteristics.

  View details for DOI 10.1007/s11325-022-02609-y

  View details for PubMedID 35412222

• Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2020. Mayo Clinic proceedings Shanafelt, T. D., West, C. P., Sinsky, C., Trockel, M., Tutty, M., Wang, H., Carlasare, L. E., Dyrbye, L. N. 2022; 97 (3): 491-506

  Abstract

  OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) among physicians and US workers in 2020 relative to 2011, 2014, and2017.METHODS: Between November 20, 2020, and March 23, 2021, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our prior studies. Burnout and WLI were measured using standard tools. Information about specific work-related COVID-19 experiences was collected.RESULTS: There were 7510 physicians who participated in the survey. Nonresponder analysis suggested that participants were representative of US physicians. Mean emotional exhaustion and depersonalization scores were lower in 2020 than in 2017, 2014, and 2011 (all P<.001). However, emotional exhaustion and depersonalization scores did not improve in specialties most heavily affected by COVID-19. Overall, 38.2% of physicians reported 1 or more symptoms of burnout in 2020 compared with 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Providing care without adequate personal protective equipment (odds ratio [OR], 1.53; 95% CI, 1.35 to 1.72) and having suffered disruptive economic consequences due to COVID-19 (OR, 1.49; 95% CI, 1.32 to 1.69) were independently associated with risk of burnout. On multivariable analysis, physicians were at increased risk for burnout (OR, 1.41; 95% CI, 1.25 to 1.58) and were less likely to be satisfied with WLI (OR, 0.71; 95% CI, 0.64 to 0.79) than other working US adults.CONCLUSION: Burnout and satisfaction with WLI among US physicians improved between 2017 and 2020. The impact of the COVID-19 pandemic on physicians varies on the basis of professional characteristics and experiences. Physicians remain at increased risk for burnout relative to workers in other fields.

  View details for DOI 10.1016/j.mayocp.2021.11.021

  View details for PubMedID 35246286

• Burnout And Professional Fulfillment Among Brazilian Occupational Physicians Silva-Junior, J., Niituma Ogata, A., Scarpellini, B., da Cunha, A., Trockel, M., Demarch, R. ELSEVIER. 2022: S235

  View details for Web of Science ID 000760944700762

• Can an E-Mail-Delivered CBT for Insomnia Validated in the West Be Effective in the East? A Randomized Controlled Trial. International journal of environmental research and public health Okajima, I., Tanizawa, N., Harata, M., Suh, S., Yang, C., Li, S. X., Trockel, M. T. 1800; 19 (1)

  Abstract

  This study examined the effects of an e-mail-delivered cognitive behavioral therapy for insomnia (CBT-I), validated in Western countries, on insomnia severity, anxiety, and depression in young adults with insomnia in Eastern countries, particularly Japan. This prospective parallel-group randomized clinical trial included college students with Insomnia Severity Index (ISI) scores of ten or higher. Participants were recruited via advertising on a university campus and randomized to an e-mail-delivered CBT-I (REFRESH) or self-monitoring (SM) with sleep diaries group. The primary outcomes were insomnia severity, anxiety, and depression; secondary outcomes were sleep hygiene practices, dysfunctional beliefs, sleep reactivity, and pre-sleep arousal. All measurements were assessed before and after the intervention. A total of 48 participants (mean (SD) age, 19.56 (1.86) years; 67% female) were randomized and included in the analysis. The results of the intent-to-treat analysis showed a significant interaction effect for insomnia severity, anxiety, depression, sleep hygiene practice, and pre-sleep arousal. Compared with the SM group, the REFRESH group was more effective in reducing insomnia severity (Hedges' g = 1.50), anxiety (g = 0.97), and depression (g = 0.61) post-intervention. These findings suggest that an e-mail-delivered CBT-I may be an effective treatment for young adults with elevated insomnia symptoms living in Japan.

  View details for DOI 10.3390/ijerph19010186

  View details for PubMedID 35010445

• Psychometric properties of the Peceived Benefits of Thinness Scale in college-aged women. Body image Flatt, R. E., Karam, A. M., Fitzsimmons-Craft, E. E., Balantekin, K. N., Graham, A. K., Eichen, D. M., Monterubio, G. E., Goel, N. J., Fowler, L. A., Sadeh-Sharvit, S., Wilfley, D., Mazina, V., Taylor, C. B., Trockel, M. 1800; 40: 103-109

  Abstract

  Thin ideal internalization is a risk factor for disordered eating behaviors, poor body image, and eating disorders (EDs). This paper evaluated the psychometric properties of a novel measure, the Perceived Benefits of Thinness Scale (PBTS), which assesses how individuals feel being thinner would affect various aspects of their lives. Three separate studies with unique samples of college-aged women over 18 years were conducted to assess reliability and validity. In Study 1, exploratory and confirmatory factor analyses suggested all PBTS items loaded onto one factor that was distinct from a measure of weight and shape concerns. A large correlation between changes in PTBS scores and changes in ED psychopathology scores over 8 months (r=.57, p<.01) suggested sensitivity to change. Greater severity in ED pathology was also associated with higher scores on the PBTS. In Study 2, the PBTS showed good test-retest reliability (r=.84, p<.001) and, in Study 3, expected correlations with existing measures of thin ideal internalization (rs=.38-.60, ps<.001). Overall, the PBTS displayed good factor structure, reliability, concurrent validity, and sensitivity to change. By emphasizing social, emotional, and quality of life benefits, the PBTS may serve clinicians, researchers, and patients in understanding thin ideal internalization and associated ED risk.

  View details for DOI 10.1016/j.bodyim.2021.11.005

  View details for PubMedID 34896896

• Performance Nutrition for Physician Trainees Working Overnight Shifts: A Randomized Controlled Trial. Academic medicine : journal of the Association of American Medical Colleges Makowski, M. S., Trockel, M. T., Menon, N. K., Wang, H., Katznelson, L., Shanafelt, T. D. 2021

  Abstract

  PURPOSE: To compare acute effects of 2 dietary interventions with usual dietary habits on physician trainees' alertness during overnight shifts.METHOD: This registered, controlled, block-randomized crossover trial (NCT03698123) was conducted between October 2018 and May 2019 at Stanford Medicine. Physician trainees working at least 3 overnight shifts during a 1-week period were recruited. During the first overnight shift, participants followed their usual dietary habits. During the intervention nights (low carbohydrate-to-protein ratio and high carbohydrate-to-protein ratio interventions), participants received healthy dinners, snacks, water, and, upon request, caffeinated beverages, at the beginning of their shifts and were instructed to eat meals before 10 p.m. The sequence of interventions on the second and third nights were block-randomized across study weeks. Outcome measures (a priori) were overnight changes in validated measures of specific neurobehavioral dimensions: psychomotor vigilance, sensory-motor speed, working memory, and risk decision-making, as well as self-reported sleepiness and work exhaustion.RESULTS: Sixty-one physician trainees participated in this study. Compared to usual dietary habits, overnight changes in psychomotor vigilance scores (scale 0-1,000) improved by 51.02 points (95% confidence interval [CI]: 12.08, 89.96); sleepiness (scale 1-7) improved by 0.69 points (95% CI: 0.33, 1.05) under the low carbohydrate-to-protein ratio intervention. Compared to usual dietary habits, overnight changes in sleepiness (scale 1-7) improved by 0.61 points (95% CI: 0.25, 0.96) under the high carbohydrate-to-protein ratio intervention. Neither intervention had beneficial effects relative to usual dietary habits with respect to sensory-motor speed, working memory, risk decision-making, or work exhaustion. There were no differences in outcomes between low carbohydrate-to-protein ratio and high carbohydrate-to-protein ratio interventions.CONCLUSIONS: Dietary interventions may mitigate negative effects of physician trainee sleep deprivation during overnight shifts. Future studies are warranted to further examine the effectiveness of nutritional strategies on physician alertness during overnight shifts.

  View details for DOI 10.1097/ACM.0000000000004509

  View details for PubMedID 34753859

• Beyond burnout: Understanding the well-being gender gap in general surgery by examining professional fulfillment and control over schedule. American journal of surgery Mete, M., Dickman, J., Rowe, S., Trockel, M. T., Rotenstein, L., Khludenev, G., Marchalik, D. 2021

  Abstract

  BACKGROUND: Prior research has revealed a gender gap in physician burnout. Our study attempts to elucidate the cause for the differences in burnout among male and female general surgeons (GS).METHODS: The study is based on a sample of 431GS from 11 healthcare organizations participating in the Physician Wellness Academic Consortium.RESULTS: Female (N=154) and male (N=277) GS significantly differed in burnout (46% vs 33%, p=0.008) and professional fulfillment (PF), (37% vs 56% p<0.001). Male surgeons reported a higher sense of control over their schedule (COS) (5.0 vs 4.2, p=0.001). Mediation analyses showed that the gender effect on burnout was fully mediated through PF and COS.CONCLUSIONS: This study demonstrates that the observed differences in burnout between female and male GS are due to their differences in PF and COS. Longitudinal research is needed to determine whether interventions targeting PF and COS may mitigate burnout among female GS.

  View details for DOI 10.1016/j.amjsurg.2021.08.033

  View details for PubMedID 34517966

• How Feedback Is Given Matters: A Cross-Sectional Survey of Patient Satisfaction Feedback Delivery and Physician Well-being. Mayo Clinic proceedings Vilendrer, S. M., Kling, S. M., Wang, H., Brown-Johnson, C., Jayaraman, T., Trockel, M., Asch, S. M., Shanafelt, T. D. 2021

  Abstract

  OBJECTIVE: To evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making.PARTICIPANTS AND METHODS: A cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates.RESULTS: Of 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P<.001). Physicians who received feedback that included one-on-one discussions (as opposed to feedback without this channel) held more positive perceptions of the feedback's impact on patient care (OR, 2.0; 95% CI, 1.3 to 3.0; P=.003), whereas perceptions were less positive in physicians whose feedback included comparisons to named colleagues (OR, 0.5; 95% CI, 0.3 to 0.8; P=.003).CONCLUSION: Providing patient satisfaction feedback to physicians was associated with mixed results, and physician perceptions of the impact of feedback depended on the characteristics of feedback delivery. Our findings suggest that feedback is viewed most constructively by physicians when delivered through one-on-one discussions and without comparison to peers.

  View details for DOI 10.1016/j.mayocp.2021.03.039

  View details for PubMedID 34479736

• Examining the measurement equivalence of the Maslach Burnout Inventory across age, gender, and specialty groups in US physicians. Journal of patient-reported outcomes Brady, K. J., Sheldrick, R. C., Ni, P., Trockel, M. T., Shanafelt, T. D., Rowe, S. G., Kazis, L. E. 2021; 5 (1): 43

  Abstract

  BACKGROUND: Disparities in US physician burnout rates across age, gender, and specialty groups as measured by the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI) are well documented. We evaluated whether disparities in US physician burnout are explained by differences in the MBI's functioning across physician age, gender, and specialty groups.METHODS: We assessed the measurement equivalence of the MBI across age, gender, and specialty groups in multi-group item response theory- (IRT-) based differential item functioning (DIF) analyses using secondary, cross-sectional survey data from US physicians (n=6577). We detected DIF using two IRT-based methods and assessed its impact by estimating the overall average difference in groups' subscale scores attributable to DIF. We assessed DIF's practical significance by comparing differences in individuals' subscale scores and burnout prevalence estimates from models unadjusted and adjusted for DIF.RESULTS: We detected statistically significant age-, gender-, and specialty- DIF in all but one MBI item. However, in all cases, average differences in expected subscale-level scores due to DIF were<0.10 SD on each subscale. Differences in physicians' individual-level subscale scores and burnout symptom prevalence estimates across DIF- adjusted and unadjusted IRT models were also small (in all cases, mean absolute differences in individual subscale scores were<0.04 z-score units; prevalence estimates differed by <0.70%).CONCLUSIONS: Age-, gender-, and specialty-related disparities in US physician burnout are not explained by differences in the MBI's functioning across these demographic groups. Our findings support the use of the MBI as a valid tool to assess age-, gender-, and specialty-related disparities in US physician burnout.

  View details for DOI 10.1186/s41687-021-00312-2

  View details for PubMedID 34089412

• Personal and Professional Factors Associated With Work-Life Integration Among US Physicians. JAMA network open Tawfik, D. S., Shanafelt, T. D., Dyrbye, L. N., Sinsky, C. A., West, C. P., Davis, A. S., Su, F., Adair, K. C., Trockel, M. T., Profit, J., Sexton, J. B. 2021; 4 (5): e2111575

  Abstract

  Importance: Poor work-life integration (WLI) occurs when career and personal responsibilities come in conflict and may contribute to the ongoing high rates of physician burnout. The characteristics associated with WLI are poorly understood.Objective: To identify personal and professional factors associated with WLI in physicians and identify factors that modify the association between gender and WLI.Design, Setting, and Participants: This cross-sectional study was based on electronic and paper surveys administered October 2017 to March 2018 at private, academic, military, and veteran's practices across the US. It used a population-based sample of US physicians across all medical specialties. Data analysis was performed from November 2019 to July 2020.Main Outcomes and Measures: WLI was assessed using an 8-item scale (0-100 point scale, with higher scores indicating favorable WLI), alongside personal and professional factors. Multivariable linear regressions evaluated independent associations with WLI as well as factors that modify the association between gender and WLI.Results: Of 5197 physicians completing surveys, 4370 provided complete responses. Of the physicians who provided complete responses, 2719 were men, 3491 were White/Caucasian (80.8%), 3560 were married (82.4%), and the mean (SD) age was 52.3 (12.0) years. The mean (SD) WLI score was 55 (23). Women reported lower (worse) mean (SD) WLI scores than men overall (52 [22] vs 57 [23]; mean difference, -5 [-0.2 SDs]; P<.001). In multivariable regression, lower WLI was independently associated with being a woman (linear regression coefficient, -6; SE, 0.7; P<.001) as well as being aged 35 years or older (eg, aged 35 to 44 years: linear regression coefficient, -7; SE, 1.4; P<.001), single (linear regression coefficient, -3 vs married; SE, 1.1; P=.003), working more hours (eg, 50 to 59 hours per week vs less than 40 hours per week: linear regression coefficient, -9; SE, 1.0; P<.001) and call nights (linear regression coefficient, -1 for each call night per week; SE, 0.2; P<.001), and being in emergency medicine (linear regression coefficient, -18; SE, 1.6, P<.001), urology (linear regression coefficient, -11; SE, 4.0; P=.009), general surgery (linear regression coefficient, -4; SE, 2.0; P=.04), anesthesiology (linear regression coefficient, -4; SE, 1.7; P=.03), or family medicine (linear regression coefficient, -3; SE, 1.4; P=.04) (reference category, internal medicine subspecialties). In interaction modeling, physician age, youngest child's age, and hours worked per week modified the associations between gender and WLI, such that the largest gender disparities were observed in physicians who were aged 45 to 54 years (estimated WLI score for women, 49; 95% CI, 47-51; estimated WLI score for men, 57, 95% CI, 55-59; P<.001), had youngest child aged 23 years or older (estimated WLI score for women, 51; 95% CI, 48-54; estimated WLI score for men, 60; 95% CI, 58-62; P<.001), and were working less than 40 hours per week (estimated WLI score for women, 61; 95% CI, 59-63; estimated WLI score for men; 70; 95% CI, 68-72; P<.001).Conclusions and Relevance: This study found that lower WLI was reported by physicians who are women, single, aged 35 years or older, and who work more hours and call nights. These findings suggest that systemic change is needed to improve WLI among physicians.

  View details for DOI 10.1001/jamanetworkopen.2021.11575

  View details for PubMedID 34042994

• Novel Nonproprietary Measures of Ambulatory Electronic Health Record Use Associated with Physician Work Exhaustion. Applied clinical informatics Sinha, A., Shanafelt, T. D., Trockel, M., Wang, H., Sharp, C. 2021; 12 (3): 637-646

  Abstract

  BACKGROUND: Accumulating evidence indicates an association between physician electronic health record (EHR) use after work hours and occupational distress including burnout. These studies are based on either physician perception of time spent in EHR through surveys which may be prone to bias or by utilizing vendor-defined EHR use measures which often rely on proprietary algorithms that may not take into account variation in physician's schedules which may underestimate time spent on the EHR outside of scheduled clinic time. The Stanford team developed and refined a nonproprietary EHR use algorithm to track the number of hours a physician spends logged into the EHR and calculates the Clinician Logged-in Outside Clinic (CLOC) time, the number of hours spent by a physician on the EHR outside of allocated time for patient care.OBJECTIVE: The objective of our study was to measure the association between CLOC metrics and validated measures of physician burnout and professional fulfillment.METHODS: Physicians from adult outpatient Internal Medicine, Neurology, Dermatology, Hematology, Oncology, Rheumatology, and Endocrinology departments who logged more than 8hours of scheduled clinic time per week and answered the annual wellness survey administered in Spring 2019 were included in the analysis.RESULTS: We observed a statistically significant positive correlation between CLOC ratio (defined as the ratio of CLOC time to allocated time for patient care) and work exhaustion (Pearson's r=0.14; p=0.04), but not interpersonal disengagement, burnout, or professional fulfillment.CONCLUSION: The CLOC metrics are potential objective EHR activity-based markers associated with physician work exhaustion. Our results suggest that the impact of time spent on EHR, while associated with exhaustion, does not appear to be a dominant factor driving the high rates of occupational burnout in physicians.

  View details for DOI 10.1055/s-0041-1731678

  View details for PubMedID 34261173

• Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey. Joint Commission journal on quality and patient safety Harry, E. n., Sinsky, C. n., Dyrbye, L. N., Makowski, M. S., Trockel, M. n., Tutty, M. n., Carlasare, L. E., West, C. P., Shanafelt, T. D. 2021; 47 (2): 76–85

  Abstract

  Cognitive task load can affect providers' ability to perform their job well and may contribute to burnout.The researchers evaluated whether task load, measured by the National Aeronautics and Space Administration (NASA) Task Load Index (TLX), correlated with burnout scores in a large national study of US physicians between October 2017 and March 2018 with a 17.1% response rate. Burnout was measured using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, and a high score on either score was considered a manifestation of professional burnout. The NASA-TLX was chosen to evaluate physician task load (PTL) due to its robust validation and use across many industries, including health care, over the past 30 years. The domains included in the PTL were mental, physical, and temporal demands, and perception of effort.Mean score in task load dimension varied by specialty. In aggregate, high emotional exhaustion, depersonalization, and one symptom of burnout was seen in 38.8%, 27.4%, and 44.0% of participants, respectively. The mean PTL score was 260.9/400 (standard deviation = 71.4). The specialties with the highest PTL score were emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties. A dose response relationship between PTL and burnout was observed. For every 40-point (10%) decrease in PTL there was 33% lower odds of experiencing burnout (odds ratio = 0.67, 95% confidence interval = 0.65-0.70, p < 0.0001).The relationship between PTL and burnout may suggest areas of particular focus to improve the practice environment and reduce physician burnout.

  View details for DOI 10.1016/j.jcjq.2020.09.011

  View details for PubMedID 33168367

• Overweight and obesity are associated with increased eating disorder correlates and general psychopathology in university women with eating disorders. Eating behaviors Balantekin, K. N., Grammer, A. C., Fitzsimmons-Craft, E. E., Eichen, D. E., Graham, A. K., Monterubio, G. E., Firebaugh, M. L., Karam, A. M., Sadeh-Sharvit, S. n., Goel, N. J., Flatt, R. E., Trockel, M. T., Taylor, C. B., Wilfley, D. E. 2021; 41: 101482

  Abstract

  Examine how eating disorder (ED) correlates, ED-related clinical impairment, general psychopathology, and ED diagnoses differ across weight statuses in a sample of university women with EDs.Participants were 690 women from 28 U.S. universities who screened positive for an ED (with the exception of anorexia nervosa [AN]) and participated in the Healthy Body Image Program study. ED correlates, ED-related clinical impairment, general psychopathology (i.e., depression and anxiety), and ED diagnoses were compared across weight statuses (i.e., healthy weight, overweight, obesity) using analyses of variance and chi-square tests.Women with EDs and overweight or obesity had higher levels of, perceived benefit of thinness, depressive symptoms, anxiety, and weight/shape concerns (obesity only) than those with healthy weight (ps ≤ .017). Compared to those with healthy weight, those with obesity had higher rates of clinical and sub-clinical binge eating disorder and lower rates of bulimia nervosa (p < .001).Overweight and obesity in individuals with EDs, excluding AN, are associated with greater severity of ED correlates, ED-related clinical impairment, and co-morbid general psychopathology. The current study highlights the need to consider weight status in ED treatment and for optimization of ED treatments to address shared risk factors between EDs and overweight and obesity.

  View details for DOI 10.1016/j.eatbeh.2021.101482

  View details for PubMedID 33609964

• Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-Being and Professional Fulfillment. Academic medicine : journal of the Association of American Medical Colleges Shanafelt, T., Trockel, M., Rodriguez, A., Logan, D. 2020; Publish Ahead of Print

  Abstract

  These are challenging times for physicians. Extensive changes in the practice environment have altered the nature of physician's interactions with patients and their role in the health care delivery system. Many physicians feel as if they are "cogs in the wheel" of austere corporations that care more about productivity and finances than compassion or quality. They often do not see how the strategy and plan of their organization align with the values of the profession. Despite their expertise, they frequently do not feel they have a voice or input in the operational plan of their work unit, department, or organization. At their core, the authors believe all of these factors represent leadership issues. Many models of leadership have been proposed, and there are a number of effective philosophies and approaches. Here, the authors propose a new integrative model of Wellness-Centered Leadership (WCL). WCL includes core skills and qualities from the foremost leadership philosophies along with evidence on the relationship between leadership and physician well-being and distills them into a single framework designed to cultivate leadership behaviors that promote engagement and professional fulfillment. The 3 elements of WCL are: care about people always, cultivate individual and team relationships, and inspire change. A summary of the mindset, behaviors, and outcomes of the elements of the WCL model is presented and the application of the elements for physician leaders is discussed. The authors believe that learning and developing the skills that advance these elements should be the aspiration of all health care leaders and a foundational focus of leadership development programs. If cultivated, the authors believe that WCL will empower individual and team performance to address the current problems faced by health care organizations as well as the iterative innovation needed to address challenges that may arise in the decades to come.

  View details for DOI 10.1097/ACM.0000000000003907

  View details for PubMedID 33394666

• Perceived electronic health record usability as a predictor of task load and burnout among US physicians: A mediation analysis. Journal of medical Internet research Melnick, E. R., Harry, E., Sinsky, C. A., Dyrbye, L. N., Wang, H., Trockel, M. T., West, C. P., Shanafelt, T. 2020

  Abstract

  BACKGROUND: EHR usability and physician task load both contribute to physician professional burnout. The association between perceived EHR usability and workload has not previously been studied at a national level. Better understanding these interactions could give further information as to the drivers of extraneous task load.OBJECTIVE: To determine the relationship between physician perceived EHR usability and workload by specialty, and evaluate for associations with professional burnout.METHODS: A secondary analysis of a cross-sectional survey of US physicians from all specialties that was conducted from October 2017 to March 2018. Among the 1,250 physicians invited to respond to the sub-survey analyzed here, 848 (67.8%) completed it. EHR usability was assessed with the System Usability Scale (SUS; range 0-100). Provider task load (PTL) was assessed using the mental demand, physical demand, temporal demand, and effort required subscales of the NASA-Task Load Index (TLX; range 0-400). Burnout was measured using the Maslach Burnout Inventory.RESULTS: The mean scores were SUS 46.1 (SD 46.1) and PTL 262.5 (SD 71.7). On multivariable analysis adjusting for age, gender, relationship status, medical specialty, practice setting, hours worked per week, and number of nights on call per week, physician-rated EHR usability was associated with PTL with each 1 point more favorable SUS score associated with a 0.57 point lower PTL score (p < .001). On mediation analysis, higher SUS was associated with lower PTL, which was associated with lower odds of burnout.CONCLUSIONS: A strong association was observed between EHR usability and workload among US physicians with more favorable usability associated with less workload. Both outcomes were associated with the odds of burnout with task load acting as a mediator between EHR usability and burnout. Improving EHR usability while decreasing task load has the potential to allow practicing physicians more working memory for medical decision-making and patient communication.CLINICALTRIAL: Not applicable.

  View details for DOI 10.2196/23382

  View details for PubMedID 33289493

• Resilience and Burnout Among Physicians and the General US Working Population. JAMA network open West, C. P., Dyrbye, L. N., Sinsky, C., Trockel, M., Tutty, M., Nedelec, L., Carlasare, L. E., Shanafelt, T. D. 2020; 3 (7): e209385

  Abstract

  Importance: The prevalence of physician burnout is well documented, and resilience training has been proposed as an option to support physician well-being. However, the resilience of physicians compared with that of the US working population is not established, and the association between resilience and physician burnout is not well understood.Objectives: To evaluate resilience among physicians and US workers, and to determine the association between resilience and burnout among US physicians.Design, Setting, and Participants: A cross-sectional national survey study of 5445 US physicians and a probability-based sample of 5198 individuals in the US working population was conducted between October 12, 2017, and March 15, 2018.Main Outcomes and Measures: Resilience was measured using the 2-item Connor-Davidson Resilience Scale (total scores range from 0-8; higher scores indicate greater resilience); burnout was measured using the full Maslach Burnout Inventory with overall burnout indicated by a score of at least 27 on the 0 to 54 emotional exhaustion subscale and/or at least 10 on the depersonalization subscale (higher scores indicate greater burnout).Results: Of 30 456 physicians who received an invitation to participate, 5445 (17.9%) completed surveys (2995 men [62.1%]; median [IQR] age of 53 [42-62] years). In multivariable analysis, mean (SD) resilience scores were higher among physicians than the general employed population (6.49 [1.30] vs 6.25 [1.37]; adjusted mean difference, 0.25 points; 95% CI, 0.19-0.32; P<.001). Among physicians, resilience was associated with burnout. Physicians without overall burnout had higher mean (SD) resilience scores than physicians with burnout (6.82 [1.15] vs 6.13 [1.36]; adjusted mean difference, 0.68 points, 95% CI, 0.61-0.76; P<.001). Each 1-point increase in resilience score was associated with 36% lower odds of overall burnout (odds ratio, 0.64; 95% CI, 0.60-0.67; P<.001). However, 392 of 1350 physicians (29%) with the highest possible resilience score had burnout.Conclusions and Relevance: The findings of this national survey study suggest that physicians exhibited higher levels of resilience than the general working population in the US. Resilience was inversely associated with burnout symptoms, but burnout rates were substantial even among the most resilient physicians. Additional solutions, including efforts to address system issues in the clinical care environment, are needed to reduce burnout and promote physician well-being.

  View details for DOI 10.1001/jamanetworkopen.2020.9385

  View details for PubMedID 32614425

• Describing the emotional exhaustion, depersonalization, and low personal accomplishment symptoms associated with Maslach Burnout Inventory subscale scores in US physicians: an item response theory analysis. Journal of patient-reported outcomes Brady, K. J., Ni, P., Sheldrick, R. C., Trockel, M. T., Shanafelt, T. D., Rowe, S. G., Schneider, J. I., Kazis, L. E. 2020; 4 (1): 42

  Abstract

  PURPOSE: Current US health policy discussions regarding physician burnout have largely been informed by studies employing the Maslach Burnout Inventory (MBI); yet, there is little in the literature focused on interpreting MBI scores. We described the burnout symptoms and precision associated with MBI scores in US physicians.METHODS: Using item response theory (IRT) analyses of secondary, cross-sectional survey data, we created response profiles describing the probability of burnout symptoms associated with US physicians' MBI emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) subscale scores. Response profiles were mapped to raw subscale scores and used to predict symptom endorsements at mean scores and commonly used cut-points.RESULTS: The average US physician was likely to endorse feeling he/she is emotionally drained, used up, frustrated, and working too hard and all PA indicators once weekly or more but was unlikely to endorse feeling any DP symptoms once weekly or more. At the commonly used EE and DP cut-points of 27 and 10, respectively, a physician was unlikely to endorse feeling burned out or any DP symptoms once weekly or more. Each subscale assessed the majority of sample score ranges with ≥ 0.70 reliability.CONCLUSIONS: We produced a crosswalk mapping raw MBI subscale scores to scaled scores and response profiles calibrated in a US physician sample. Our results can be used to better understand the meaning and precision of MBI scores in US physicians; compare individual/group MBI scores against a reference population of US physicians; and inform the selection of subscale cut-points for defining categorical physician burnout outcomes.

  View details for DOI 10.1186/s41687-020-00204-x

  View details for PubMedID 32488344

• Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians. JAMA network open Melnick, E. R., Sinsky, C. A., Dyrbye, L. N., Trockel, M., West, C. P., Nedelec, L., Shanafelt, T. 2020; 3 (6): e207374

  View details for DOI 10.1001/jamanetworkopen.2020.7374

  View details for PubMedID 32568397

• CONTENT AND AFFECT ANALYSIS OF TEXT CORRESPONDENCE OF PARTICIPANTS IN A DIGITAL GUIDED SELF-HELP FOR EATING DISORDERS Fowler, L. A., Sadeh-Sharvit, S., Idan, O., Fitzsimmons-Craft, E. E., Smith, A. C., Goel, N. J., Flatt, R., Balantekin, K. N., Monterubio, G., Firebaugh, M., Karam, A., Graham, A. K., Funk, B., Trockel, M., Wilfley, D. E., Taylor, C. B. OXFORD UNIV PRESS INC. 2020: S44

  View details for Web of Science ID 000546262400093

• Association of Occupational Distress and Sleep-Related Impairment in Physicians With Unsolicited Patient Complaints. Mayo Clinic proceedings Welle, D., Trockel, M. T., Hamidi, M. S., Hickson, G. B., Menon, N. K., Shanafelt, T. D., Cooper, W. O. 2020; 95 (4): 719–26

  Abstract

  OBJECTIVE: To study the relationship between occupational distress and sleep-related impairment in physicians and unsolicited patient complaints.PARTICIPANTS AND METHODS: We used deidentified data from an academic medical center's physician survey administered in April and May of 2013 to perform a retrospective cohort study. Third-party stewards of the identifiable information regarding unsolicited patient complaints from January 1, 2013, through December 31, 2016, matched these data with corresponding physicians' occupational distress data. Unsolicited patient complaints were used to calculate the Patient Advocacy Reporting System (PARS) score, a validated predictor of malpractice litigation risk and clinical outcomes. Physicians were grouped into 1 of 3 PARS risk categories based on previously defined thresholds: low risk (score of 0), intermediate risk (score of 1-12), or high risk (score ≥13).RESULTS: Each 1-point increase in burnout and sleep-related impairment, on a 5-point scale, was associated with a 69% (odds ratio [OR], 1.69; 95% CI, 1.12-2.54) and 49% (OR, 1.49; 95% CI, 1.08-2.05) increased odds of being in the next higher PARS risk category, respectively, averaged across all 4 years. Professional fulfillment was a protective factor, associated with fewer unsolicited patient complaints. Each 1-point decrease in professional fulfillment was associated with a 68% (OR, 1.68; 95% CI, 1.16-2.44) increased odds of being in the next higher PARS risk category. The effect of depression on PARS risk category was not significant (OR, 1.33; 95% CI, 0.84-2.10).CONCLUSION: Findings from this research suggest that occupational distress and sleep-related impairment in physicians are associated with unsolicited patient complaints.

  View details for DOI 10.1016/j.mayocp.2019.09.025

  View details for PubMedID 32247345

• A Framework for Applying Natural Language Processing in Digital Health Interventions. Journal of medical Internet research Funk, B., Sadeh-Sharvit, S., Fitzsimmons-Craft, E. E., Trockel, M. T., Monterubio, G. E., Goel, N. J., Balantekin, K. N., Eichen, D. M., Flatt, R. E., Firebaugh, M. L., Jacobi, C., Graham, A. K., Hoogendoorn, M., Wilfley, D. E., Taylor, C. B. 2020; 22 (2): e13855

  Abstract

  Digital health interventions (DHIs) are poised to reduce target symptoms in a scalable, affordable, and empirically supported way. DHIs that involve coaching or clinical support often collect text data from 2 sources: (1) open correspondence between users and the trained practitioners supporting them through a messaging system and (2) text data recorded during the intervention by users, such as diary entries. Natural language processing (NLP) offers methods for analyzing text, augmenting the understanding of intervention effects, and informing therapeutic decision making.This study aimed to present a technical framework that supports the automated analysis of both types of text data often present in DHIs. This framework generates text features and helps to build statistical models to predict target variables, including user engagement, symptom change, and therapeutic outcomes.We first discussed various NLP techniques and demonstrated how they are implemented in the presented framework. We then applied the framework in a case study of the Healthy Body Image Program, a Web-based intervention trial for eating disorders (EDs). A total of 372 participants who screened positive for an ED received a DHI aimed at reducing ED psychopathology (including binge eating and purging behaviors) and improving body image. These users generated 37,228 intervention text snippets and exchanged 4285 user-coach messages, which were analyzed using the proposed model.We applied the framework to predict binge eating behavior, resulting in an area under the curve between 0.57 (when applied to new users) and 0.72 (when applied to new symptom reports of known users). In addition, initial evidence indicated that specific text features predicted the therapeutic outcome of reducing ED symptoms.The case study demonstrates the usefulness of a structured approach to text data analytics. NLP techniques improve the prediction of symptom changes in DHIs. We present a technical framework that can be easily applied in other clinical trials and clinical presentations and encourage other groups to apply the framework in similar contexts.

  View details for DOI 10.2196/13855

  View details for PubMedID 32130118

• Depression and anxiety mediate the relationship between insomnia and eating disorders in college women. Journal of American college health : J of ACH Goel, N. J., Sadeh-Sharvit, S., Trockel, M., Flatt, R. E., Fitzsimmons-Craft, E. E., Balantekin, K. N., Monterubio, G. E., Firebaugh, M., Wilfley, D. E., Taylor, C. B. 2020: 1–6

  Abstract

  Objective: This study examined the associations between insomnia, anxiety, and depression in college women with eating disorders (EDs). Participants: Six hundred and ninety women from 28US colleges who screened positive for an ED were assessed for psychiatric comorbidities. Women were, on average, 22.12years old, mostly White (60.1%) and undergraduates (74.3%). Methods: Two mediation models were tested to determine if depression and/or anxiety mediated the relationship between insomnia and ED symptomatology. Results: One-fifth of the sample (21.7%) reported clinically moderate and severe levels of insomnia. Both depression (B=.13, p<.001) and anxiety (B=.13, p<.001) significantly mediated the relationship between insomnia and ED psychopathology. Conclusions: Insomnia is relatively common in college-age women with EDs. Findings suggest that this association between ED and sleep disturbances can be explained, in part, by changes in depression and anxiety. Clinicians should consider incorporating mental health assessments for insomnia, depression, and anxiety into current ED prevention, intervention, and screening efforts on college campuses.

  View details for DOI 10.1080/07448481.2019.1710152

  View details for PubMedID 31971482

• Effectiveness of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders in College Women: A Cluster Randomized Clinical Trial. JAMA network open Fitzsimmons-Craft, E. E., Taylor, C. B., Graham, A. K., Sadeh-Sharvit, S. n., Balantekin, K. N., Eichen, D. M., Monterubio, G. E., Goel, N. J., Flatt, R. E., Karam, A. M., Firebaugh, M. L., Jacobi, C. n., Jo, B. n., Trockel, M. T., Wilfley, D. E. 2020; 3 (8): e2015633

  Abstract

  Eating disorders (EDs) are common, serious psychiatric disorders on college campuses, yet most affected individuals do not receive treatment. Digital interventions have the potential to bridge this gap.To determine whether a coached, digital, cognitive behavior therapy (CBT) intervention improves outcomes for college women with EDs compared with referral to usual care.This cluster randomized trial was conducted from 2014 to 2018 at 27 US universities. Women with binge-purge EDs (with both threshold and subthreshold presentations) were recruited from enrolled universities. The 690 participants were followed up for up to 2 years after the intervention. Data analysis was performed from February to September 2019.Universities were randomized to the intervention, Student Bodies-Eating Disorders, a digital CBT-guided self-help program, or to referral to usual care.The main outcome was change in overall ED psychopathology. Secondary outcomes were abstinence from binge eating and compensatory behaviors, as well as ED behavior frequencies, depression, anxiety, clinical impairment, academic impairment, and realized treatment access.A total of 690 women with EDs (mean [SD] age, 22.12 [4.85] years; 414 [60.0%] White; 120 [17.4%] Hispanic; 512 [74.2%] undergraduates) were included in the analyses. For ED psychopathology, there was a significantly greater reduction in the intervention group compared with the control group at the postintervention assessment (β [SE], -0.44 [0.10]; d = -0.40; t1387 = -4.23; P < .001), as well as over the follow-up period (β [SE], -0.39 [0.12]; d = -0.35; t1387 = -3.30; P < .001). There was not a significant difference in abstinence from any ED behaviors at the postintervention assessment (odds ratio, 1.48; 95% CI, 0.48-4.62; P = .50) or at follow-up (odds ratio, 1.51; 95% CI, 0.63-3.58; P = .36). Compared with the control group, the intervention group had significantly greater reductions in binge eating (rate ratio, 0.82; 95% CI, 0.70-0.96; P = .02), compensatory behaviors (rate ratio, 0.68; 95% CI, 0.54-0.86; P < .001), depression (β [SE], -1.34 [0.53]; d = -0.22; t1387 = -2.52; P = .01), and clinical impairment (β [SE], -2.33 [0.94]; d = -0.21; t1387 = -2.49; P = .01) at the postintervention assessment, with these gains sustained through follow-up for all outcomes except binge eating. Groups did not differ in terms of academic impairment. The majority of intervention participants (318 of 385 participants [83%]) began the intervention, whereas only 28% of control participants (76 of 271 participants with follow-up data available) sought treatment for their ED (odds ratio, 12.36; 95% CI, 8.73-17.51; P < .001).In this cluster randomized clinical trial comparing a coached, digital CBT intervention with referral to usual care, the intervention was effective in reducing ED psychopathology, compensatory behaviors, depression, and clinical impairment through long-term follow-up, as well as realizing treatment access. No difference was found between the intervention and control groups for abstinence for all ED behaviors or academic impairment. Given its scalability, a coached, digital, CBT intervention for college women with EDs has the potential to address the wide treatment gap for these disorders.ClinicalTrials.gov Identifier: NCT02076464.

  View details for DOI 10.1001/jamanetworkopen.2020.15633

  View details for PubMedID 32865576

• Disparities in Burnout and Satisfaction With Work-Life Integration in U.S. Physicians By Gender and Practice Setting. Academic medicine : journal of the Association of American Medical Colleges Marshall, A. L., Dyrbye, L. N., Shanafelt, T. D., Sinsky, C. A., Satele, D. n., Trockel, M. n., Tutty, M. n., West, C. P. 2020

  Abstract

  To explore the interaction between practice setting (academic practice [AP], private practice [PP]) and gender in relation to physician burnout and satisfaction with work-life integration (WLI).In 2017, the authors administered a cross-sectional survey of U.S. physicians and characterized rates of burnout and satisfaction with WLI using previously validated and/or standardized tools. They conducted multivariable logistic regression to determine the interaction between the included variables.Of the 3,603 participants in the final analysis, female physicians reported a higher prevalence of burnout than male physicians in both AP (50.7% vs 38.2%, P < .0001) and PP (48.1% vs 40.7%, P = .001). However, the multivariable analysis found no statistically significant gender-based differences in burnout (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.76 - 1.17, P = .60). Women and men in AP were less likely to report burnout than men in PP (OR 0.70, 95% CI 0.52 - 0.94, P = .01 and OR 0.69, 95% CI 0.53 - 0.90, P < .01, respectively); women in PP did not report different burnout rates from men in PP (OR 0.89, 95% CI 0.68 - 1.16, P = .38). Women in both AP and PP were less likely to be satisfied with WLI than men in PP (OR 0.62, 95% CI 0.47 - 0.83, P < .01 and OR 0.75, 95% CI 0.58 - 0.97, P = .03, respectively); men in AP did not report different satisfaction with WLI than men in PP (OR 1.05, 95% CI 0.82 - 1.33, P = .71).Gender differences in rates of burnout are related to practice setting and other differences in physicians' personal and professional lives. These results highlight the complex relationships among gender, practice setting, and other personal and professional factors in their influence on burnout and satisfaction with WLI.

  View details for DOI 10.1097/ACM.0000000000003521

  View details for PubMedID 32459677

• Burnout, Depression, Career Satisfaction, and Work-Life Integration by Physician Race/Ethnicity. JAMA network open Garcia, L. C., Shanafelt, T. D., West, C. P., Sinsky, C. A., Trockel, M. T., Nedelec, L. n., Maldonado, Y. A., Tutty, M. n., Dyrbye, L. N., Fassiotto, M. n. 2020; 3 (8): e2012762

  Abstract

  Previous research suggests that the prevalence of occupational burnout varies by demographic characteristics, such as sex and age, but the association between physician race/ethnicity and occupational burnout is less well understood.To investigate possible differences in occupational burnout, depressive symptoms, career satisfaction, and work-life integration by race/ethnicity in a sample of US physicians.In this cross-sectional study, data for this secondary analysis of 4424 physicians were originally collected from a cross-sectional survey of US physicians between October 12, 2017, and March 15, 2018. The dates of analysis were March 8, 2019, to May 21, 2020. Multivariable logistic regression, including statistical adjustment for physician demographic and clinical practice characteristics, was performed to examine the association between physician race/ethnicity and occupational burnout, depressive symptoms, career satisfaction, and work-life integration.Physician demographic and clinical practice characteristics included race/ethnicity, sex, age, clinical specialty, hours worked per week, primary practice setting, and relationship status.Physicians with a high score on the emotional exhaustion or depersonalization subscale of the Maslach Burnout Inventory were classified as having burnout. Depressive symptoms were measured using the Primary Care Evaluation of Mental Disorders instrument. Physicians who marked "strongly agree" or "agree" in response to the survey items "I would choose to become a physician again" and "My work schedule leaves me enough time for my personal/family life" were considered to be satisfied with their career and work-life integration, respectively.Data were available for 4424 physicians (mean [SD] age, 52.46 [12.03] years; 61.5% [2722 of 4424] male). Most physicians (78.7% [3480 of 4424]) were non-Hispanic White. Non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic Black physicians comprised 12.3% (542 of 4424), 6.3% (278 of 4424), and 2.8% (124 of 4424) of the sample, respectively. Burnout was observed in 44.7% (1540 of 3447) of non-Hispanic White physicians, 41.7% (225 of 540) of non-Hispanic Asian physicians, 38.5% (47 of 122) of non-Hispanic Black physicians, and 37.4% (104 of 278) of Hispanic/Latinx physicians. The adjusted odds of burnout were lower in non-Hispanic Asian physicians (odds ratio [OR], 0.77; 95% CI, 0.61-0.96), Hispanic/Latinx physicians (OR, 0.63; 95% CI, 0.47-0.86), and non-Hispanic Black physicians (OR, 0.49; 95% CI, 0.30-0.79) compared with non-Hispanic White physicians. Non-Hispanic Black physicians were more likely to report satisfaction with work-life integration compared with non-Hispanic White physicians (OR, 1.69; 95% CI, 1.05-2.73). No differences in depressive symptoms or career satisfaction were observed by race/ethnicity.Physicians in minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic White physicians. Future research is necessary to confirm these results, investigate factors contributing to increased rates of burnout among non-Hispanic White physicians, and assess factors underlying the observed patterns in measures of physician wellness by race/ethnicity.

  View details for DOI 10.1001/jamanetworkopen.2020.12762

  View details for PubMedID 32766802

• Relationship Between Burnout, Professional Behaviors, and Cost-Conscious Attitudes Among US Physicians. Journal of general internal medicine Dyrbye, L. N., West, C. P., Hunderfund, A. L., Sinsky, C. A., Trockel, M., Tutty, M., Carlasare, L., Satele, D., Shanafelt, T. 2019

  Abstract

  BACKGROUND: Despite the importance of professionalism, little is known about how burnout relates to professionalism among practicing physicians.OBJECTIVE: To evaluate the relationship between burnout and professional behaviors and cost-conscious attitudes.DESIGN AND PARTICIPANTS: Cross-sectional study in a national sample of physicians of whom a fourth received a sub-survey with items exploring professional behaviors and cost-conscious attitudes. Responders who were not in practice or in select specialties were excluded.MEASURES: Maslach Burnout Inventory and items on professional behaviors and cost-conscious attitudes.KEY RESULTS: Among those who received the sub-survey 1008/1224 (82.3%) responded, and 801 were eligible for inclusion. Up to one third of participants reported engaging in unprofessional behaviors related to administrative aspects of patient care in the last year, such as documenting something they did not do to close an encounter in the medical record (243/759, 32.0%). Fewer physicians reported other dishonest behavior (e.g., claiming unearned continuing medical education credit; 40/815, 4.9%). Most physicians endorsed cost-conscious attitudes with over 75% (618/821) agreeing physicians have a responsibility to try to control health-care costs and 62.9% (512/814) agreeing that cost to society is important in their care decisions regarding use of an intervention. On multivariable analysis adjusting for personal and professional characteristics, burnout was independently associated with reporting 1 or more unprofessional behaviors (OR 2.01, 95%CI 1.47-2.73, p < 0.0001) and having less favorable cost-conscious attitudes (difference on 6-24 scale - 0.90, 95%CI - 1.44 to - 0.35, p = 0.001).CONCLUSIONS: Professional burnout is associated with self-reported unprofessional behaviors and less favorable cost-conscious attitudes among physicians.

  View details for DOI 10.1007/s11606-019-05376-x

  View details for PubMedID 31734790

• The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians. Mayo Clinic proceedings Melnick, E. R., Dyrbye, L. N., Sinsky, C. A., Trockel, M., West, C. P., Nedelec, L., Tutty, M. A., Shanafelt, T. 2019

  Abstract

  OBJECTIVE: To describe and benchmark physician-perceived electronic health record (EHR) usability as defined by a standardized metric of technology usability and evaluate the association with professional burnout among physicians.PARTICIPANTS AND METHODS: This cross-sectional survey of US physicians from all specialty disciplines was conducted between October 12, 2017, and March 15, 2018, using the American Medical Association Physician Masterfile. Among the 30,456 invited physicians, 5197 (17.1%) completed surveys. A random 25% (n=1250) of respondents in the primary survey received a subsurvey evaluating EHR usability, and 870 (69.6%) completed it. EHR usability was assessed using the System Usability Scale (SUS; range 0-100). SUS scores were normalized to percentile rankings across more than 1300 previous studies from other industries. Burnout was measured using the Maslach Burnout Inventory.RESULTS: Mean ± SD SUS score was 45.9±21.9. A score of 45.9 is in the bottom 9% of scores across previous studies and categorized in the "not acceptable" range or with a grade of F. On multivariate analysis adjusting for age, sex, medical specialty, practice setting, hours worked, and number of nights on call weekly, physician-rated EHR usability was independently associated with the odds of burnout with each 1 point more favorable SUS score associated with a 3% lower odds of burnout (odds ratio, 0.97; 95% CI, 0.97-0.98; P<.001).CONCLUSION: The usability of current EHR systems received a grade of F by physician users when evaluated using a standardized metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed.

  View details for DOI 10.1016/j.mayocp.2019.09.024

  View details for PubMedID 31735343

• Developing a Portfolio to Support Physicians' Efforts to Promote Well-being: One Piece of the Puzzle. Mayo Clinic proceedings Menon, N. K., Trockel, M. T., Hamidi, M. S., Shanafelt, T. D. 2019; 94 (11): 2171–77

  View details for DOI 10.1016/j.mayocp.2019.09.010

  View details for PubMedID 31685149

• Characteristics of Academic Physicians Associated With Patient Satisfaction AMERICAN JOURNAL OF MEDICAL QUALITY Heidenreich, P., Shieh, L., Fassiotto, M., Kahn, J., Weinacker, A., Smith, R., Trockel, M., Shanafelt, T., Palaniappan, L. 2019: 1062860619876344

  View details for DOI 10.1177/1062860619876344

  View details for Web of Science ID 000488727200001

  View details for PubMedID 31529975

• Associations Between Dietary Patterns and Sleep-Related Impairment in a Cohort of Community Physicians: A Cross-sectional Study AMERICAN JOURNAL OF LIFESTYLE MEDICINE Hamidi, M. S., Shanafelt, T. D., Hausel, A., Bohman, B. D., Roberts, R., Trockel, M. T. 2019

  View details for DOI 10.1177/1559827619871923

  View details for Web of Science ID 000487182900002

• Associations Between Dietary Patterns and Sleep-Related Impairment in a Cohort of Community Physicians: A Cross-sectional Study. American journal of lifestyle medicine Makowski, M. S., Shanafelt, T. D., Hausel, A., Bohman, B. D., Roberts, R., Trockel, M. T. 2019; 15 (6): 644-652

  Abstract

  There is increasing evidence that diet can mitigate fatigue. The objective of this study was to assess the associations between dietary habits and sleep-related impairment (SRI) in a cohort of community physicians. In this cross-sectional study, we analyzed data from 245 physicians who had completed a wellness survey in March 2016 (98% response rate). Three dietary patterns were derived using principal component analysis: plant based, high protein, and high saturated fat and sugar. In the adjusted analysis, every SD increase in the plant-based dietary pattern score was associated with a 0.71-point decrease (β = -0.72; SE = 0.32; P = .027; 95% CI = -1.35 to -0.08) in the SRI score, and every SD increase in the high saturated fat and sugar dietary pattern score was associated with a 0.77-point increase (β = 0.77; SE = 0.32; P = .015; 95% CI = 0.15 to 1.39) in the SRI score. There were no associations between high protein diets and SRI scores. Physicians adhering to diets that are high in plant-based foods and low in saturated fat and added sugars had less SRI. Physicians currently face significant barriers to maintaining a healthy diet. This study highlights the potential role of workplace nutrition on SRI and work performance of physicians.

  View details for DOI 10.1177/1559827619871923

  View details for PubMedID 34916885

  View details for PubMedCentralID PMC8669895

• Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017 MAYO CLINIC PROCEEDINGS Shanafelt, T. D., West, C. P., Sinsky, C., Trockel, M., Tutty, M., Satele, D., Carlasare, L. E., Dyrbye, L. N. 2019; 94 (9): 1681–94

  View details for DOI 10.1016/j.mayocp.2018.10.023

  View details for Web of Science ID 000483753900010

• Medical student depression and its correlates across three international medical schools. World journal of psychiatry Gold, J. A., Hu, X., Huang, G., Li, W. Z., Wu, Y. F., Gao, S., Liu, Z. N., Trockel, M., Li, W. Z., Wu, Y. F., Gao, S., Liu, Z. N., Rohrbaugh, R. M., Wilkins, K. M. 2019; 9 (4): 65-77

  Abstract

  Medical students have high rates of depression, anxiety, and burnout that have been found to affect their empathy, professional behaviors, and performance as a physician. While studies have examined predictors for burnout and depression in the United States (US), no study, to our knowledge, has compared depression in medical students cross-culturally, or has attempted to examine the effect of factors influencing rates including burnout, exercise, stress, unmet mental health needs, and region.To examine rates of depression in three international cohorts of medical students, and determine variables that may explain these differences.Convenience samples of medical students from three countries (US, China, and a Middle Eastern country whose name remains anonymous per request from the school) were surveyed in this observational study. Using the Patient Health Questionnaire-2 (PHQ-2) and a modified Maslach Burnout Inventory, depression and burnout were examined among medical students from the three cohorts (n = 473). Chi-square test and analysis of variance were used to examine differences in demographics, behavioral, and psychological variables across these three schools to identify potentially confounding descriptive characteristics. Analysis of covariance compared depression and the emotional exhaustion component of burnout identified through Principal Component Analysis across countries. Multiple linear regression was used to analyze the impact of demographic, behavioral, and psychological variables on screening positive for depression.Medical students from the Middle Eastern country had the highest rates of positive depression screens (41.1%), defined as a PHQ-2 score of ≥ 3, followed by China (14.1 %), and then the US (3.8%). More students in the Middle Eastern school had unmet mental health needs (50.8%) than at the medical school in China (34.8%) or the school in the US (32.8%) (Pearson chi-square significance < 0.05). Thus, PHQ-2 scores were adjusted for unmet mental health needs; however, the Middle Eastern country continued to have the highest depression. Adjusting for PHQ-2 score, medical students from the US scored the highest on emotional exhaustion (a measure of burnout). Demographic variables did not significantly predict medical student depression; however, lack of exercise, unmet mental health needs, stress, and emotional exhaustion predicted nearly half of depression in these cohorts. In comparison to the US, coming from the Middle Eastern country and China predicted higher levels of depression.Depression rates differ in three international cohorts of medical students. Measured factors contributed to some observed differences. Identifying site-specific prevention and intervention strategies in medical student mental health is warranted.

  View details for DOI 10.5498/wjp.v9.i4.65

  View details for PubMedID 31799152

  View details for PubMedCentralID PMC6885455

• Medical student depression and its correlates across three international medical schools WORLD JOURNAL OF PSYCHIATRY Gold, J. A., Hu, X., Huang, G., Li, W., Wu, Y., Gao, S., Liu, Z., Trockel, M., Rohrbaugh, R. M., Wilkins, K. M. 2019; 9 (4): 65–77

  View details for DOI 10.5498/wjp.v9.i4.65

  View details for Web of Science ID 000481646500001

• Healing the Professional Culture of Medicine. Mayo Clinic proceedings Shanafelt, T. D., Schein, E., Minor, L. B., Trockel, M., Schein, P., Kirch, D. 2019

  Abstract

  The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.

  View details for DOI 10.1016/j.mayocp.2019.03.026

  View details for PubMedID 31303431

• Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App BEHAVIORAL SLEEP MEDICINE Miller, K. E., Kuhn, E., Owen, J. E., Taylor, K., Yu, J. S., Weiss, B. J., Crowley, J. J., Trockel, M. 2019; 17 (4): 481–91

  View details for DOI 10.1080/15402002.2017.1403326

  View details for Web of Science ID 000470675200009

• Screening and offering online programs for eating disorders: Reach, pathology, and differences across eating disorder status groups at 28U.S. universities. The International journal of eating disorders Fitzsimmons-Craft, E. E., Balantekin, K. N., Eichen, D. M., Graham, A. K., Monterubio, G. E., Sadeh-Sharvit, S., Goel, N. J., Flatt, R. E., Saffran, K., Karam, A. M., Firebaugh, M., Trockel, M., Taylor, C. B., Wilfley, D. E. 2019

  Abstract

  OBJECTIVE: The Internet-based Healthy Body Image (HBI) Program, which uses online screening to identify individuals at low risk of, high risk of, or with an eating disorder (ED) and then directs users to tailored, evidence-based online or in-person interventions to address individuals' risk or clinical status, was deployed at 28U.S. universities as part of a randomized controlled trial. The purpose of this study is to report on: (a) reach of HBI, (b) screen results, and (c) differences across ED status groups.METHOD: All students on participating campuses ages 18years or older were eligible, although recruitment primarily targeted undergraduate females.RESULTS: The screen was completed 4,894 times, with an average of 1.9% of the undergraduate female student body on each campus taking the screen. ED risk in participating students was high-nearly 60% of students screened were identified as being at high risk for ED onset or having an ED. Key differences emerged across ED status groups on demographics, recruitment method, ED pathology, psychiatric comorbidity, and ED risk factors, highlighting increasing pathology and impairment in the high-risk group.DISCUSSION: Findings suggest efforts are needed to increase reach of programs like HBI. Results also highlight the increasing pathology and impairment in the high-risk group and the importance of programs such as HBI, which provide access to timely screening and intervention to prevent onset of clinical EDs.

  View details for DOI 10.1002/eat.23134

  View details for PubMedID 31268183

• Burnout, Professional Fulfillment and Intent-to-Leave Among Ophthalmologists: A National Study Kosowsky, T., Higgins, M. S., Marchalik, D., Trockel, M., Rowe, S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019

  View details for Web of Science ID 000488800705045

• Estimating the Attributable Cost of Physician Burnout in the United States. Annals of internal medicine Han, S., Shanafelt, T. D., Sinsky, C. A., Awad, K. M., Dyrbye, L. N., Fiscus, L. C., Trockel, M., Goh, J. 2019

  Abstract

  Background: Although physician burnout is associated with negative clinical and organizational outcomes, its economic costs are poorly understood. As a result, leaders in health care cannot properly assess the financial benefits of initiatives to remediate physician burnout.Objective: To estimate burnout-associated costs related to physician turnover and physicians reducing their clinical hours at national (U.S.) and organizational levels.Design: Cost-consequence analysis using a mathematical model.Setting: United States.Participants: Simulated population of U.S. physicians.Measurements: Model inputs were estimated by using the results of contemporary published research findings and industry reports.Results: On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year.Limitations: Possibility of nonresponse bias and incomplete control of confounders in source data. Some parameters were unavailable from data and had to be extrapolated.Conclusion: Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.

  View details for DOI 10.7326/M18-1422

  View details for PubMedID 31132791

• A protected time policy to improve dental health among resident physicians JOURNAL OF THE AMERICAN DENTAL ASSOCIATION Jun, T., Liebert, C., Esquivel, M., Cox, J., Trockel, M., Katznelson, L. 2019; 150 (5): 362-+

  Abstract

  Resident physicians underuse preventive dental health services. The authors assessed the barriers to and need for oral health care among residents and piloted a program to enhance dental health care among house staff.Participants from 5 residency programs received 2 hours of protected time during business hours for visits to a nearby dental office. The authors surveyed participating residents before and after the visits about barriers to seeking oral health care and their experiences with the program. The authors recorded dental findings for each participant.A total of 35 of 243 eligible residents (14.4%) participated in the study; 71.4% reported delaying or skipping preventive dental examinations during residency. Lack of time and norms and peer perceptions were important barriers; 28.6% of residents had dental findings requiring further management.Residents neglect preventive oral health care because of work obligations. More than one-quarter of residents had clinically significant dental findings. Providing protected time addressed common barriers and was well received.Resident physicians have unmet oral health care needs. Collaborations between residency programs and dental practices to provide protected time for residents to seek oral health care could address common barriers to care.

  View details for DOI 10.1016/j.adaj.2018.12.016

  View details for Web of Science ID 000465431400024

  View details for PubMedID 31029211

• Burnout Among Physicians Compared With Individuals With a Professional or Doctoral Degree in a Field Outside of Medicine. Mayo Clinic proceedings Shanafelt, T. D., Sinsky, C., Dyrbye, L. N., Trockel, M., West, C. P. 2019; 94 (3): 549–51

  View details for PubMedID 30832797

• Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017. Mayo Clinic proceedings Shanafelt, T. D., West, C. P., Sinsky, C., Trockel, M., Tutty, M., Satele, D. V., Carlasare, L. E., Dyrbye, L. N. 2019

  Abstract

  OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life integration among physicians and other US workers in 2017 compared with 2011 and2014.PARTICIPANTS AND METHODS: Between October 12, 2017, and March 15, 2018, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our 2011 and 2014 studies. A secondary survey with intensive follow-up was conducted in a sample of nonresponders to evaluate response bias. Burnout and work-life integration were measured using standard tools.RESULTS: Of 30,456 physicians who received an invitation to participate, 5197 (17.1%) completed surveys. Among the 476 physicians in the secondary survey of nonresponders, 248 (52.1%) responded. A comparison of responders in the 2 surveys revealed no significant differences in burnout scores (P=.66), suggesting that participants were representative of US physicians. When assessed using the Maslach Burnout Inventory, 43.9% (2147 of 4893) of the physicians who completed the MBI reported at least one symptom of burnout in 2017 compared with 54.4% (3680 of 6767) in 2014 (P<.001) and 45.5% (3310 of 7227) in 2011 (P=.04). Satisfaction with work-life integration was more favorable in 2017 (42.7% [2056 of 4809]) than in 2014 (40.9% [2718 of 6651]; P<.001) but less favorable than in 2011 (48.5% [3512 of 7244]; P<.001). On multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians were at increased risk for burnout (odds ratio, 1.39; 95% CI, 1.26-1.54; P<.001) and were less likely to be satisfied with work-life integration (odds ratio, 0.77; 95% CI, 0.70-0.85; P<.001) than other working US adults.CONCLUSION: Burnout and satisfaction with work-life integration among US physicians improved between 2014 and 2017, with burnout currently near 2011 levels. Physicians remain at increased risk for burnout relative to workers in other fields.

  View details for PubMedID 30803733

• Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis. Annals of internal medicine Tawfik, D. S., Scheid, A. n., Profit, J. n., Shanafelt, T. n., Trockel, M. n., Adair, K. C., Sexton, J. B., Ioannidis, J. P. 2019

  Abstract

  Whether health care provider burnout contributes to lower quality of patient care is unclear.To estimate the overall relationship between burnout and quality of care and to evaluate whether published studies provide exaggerated estimates of this relationship.MEDLINE, PsycINFO, Health and Psychosocial Instruments (EBSCO), Mental Measurements Yearbook (EBSCO), EMBASE (Elsevier), and Web of Science (Clarivate Analytics), with no language restrictions, from inception through 28 May 2019.Peer-reviewed publications, in any language, quantifying health care provider burnout in relation to quality of patient care.2 reviewers independently selected studies, extracted measures of association of burnout and quality of care, and assessed potential bias by using the Ioannidis (excess significance) and Egger (small-study effect) tests.A total of 11 703 citations were identified, from which 123 publications with 142 study populations encompassing 241 553 health care providers were selected. Quality-of-care outcomes were grouped into 5 categories: best practices (n = 14), communication (n = 5), medical errors (n = 32), patient outcomes (n = 17), and quality and safety (n = 74). Relations between burnout and quality of care were highly heterogeneous (I2 = 93.4% to 98.8%). Of 114 unique burnout-quality combinations, 58 indicated burnout related to poor-quality care, 6 indicated burnout related to high-quality care, and 50 showed no significant effect. Excess significance was apparent (73% of studies observed vs. 62% predicted to have statistically significant results; P = 0.011). This indicator of potential bias was most prominent for the least-rigorous quality measures of best practices and quality and safety.Studies were primarily observational; neither causality nor directionality could be determined.Burnout in health care professionals frequently is associated with poor-quality care in the published literature. The true effect size may be smaller than reported. Future studies should prespecify outcomes to reduce the risk for exaggerated effect size estimates.Stanford Maternal and Child Health Research Institute.

  View details for DOI 10.7326/M19-1152

  View details for PubMedID 31590181

• Authors' response. Journal of the American Dental Association (1939) Jun, T. W., Liebert, C. A., Esquivel, M. n., Cox, J. A., Trockel, M. n., Katznelson, L. n. 2019; 150 (7): 568–69

  View details for DOI 10.1016/j.adaj.2019.05.010

  View details for PubMedID 31248480

• Efficacy of a Parent-Based, Indicated Prevention for Anorexia Nervosa: Randomized Controlled Trial. Journal of medical Internet research Jacobi, C., Hutter, K., Volker, U., Mobius, K., Richter, R., Trockel, M., Jones Bell, M., Lock, J., Taylor, C. B. 2018; 20 (12): e296

  Abstract

  BACKGROUND: Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak.OBJECTIVE: The primary objective of this study was to evaluate the efficacy of an indicated, parent-based, Web-based preventive program Eltern als Therapeuten (E@T) in reducing risk factors and symptoms of AN.METHODS: Girls aged between 11 and 17 years were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre- and postintervention (6 weeks later) and at 6- and 12-month follow-up (FU).RESULTS: A total of 12,377 screening questionnaires were handed out in 86 German schools, and 3941 including consent returned. Overall, 477 (447/3941, 12.10%) girls were identified as at risk for AN and 256 of those could be contacted. In all, 66 families (66/256, 25.8% of those contacted) were randomized to the E@T or a wait-list control condition, 43 (43/66, 65%) participated in postassessments, and 27 (27/66, 41%) in 12-month FUs. Due to low participation and high dropout rates of parents, recruitment was terminated prematurely. At 12-month FU, girls' expected body weight (EBW) percentage was significantly greater for intervention participants compared with control participants (group by time interaction beta=21.0 [CI 5.81 to 36.13], P=.007; group by time squared interaction beta=-15.5 [CI -26.6 to -4.49], P=.007; estimated Cohen d=0.42]. No other significant effects were found on risk factors and attitudes of disturbed eating.CONCLUSIONS: Despite a significant increase in girls' EBW percentage, parental participation and adherence to the intervention were low. Overall, parent-based, indicated prevention for children at risk for AN does not seem very promising, although it might be useful for parents who engage in the intervention.TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 18614564; http://www.isrctn.com/ISRCTN18614564 (Archived by WebCite at http://www.webcitation.org/74FTV1EpF).

  View details for PubMedID 30552078

• Building a Program on Well-Being: Key Design Considerations to Meet the Unique Needs of Each Organization. Academic medicine : journal of the Association of American Medical Colleges Shanafelt, T., Trockel, M., Ripp, J., Murphy, M. L., Sandborg, C., Bohman, B. 2018

  Abstract

  The current health care practice environment has resulted in a crescendo of burnout among physicians, nurses, and advanced practice providers. Burnout among health care professionals is primarily caused by organizational factors rather than problems with personal resilience. Four major drivers motivate health care leaders to build well-being programs: the moral-ethical case (caring for their people), the business case (cost of turnover and lower quality), the tragic case (a physician suicide), and the regulatory case (accreditation requirements). Ultimately, health care provider burnout harms patients. The authors discuss the purpose; scope; structure and resources; metrics of success; and a framework for action for organizational well-being programs. The purpose such a program is to oversee organizational efforts to reduce the occupational risk for burnout, cultivate professional well-being among health care professionals and, in turn, optimize the function of health care systems. The program should measure, benchmark, and longitudinally assess these domains. The successful program will develop deep expertise regarding the drivers of professional fulfillment among health care professionals; an approach to evaluate system flaws and relevant dimensions of organizational culture; and knowledge and experience with specific tactics to foster improvement. Different professional disciplines have both shared challenges and unique needs. Effective programs acknowledge and address these differences rather than ignore them. Ultimately, a professional workforce with low burnout and high professional fulfillment is vital to providing the best care to patients. Vanguard institutions have embraced this understanding and are pursuing health care provider well-being as a core organizational strategy.

  View details for PubMedID 30134268

• Correlates of suicidal ideation in college women with eating disorders. The International journal of eating disorders Goel, N. J., Sadeh-Sharvit, S., Flatt, R. E., Trockel, M., Balantekin, K. N., Fitzsimmons-Craft, E. E., Monterubio, G. E., Firebaugh, M., Jacobi, C., Wilfley, D. E., Taylor, C. B. 2018

  Abstract

  OBJECTIVE: To identify the correlates of suicidal ideation (SI) in a large sample of college women with eating disorders (EDs).METHOD: A total of 690 female college students from 28 US colleges who screened positive for an ED, with the exception of anorexia nervosa, were assessed for SI. Univariate logistic regression analyses were performed to determine independent correlates of SI. Measures included: ED psychopathology, ED behaviors (i.e., binge eating, vomiting, laxatives, compulsive exercise), current co-morbid psychopathology (i.e., depression, anxiety, insomnia), weight/shape concerns, ED-related clinical impairment, and body mass index (BMI). All significant variables were included in a backward binary multivariate logistic regression model to determine which variables were most strongly associated with SI.RESULTS: A total of 25.6% of the sample reported SI. All variables examined were significantly independently associated with SI, with the exception of compulsive exercise. Depression, anxiety, and vomiting remained as significant correlates of SI in the multivariate logistic regression model.DISCUSSION: ED screening on college campuses should assess for suicidality, and prevention and treatment efforts should target vomiting and co-morbid depression and anxiety symptoms to reduce risk of SI for high-risk individuals.

  View details for PubMedID 29626350

• A Roadmap for Research on Resident Well-Being AMERICAN JOURNAL OF MEDICINE Quinn, M. A., Bazari, H., Ripp, J., Block, L., Chretien, K. C., Fried, E. D., Leiter, R. E., Pincavage, A. T., Spataro, B., Trockel, M., West, C. P. 2018; 131 (3): 323–28

  View details for PubMedID 29246867

• What Do We Mean by Physician Wellness? A Systematic Review of Its Definition and Measurement ACADEMIC PSYCHIATRY Brady, K. S., Trockel, M. T., Khan, C. T., Raj, K. S., Murphy, M., Bohman, B., Frank, E., Louie, A. K., Roberts, L. 2018; 42 (1): 94–108

  Abstract

  Physician wellness (well-being) is recognized for its intrinsic importance and impact on patient care, but it is a construct that lacks conceptual clarity. The authors conducted a systematic review to characterize the conceptualization of physician wellness in the literature by synthesizing definitions and measures used to operationalize the construct.A total of 3057 references identified from PubMed, Web of Science, and a manual reference check were reviewed for studies that quantitatively assessed the "wellness" or "well-being" of physicians. Definitions of physician wellness were thematically synthesized. Measures of physician wellness were classified based on their dimensional, contextual, and valence attributes, and changes in the operationalization of physician wellness were assessed over time (1989-2015).Only 14% of included papers (11/78) explicitly defined physician wellness. At least one measure of mental, social, physical, and integrated well-being was present in 89, 50, 49, and 37% of papers, respectively. The number of papers operationalizing physician wellness using integrated, general-life well-being measures (e.g., meaning in life) increased [X 2 = 5.08, p = 0.02] over time. Changes in measurement across mental, physical, and social domains remained stable over time.Conceptualizations of physician wellness varied widely, with greatest emphasis on negative moods/emotions (e.g., burnout). Clarity and consensus regarding the conceptual definition of physician wellness is needed to advance the development of valid and reliable physician wellness measures, improve the consistency by which the construct is operationalized, and increase comparability of findings across studies. To guide future physician wellness assessments and interventions, the authors propose a holistic definition.

  View details for PubMedID 28913621

• A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women. Journal of American college health : J of ACH Graham, A. K., Trockel, M. n., Weisman, H. n., Fitzsimmons-Craft, E. E., Balantekin, K. N., Wilfley, D. E., Taylor, C. B. 2018: 1–10

  Abstract

  As eating disorders (EDs) often emerge during college, managing EDs would ideally integrate prevention and treatment. To achieve this goal, an efficient tool is needed that detects clinical symptoms and level of risk. This study evaluated the performance of a screen designed to identify individuals at risk for or with an ED.Five hundred forty-nine college-age women.Participants completed a screen and diagnostic interview.Using parsimonious thresholds for ED diagnoses, screen sensitivity ranged from 0.90 (anorexia nervosa) to 0.55 (purging disorder). Specificity ranged from 0.99 (anorexia nervosa) to 0.78 (subthreshold binge eating disorder) compared to diagnostic interview. Moderate to high area under the curve values were observed. The screen had high sensitivity for detecting high risk.The screen identifies students at risk and has acceptable sensitivity and specificity for identifying most ED diagnoses. This tool is critical for establishing stepped care models for ED intervention.

  View details for PubMedID 29979922

  View details for PubMedCentralID PMC6320726

• Encouraging Mindfulness in Medical House Staff via Smartphone App: A Pilot Study. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry Wen, L., Sweeney, T. E., Welton, L., Trockel, M., Katznelson, L. 2017; 41 (5): 646-650

  Abstract

  Stress and burnout are increasingly recognized as urgent issues among resident physicians, especially given the concerning implications of burnout on physician well-being and patient care outcomes.The authors assessed how a mindfulness and meditation practice among residents, supported via a self-guided, smartphone-based mindfulness app, affects wellness as measured by prevalidated surveys.Residents in the departments of general surgery, anesthesia, and obstetrics and gynecology were recruited for participation in this survey-based, four-week, single-arm study. All participants used the app (Headspace) on a self-guided basis, and took surveys at enrollment, at 2 weeks, and at 4 weeks. The Positive and Negative Affect Schedule (PANAS) assessed mood, and the Freiburg Mindfulness Inventory (FMI) measured mindfulness.Forty-three residents enrolled in this study from April 2015 to August 2016; 30 residents (90% female) completed two or more surveys, and so were included for further analysis. In a comparison of baseline scores to week four scores, there was a significant increase in FMI at week four (36.88 ± 7.00; Cohen's d = 0.77, p = 0.005), a trend toward increase in the positive affect score (PAS) (31.73 ± 6.07; Cohen's d = 0.38, p = 0.08), and no change in negative affect score (NAS) (21.62 ± 7.85; Cohen's d = -0.15, p = NS). In mixed-effect multivariate modeling, both the PAS and the FMI scores showed significant positive change with increasing use of the smartphone app (PAS, 0.31 (95% CI 0.03-0.57); FMI, 0.38 (95% CI 0.11-0.66)), while the NAS did not show significant change.Study limitations include self-guided app usage, a homogenous study subject population, insufficient study subjects to perform stratified analysis of the impact of specialty on the findings, lack of control group, and possible influence from the Hawthorne effect. This study suggests the feasibility and efficacy of a short mindfulness intervention delivered by a smartphone app to improve mindfulness and associated resident physician wellness parameters.

  View details for DOI 10.1007/s40596-017-0768-3

  View details for PubMedID 28795335

• Web-Based Aftercare for Women With Bulimia Nervosa Following Inpatient Treatment: Randomized Controlled Efficacy Trial. Journal of medical Internet research Jacobi, C., Beintner, I., Fittig, E., Trockel, M., Braks, K., Schade-Brittinger, C., Dempfle, A. 2017; 19 (9): e321

  Abstract

  Relapse rates in bulimia nervosa (BN) are high even after successful treatment, but patients often hesitate to take up further treatment. An easily accessible program might help maintain treatment gains. Encouraged by the effects of Web-based eating disorder prevention programs, we developed a manualized, Web-based aftercare program (IN@) for women with BN following inpatient treatment.The objective of this study was to determine the efficacy of the web-based guided, 9-month, cognitive-behavioral aftercare program IN@ for women with BN following inpatient treatment.We conducted a randomized controlled efficacy trial in 253 women with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) BN and compared the results of IN@ with treatment as usual (TAU). Assessments were carried out at hospital admission (T0), hospital discharge/baseline (T1), postintervention (T2; 9 months after baseline), 9-month follow-up (T3; 18 months after baseline). The primary outcome, abstinence from binge eating and compensatory behaviors during the 2 months preceding T2, was analyzed by intention to treat, using logistic regression analyses. Frequencies of binge eating and vomiting episodes, and episodes of all compensatory behaviors were analyzed using mixed effects models.At T2, data from 167 women were available. There were no significant differences in abstinence rates between the TAU group (n=24, 18.9%) and the IN@ group (n=27, 21.4%; odds ratio, OR=1.29; P=.44). The frequency of vomiting episodes in the IN@ group was significantly (46%) lower than in the TAU group (P=.003). Moderator analyses revealed that both at T2 and T3, women of the intervention group who still reported binge eating and compensatory behaviors after inpatient treatment benefited from IN@, whereas women who were already abstinent after the inpatient treatment did not (P=.004; P=.002). Additional treatment utilization was high in both groups between baseline and follow-up.Overall, data from this study suggest moderate effects of IN@. High rates of outpatient treatment utilization after inpatient treatment may have obscured potential intervention effects on abstinence. An aftercare intervention might be more beneficial as part of a stepped-care approach.International Standard Randomized Controlled Trial Number (ISRCTN): 08870215; http://www.isrctn.com/ISRCTN08870215 (Archived by WebCite at http://www.webcitation.org/6soA5bIit).

  View details for DOI 10.2196/jmir.7668

  View details for PubMedID 28939544

  View details for PubMedCentralID PMC5630693

• Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness and Reduce Burnout ANNALS OF INTERNAL MEDICINE Dyrbye, L. N., Trockel, M., Frank, E., Olson, K., Linzer, M., Lemaire, J., Swensen, S., Shanafelt, T., Sinsky, C. A. 2017; 166 (10): 743-+

  View details for PubMedID 28418518

• Factors Associated With Provider Burnout in the NICU PEDIATRICS Tawfik, D. S., Phibbs, C. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Trockel, M., Profit, J. 2017; 139 (5)

  Abstract

  NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.

  View details for DOI 10.1542/peds.2016-4134

  View details for Web of Science ID 000400371500040

  View details for PubMedID 28557756

• "Physician Wellness" as Published in Academic Psychiatry ACADEMIC PSYCHIATRY Louie, A. K., Trockel, M. T., Balon, R., Coverdale, J. H., Beresin, E. V., Brenner, A. M., Guerrero, A. S., Roberts, L. 2017; 41 (2): 155–58

  View details for PubMedID 28213884

• Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App. Behavioral sleep medicine Miller, K. E., Kuhn, E. n., Owen, J. E., Taylor, K. n., Yu, J. S., Weiss, B. J., Crowley, J. J., Trockel, M. n. 2017: 1–11

  Abstract

  Clinicians' perceptions of CBT-I Coach, a patient-facing mobile app for cognitive-behavioral therapy for insomnia (CBT-I), are critical to its adoption and integration into practice. Diffusion of innovations theory emphasizes the influence of perceptions, including the relative advantage to current practice, the compatibility to clinicians' needs, the complexity, the innovation's trialability, and observability. This study intended to evaluate the use and perceptions of CBT-I Coach among Veterans Affairs (VA)-trained CBT-I clinicians.Clinicians (N = 108) were surveyed about their use, feedback, and perceptions of CBT-I Coach a year after the app became available.Overall perceptions of CBT-I Coach were favorable. Fifty percent of clinicians reported using CBT-I Coach, with 98% intending to continue use. The app was perceived to increase sleep diary completion and homework compliance. Clinicians viewed the app as providing accessibility to helpful tools and improving patient engagement. Of those not using the app, 83% endorsed intention to use it. Reasons for nonuse were lack of patient access to smart phones, not being aware of the app, not having time to learn it, and inability to directly access app data. Those who reported using CBT-I Coach had more favorable perceptions across all constructs (p < .01 - p < .001), except relative advantage, compared to nonusers. Users perceived it as less complex and more compatible with their practice than nonusers.Continued efforts are needed to increase adoption and enhance use of CBT-I Coach, as well as study if reported benefits can be evidenced more directly.

  View details for PubMedID 29120247

• Reciprocal longitudinal relations between weight/shape concern and comorbid pathology among women at very high risk for eating disorder onset. Eating and weight disorders : EWD Fitzsimmons-Craft, E. E., Eichen, D. M., Kass, A. E., Trockel, M. n., Crosby, R. D., Taylor, C. B., Wilfley, D. E. 2017

  Abstract

  Understanding how known eating disorder (ED) risk factors change in relating to one another over time may inform efficient intervention targets. We examined short-term (i.e., 1 month) reciprocal longitudinal relations between weight/shape concern and comorbid symptoms (i.e., depressed mood, anxiety) and behaviors (i.e., binge drinking) over the course of 24 months using cross-lagged panel models.Participants were 185 women aged 18-25 years at very high risk for ED onset, randomized to an online ED preventive intervention or waitlist control. We also tested whether relations differed based on intervention receipt.Weight/shape concern in 1 month significantly predicted depressed mood the following month; depressed mood in 1 month also predicted weight/shape concern the following month, but the effect size was smaller. Likewise, weight/shape concern in 1 month significantly predicted anxiety the following month, but the reverse was not true. Results showed no temporal relations between weight/shape concern and binge drinking in either direction. Relations between weight/shape concern, and comorbid symptoms and behaviors did not differ based on intervention receipt.Results support focusing intervention on reducing weight/shape concern over reducing comorbid constructs for efficient short-term change.Level I, evidence obtained from a properly designed randomized controlled trial.

  View details for PubMedID 29285745

  View details for PubMedCentralID PMC6170712

• Efficacy of Cognitive-Behavioral Therapy for Insomnia Combined With Antidepressant Pharmacotherapy in Patients With Comorbid Depression and Insomnia: A Randomized Controlled Trial. journal of clinical psychiatry Manber, R., Buysse, D. J., Edinger, J., Krystal, A., Luther, J. F., Wisniewski, S. R., Trockel, M., Kraemer, H. C., Thase, M. E. 2016; 77 (10): e1316-e1323

  Abstract

  The Treatment of Insomnia and Depression (TRIAD) study evaluated the efficacy of combining depression pharmacotherapy (using MED, an ecologically valid and generalizable antidepressant medication algorithm) with cognitive-behavioral therapy for insomnia (CBT-I) among individuals with comorbid insomnia and major depressive disorder (MDD) to determine if change in insomnia severity mediates antidepressant outcome.This 16-week, 3-site, randomized controlled trial (RCT) randomly assigned 150 participants (recruited between March 2009 and August 2013), who met DSM-IV-TR criteria for insomnia and MDD and were not receiving treatment for either, to receive depression pharmacotherapy plus 7 sessions of either CBT-I or a credible control therapy for insomnia (CTRL). Depression pharmacotherapy followed a standardized 2-step algorithm, which included escitalopram, sertraline, and desvenlafaxine in a prescribed sequence. Primary measures were the Hamilton Depression Rating Scale and the depression module of the Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Nonpatient Edition, administered by raters masked to treatment assignment, and the self-administered Insomnia Severity Index (ISI).CBT-I was superior to CTRL in reducing insomnia severity (P = .028). The overall difference in depression remission between the treatments was not statistically significant (44% in CBT-I and 36% in CTRL; number needed to treat = 15). However, planned secondary analysis revealed that improvements in insomnia at week 6 mediated eventual remission from depression, with early change in ISI predicting depression remission in the CBT-I (P = .0002) but not in the CTRL arm (P = .26).CBT-I is an efficacious treatment for insomnia comorbid with MDD among patients treated with antidepressant medications. Improvement in insomnia may be related to the change in depression. Future studies should identify which patients are most likely to benefit from the addition of an insomnia-focused therapy to standard antidepressant treatments.ClinicalTrials.gov identifier NCT00767624.

  View details for DOI 10.4088/JCP.15m10244

  View details for PubMedID 27788313

• Facebook usage among those who have received treatment for an eating disorder in a group setting. International journal of eating disorders Saffran, K., Fitzsimmons-Craft, E. E., Kass, A. E., Wilfley, D. E., Taylor, C. B., Trockel, M. 2016; 49 (8): 764-777

  Abstract

  This study explored Facebook use among individuals with a history of receiving treatment for an eating disorder (ED) in a group setting (e.g., inpatient, residential, outpatient group), focusing primarily on comparisons individuals make about their bodies, eating, or exercise to those of their peers from treatment on Facebook and the relation between these comparisons and ED pathology.Individuals (N = 415; mean age 28.15 years ± 8.41; 98.1% female) who self-reported receipt of ED treatment in a group setting were recruited via e-mail and social media to complete an online survey.Participants reported having an average of 10-19 Facebook friends from treatment and spending up to 30 min per day interacting on Facebook with individuals from treatment or ED-related organizations. More comparison to treatment peers on Facebook was associated with greater ED psychopathology and ED-related impairment. Conversely, positive interaction with treatment peers on Facebook was associated with lower ED psychopathology and ED-related impairment. Individuals who had been in treatment longer, more times, and more recently had more Facebook friends from treatment and ED-related organizations as well as spent more time in ED groups' pages on Facebook. Few participants (19.5%) reported that a therapist asked about the impact of Facebook on pathology.Interactions on Facebook could affect patients' recovery and potential for relapse. It may be helpful for treatment providers to discuss Facebook use and its potential benefits and drawbacks with patients preparing for discharge from group treatment. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:764-777).

  View details for DOI 10.1002/eat.22567

  View details for PubMedID 27302908

• Reducing Eating Disorder Onset in a Very High Risk Sample With Significant Comorbid Depression: A Randomized Controlled Trial JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Taylor, C. B., Kass, A. E., Trockel, M., Cunning, D., Weisman, H., Bailey, J., Sinton, M., Aspen, V., Schecthman, K., Jacobi, C., Wilfley, D. E. 2016; 84 (5): 402-414

  Abstract

  Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated.206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II.ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4).An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research. (PsycINFO Database Record

  View details for DOI 10.1037/ccp0000077

  View details for Web of Science ID 000374765200003

  View details for PubMedID 26795936

  View details for PubMedCentralID PMC4836995

• Universal prevention efforts should address eating disorder pathology across the weight spectrum: Implications for screening and intervention on college campuses. Eating behaviors Kass, A. E., Jones, M., Kolko, R. P., Altman, M., Fitzsimmons-Craft, E. E., Eichen, D. M., Balantekin, K. N., Trockel, M., Taylor, C. B., Wilfley, D. E. 2016

  Abstract

  Given shared risk and maintaining factors between eating disorders and obesity, it may be important to include both eating disorder intervention and healthy weight management within a universal eating disorder care delivery program. This study evaluated differential eating disorder screening responses by initial weight status among university students, to assess eating disorder risk and pathology among individuals with overweight/obesity versus normal weight or underweight.1529 individuals were screened and analyzed. Screening was conducted via pilot implementation of the Internet-based Healthy Body Image program on two university campuses.Fifteen percent of the sample had overweight/obesity. Over half (58%) of individuals with overweight/obesity screened as high risk for an eating disorder or warranting clinical referral, and 58% of individuals with overweight/obesity endorsed a ≥10-pound weight change over the past year. Compared to individuals with normal weight or underweight, individuals with overweight/obesity were more likely to identify as Black, endorse objective binge eating and fasting, endorse that eating disorder-related concerns impaired their relationships/social life and made them feel badly, and endorse higher weight/shape concerns.Results suggest rates of eating disorder pathology and clinical impairment are highest among students with overweight/obesity, and targeted intervention across weight categories and diverse races/ethnicities is warranted within universal eating disorder intervention efforts. Integrating eating disorder intervention and healthy weight management into universal prevention programs could reduce the incidence and prevalence of eating disorders, unhealthy weight control practices, and obesity among university students.

  View details for DOI 10.1016/j.eatbeh.2016.03.019

  View details for PubMedID 27090854

• Non-suicidal self-injury and suicidal ideation in relation to eating and general psychopathology among college-age women. Psychiatry research Eichen, D. M., Kass, A. E., Fitzsimmons-Craft, E. E., Gibbs, E., Trockel, M., Barr Taylor, C., Wilfley, D. E. 2016; 235: 77-82

  Abstract

  Non-suicidal self-injury (NSSI) and suicidal ideation are potent risk factors for suicide and are associated with general and eating disorder-specific psychopathology. Limited research has examined the effects of combined NSSI+suicidal ideation thus concurrent examination is needed to understand potential differential effects on psychopathology. College-aged women (N=508) completed self-report measures of NSSI, suicidal ideation, general psychopathology, and Eating Disorder-specific psychopathology. MANOVAs determined whether the NSSI/SI status groups differed on general and eating disorder pathology measures as a set. Significant MANOVAs were followed up with univariate ANOVAs and posthoc tests. Thirteen women endorsed NSSI+Suicidal Ideation, 70 endorsed NSSI-only, 25 endorsed Suicidal Ideation-only, and 400 endorsed no NSSI/Suicidal Ideation. Both general and eating disorder-specific psychopathology differed across groups. NSSI+Suicidal Ideation and Suicidal Ideation-only groups typically endorsed higher general psychopathology than the no NSSI/Suicidal Ideation and NSSI-only groups. Regarding eating disorder pathology, the NSSI+Suicidal Ideation group was more pathological than no NSSI/Suicidal Ideation and NSSI-only, except on the weight concerns scale, where NSSI+Suicidal Ideation only differed from no NSSI/Suicidal Ideation. The NSSI+Suicidal Ideation group was only greater than Suicidal Ideation-only on measures of depression and eating concern. Results highlight the importance of screening for both NSSI and suicidal ideation, especially for individuals with eating disorder symptoms. Likewise, screening for eating disorder pathology may be beneficial for individuals presenting with NSSI and suicidal ideation.

  View details for DOI 10.1016/j.psychres.2015.11.046

  View details for PubMedID 26654754

  View details for PubMedCentralID PMC4724479

• CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia JOURNAL OF CLINICAL SLEEP MEDICINE Kuhn, E., Weiss, B. J., Taylor, K. L., Hoffman, J. E., Ramsey, K. M., Manber, R., Gehrman, P., Crowley, J. J., Ruzek, J. I., Trockel, M. 2016; 12 (4): 597-606

  Abstract

  This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (n = 138) and use of it two years after it was released (n = 176).VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released.Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (β = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (β = 0.286, p < 0.01), compatibility with their own needs and values (β = 0.307, p < 0.01), and expectations about the complexity of the app (β = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes.Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.

  View details for DOI 10.5664/jcsm.5700

  View details for Web of Science ID 000374140000019

  View details for PubMedID 26888586

  View details for PubMedCentralID PMC4795288

• Effectiveness of Cognitive Behavioral Therapy for Veterans with Depression and Suicidal Ideation ARCHIVES OF SUICIDE RESEARCH Brown, G. K., Karlin, B. E., Trockel, M., Gordienko, M., Yesavage, J., Taylor, C. B. 2016; 20 (4): 677-682

  Abstract

  The current study examined suicidal ideation (SI) and depression outcomes among Veterans receiving Cognitive Behavioral Therapy for depression (CBT-D) throughout the Department of Veterans Affairs health care system. Patient outcomes included Beck Depression Inventory-II total score and SI item. Of 902 patients, 427 (47%) had no SI, 405 (45%) had SI but no suicidal intent, 26 (3%) indicated suicidal desire, 8 (1%) indicated suicide intent if they had the chance, and 36 (4%) did not answer this question at session one. The odds of SI decreased by 64% from 1.03 at session one to 0.37 at final assessment (OR = 0.36; 95% CI: 0.31, 0.43). Findings reveal that CBT-D was associated with significant decreases in SI and depression among Veterans.

  View details for DOI 10.1080/13811118.2016.1162238

  View details for Web of Science ID 000392982200014

  View details for PubMedID 26983897

• Attention-deficit/hyperactivity disorder-specific stimulant misuse, mood, anxiety, and stress in college-age women at high risk for or with eating disorders JOURNAL OF AMERICAN COLLEGE HEALTH Gibbs, E. L., Kass, A. E., Eichen, D. M., Fitzsimmons-Craft, E. E., Trockel, M., Wilfley, D. E., Taylor, C. B. 2016; 64 (4): 300-308

  Abstract

  To examine the misuse of attention-deficit/hyperactivity disorder (ADHD)-specific stimulants in a college population at high risk for or with clinical or subclinical eating disorders.Four hundred forty-eight college-age women aged 18-25 at high risk for or with a clinical or subclinical eating disorder.Participants completed assessments of stimulant misuse and psychopathology from September 2009 to June 2010.Greater eating disorder pathology, objective binge eating, purging, eating disorder-related clinical impairment, depressive symptoms, perceived stress, and trait anxiety were associated with an increased likelihood of stimulant misuse. Subjective binge eating, excessive exercise, and dietary restraint were not associated with stimulant misuse.ADHD-specific stimulant misuse is associated with eating disorder and comorbid pathology among individuals at high risk for or with clinical or subclinical eating disorders. Screening for stimulant misuse and eating disorder pathology may improve identification of college-age women who may be engaging in maladaptive behaviors and inform prevention efforts.

  View details for DOI 10.1080/07448481.2016.1138477

  View details for Web of Science ID 000375464400004

  View details for PubMedID 26822019

  View details for PubMedCentralID PMC4904716

• An exploration of key issues and potential solutions that impact physician wellbeing and professional fulfillment at an academic center. PeerJ Schrijver, I., Brady, K. J., Trockel, M. 2016; 4

  Abstract

  Background. Physician wellness is a vital element of a well-functioning health care system. Not only is physician wellness empirically associated with quality and patient outcomes, but its ramifications span individual, interpersonal, organizational, and societal levels. The purpose of this study was to explore academic physicians' perceptions about their work-related wellness, including the following questions: (a) What are the workplace barriers and facilitators to their wellness? (b) What workplace solutions do theythinkwouldimprove their wellness? (c)What motivates their work? and (d) What existing wellness programs are they aware of? Methods. A multi-method design was applied to conduct a total of 19 focus group sessions in 17 clinical departments. All academic faculty ranks and career lines were represented in the 64 participating physicians, who began the sessions with five open-ended survey questions pertaining to physician wellness in their work environment. Participants entered their answers into a web-based survey program that enabled anonymous data collection. The initial survey component was followed by semi-structured focus group discussion. Data analysis of this qualitative study was informed by the general inductive approach as well as a review of extant literature through September 2015 on physician wellness, professional fulfillment, satisfaction, dissatisfaction, burnout and work-life. Results. Factors intrinsic to the work of physicians dominated the expressed reasons for work motivation. These factors all related to the theme of overall contribution, with categories of meaningful work, patient care, teaching, scientific discovery, self-motivation and matching of career interests. Extrinsic factors such as perceptions of suboptimal goal alignment, inadequate support, restricted autonomy, lack of appreciation, and suboptimal compensation and benefits dominated the risk of professional dissatisfaction. Discussion. Our findings indicate that the factors that enhance professional fulfillment and those that precipitate burnout are distinct: motivation and quality of work performed were supported by domains intrinsic to the work itself, whereas external dysfunctional work aspects resulted in frustration. Thus, it can be anticipated that optimization of physician wellness would require tailored approaches in each of these dimensions with sustained funding and support for wellness initiatives. Physicians identified the availability of resources to enable them to thrive and provide excellent patient care as their most important wellness-enhancing factor.

  View details for DOI 10.7717/peerj.1783

  View details for PubMedID 26989621

  View details for PubMedCentralID PMC4793321

• Effectiveness of Acceptance and Commitment Therapy in treating depression and suicidal ideation in Veterans BEHAVIOUR RESEARCH AND THERAPY Walser, R. D., Garvert, D. W., Karlin, B. E., Trockel, M., Ryu, D. M., Taylor, C. B. 2015; 74: 25-31

  Abstract

  This paper examines the effects of Acceptance and Commitment Therapy for depression (ACT-D), and the specific effects of experiential acceptance and mindfulness, in reducing suicidal ideation (SI) and depression among Veterans.Patients included 981 Veterans, 76% male, mean age 50.5 years. Depression severity and SI were assessed using the BDI-II. Experiential acceptance and mindfulness were measured with the Acceptance and Action Questionnaire-II (AAQ-II) and the Five Facet Mindfulness Questionnaire, respectively.Of the 981 patients, 647 (66.0%) completed 10 or more sessions or finished early due to symptom relief. For Veterans with SI at baseline, mean BDI-II score decreased from 33.5 to 22.9. For Veterans with no SI at baseline, mean BDI-II score decreased from 26.3 to 15.9. Mixed models with repeated measurement indicated a significant reduction in depression severity from baseline to final assessment (b = -10.52, p < .001). After adjusting for experiential acceptance and mindfulness, patients with SI at baseline demonstrated significantly greater improvement in depression severity during ACT-D treatment, relative to patients with no SI at baseline (b = -2.81, p = .001). Furthermore, increases in experiential acceptance and mindfulness scores across time were associated with a reduction in depression severity across time (b = -0.44, p < .001 and b = -0.09, p < .001, respectfully), and the attenuating effect of mindfulness on depression severity increased across time (b = -0.05, p = .042). Increases in experiential acceptance scores across time were associated with lower odds of SI across time (odds ratio = 0.97, 95% CI [0.95, 0.99], p = .016) and the attenuating effect of experiential acceptance on SI increased across time (odds ratio = 0.96, 95% CI [0.92, 0.99], p = .023). Overall the number of patients with no SI increased from 44.5% at baseline to 65% at follow-up.Veterans receiving ACT-D demonstrated decreased depression severity and decreased odds of SI during treatment. Increases in experiential acceptance and mindfulness scores were associated with reduction in depression severity across time and increases in experiential acceptance scores were associated with reductions in SI across time.

  View details for DOI 10.1016/j.brat.2015.08.012

  View details for Web of Science ID 000364269400004

  View details for PubMedID 26378720

• Group Dialectical-Behavior Therapy Skills Training for Conversion Disorder With Seizures. journal of neuropsychiatry and clinical neurosciences Bullock, K. D., Mirza, N., Forte, C., Trockel, M. 2015; 27 (3): 240-243

  Abstract

  Neuroimaging evidence suggests deficits in affective regulation in conversion disorder (CD). Dialectical-behavior therapy skills training (DBT-ST) was developed to target emotion dysregulation. This study was aimed to test the feasibility of stand-alone DBT-ST for CD using Linehan's manual for borderline personality disorder. In a prospective naturalistic design, 19 adult outpatients diagnosed with video EEG-confirmed seizure type CD were recruited and received weekly group DBT. Seventeen out of 19 subjects finished an average of 20.5 weeks of treatment. The mean seizure rate decreased by 66%. Cessation of seizures occurred in 35% of the sample. Completion rates reached 90%.

  View details for DOI 10.1176/appi.neuropsych.13120359

  View details for PubMedID 25959039

• Identification as overweight by medical professionals: Relation to eating disorder diagnosis and risk EATING BEHAVIORS Kass, A. E., Wang, A. Z., Kolko, R. P., Holland, J. C., Altman, M., Trockel, M., Taylor, C. B., Wilfley, D. E. 2015; 17: 62-68

  Abstract

  Discussions about weight between medical professionals and young adults may increase risk of eating disorders (EDs). Clarifying the relation between screening for overweight and ED risk is needed.548 college-age women were classified as at-risk (n=441) or with an ED (n=107), and were assessed for disordered eating attitudes, behaviors, and relevant history, including, "Has a doctor, nurse, or other medical professional ever told you that you were overweight?" Regression analyses were used to evaluate the relations between being identified as overweight and current disordered eating behaviors, attitudes, and ED diagnosis, without and with covariates (history of weight-related teasing, history of an ED, family history of being identified as overweight, and current body mass index).146 (26.6%) women reported being previously identified as overweight by a medical professional. There was no relation between being previously identified as overweight and having an ED. Those identified as overweight were more likely to have weight/shape concerns above a high-risk cutoff, but showed no difference in dietary restraint, binge eating, purging behaviors, or excessive exercise compared to those not identified.Being previously identified as overweight by a medical professional was associated with increased weight/shape concerns but not with current disordered eating behaviors or ED status. Minimizing the potential negative effects of overweight screening on weight and shape concerns by providing patients with strategies to increase healthy lifestyle behaviors and long-term support for healthy weight loss goals may have a positive impact on reducing the public health problem of overweight and obesity.

  View details for DOI 10.1016/j.eatbeh.2014.12.013

  View details for Web of Science ID 000351834000013

  View details for PubMedID 25602172

  View details for PubMedCentralID PMC4380786

• National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans. International journal of geriatric psychiatry Karlin, B. E., Trockel, M., Spira, A. P., Taylor, C. B., Manber, R. 2015; 30 (3): 308-315

  Abstract

  Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment in real-world clinical settings and even less has examined effects on outcomes beyond reducing insomnia, such as improved quality of life. The current article examines and compares outcomes of older versus younger (age 18-64 years) veterans receiving CBT-I nationally in nonsleep specialty settings.Patient outcomes were assessed using the Insomnia Severity Index, Beck Depression Inventory-II, and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.A total of 536 younger veterans and 121 older veterans received CBT-I; 77% of older and 64% of younger patients completed all sessions or finished early due to symptom relief. Mean insomnia scores declined from 19.5 to 9.7 in the older group and from 20.9 to 11.1 in the younger group. Within-group effect sizes were d = 2.3 and 2.2 for older and younger groups, respectively. CBT-I also yielded significant improvements in depression and quality of life for both age groups. High and increasing levels of therapeutic alliance were observed for both age groups.Older (and younger) patients receiving CBT-I from nonsleep specialists experienced large reductions in insomnia and improvements in depression and quality of life. Effects were similar for both age groups, and the rate of dropout was lower among older adults. The results provide strong support for the effectiveness and acceptability of CBT-I for older adults receiving care in routine treatment settings. Copyright © 2014 John Wiley & Sons, Ltd.

  View details for DOI 10.1002/gps.4143

  View details for PubMedID 24890708

• Comparison of the Effectiveness of Cognitive Behavioral Therapy for Depression among Older Versus Younger Veterans: Results of a National Evaluation. journals of gerontology. Series B, Psychological sciences and social sciences Karlin, B. E., Trockel, M., Brown, G. K., Gordienko, M., Yesavage, J., Taylor, C. B. 2015; 70 (1): 3-12

  Abstract

  The effectiveness of cognitive behavioral therapy for depression (CBT-D) among older adults in routine clinical settings has received limited attention. The current article examines and compares outcomes of older versus younger veterans receiving CBT-D nationally.Patient outcomes were assessed using the Beck Depression Inventory-II and World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.A total of 764 veterans aged 18-64 and 100 veterans aged 65+ received CBT-D; 68.0% of older and 68.3% of younger patients completed all sessions or finished early due to symptom relief, and mean depression scores declined from 27.0 (standard deviation [SD] = 10.7) to 16.2 (SD = 12.4) in the older group and from 29.1 (SD = 11.2) to 17.8 (SD = 13.5) in the younger group. Within-group effect sizes were d = 1.01 for both groups. Significant increases in quality of life and therapeutic alliance were observed for both groups.CBT-D resulted in significant improvements in depression and quality of life among older patients. Outcomes and rate of attrition were equivalent to younger patients. Findings indicate that CBT-D is an effective and acceptable treatment for older veterans in real-world settings with often high levels of depression.

  View details for DOI 10.1093/geronb/gbt096

  View details for PubMedID 24218096

• Psychiatric co-morbidity in women presenting across the continuum of disordered eating EATING BEHAVIORS Aspen, V., Weisman, H., Vannucci, A., Nafiz, N., Gredysa, D., Kass, A. E., Trockel, M., Jacobi, C., Wilfley, D. E., Taylor, C. B. 2014; 15 (4): 686-693

  View details for DOI 10.1016/j.eatbeh.2014.08.023

  View details for Web of Science ID 000345402700034

• Moderators and mediators of outcome in Internet-based indicated prevention for eating disorders BEHAVIOUR RESEARCH AND THERAPY Voelker, U., Jacobi, C., Trockel, M. T., Taylor, C. B. 2014; 63: 114-121

  View details for DOI 10.1016/j.brat.2014.09.008

  View details for Web of Science ID 000348006900014

• Internet-based preventive intervention for reducing eating disorder risk: A randomized controlled trial comparing guided with unguided self-help BEHAVIOUR RESEARCH AND THERAPY Kass, A. E., Trockel, M., Safer, D. L., Sinton, M. M., Cunning, D., Rizk, M. T., Genkin, B. H., Weisman, H. L., Bailey, J. O., Jacobi, C., Wilfley, D. E., Taylor, C. B. 2014; 63: 90-98

  View details for DOI 10.1016/j.brat.2014.09.010

  View details for Web of Science ID 000348006900011

• Internet-based preventive intervention for reducing eating disorder risk: A randomized controlled trial comparing guided with unguided self-help. Behaviour research and therapy Kass, A. E., Trockel, M., Safer, D. L., Sinton, M. M., Cunning, D., Rizk, M. T., Genkin, B. H., Weisman, H. L., Bailey, J. O., Jacobi, C., Wilfley, D. E., Taylor, C. B. 2014; 63C: 90-98

  Abstract

  Student Bodies, an internet-based intervention, has successfully reduced weight/shape concerns and prevented eating disorders in a subset of college-age women at highest risk for an eating disorder. Student Bodies includes an online, guided discussion group; however, the clinical utility of this component is unclear. This study investigated whether the guided discussion group improves program efficacy in reducing weight/shape concerns in women at high risk for an eating disorder. Exploratory analyses examined whether baseline variables predicted who benefitted most. Women with high weight/shape concerns (N = 151) were randomized to Student Bodies with a guided discussion group (n = 74) or no discussion group (n = 77). Regression analyses showed weight/shape concerns were reduced significantly more among guided discussion group than no discussion group participants (p = 0.002; d = 0.52); guided discussion group participants had 67% lower odds of having high-risk weight/shape concerns post-intervention (p = 0.02). There were no differences in binge eating at post-intervention between the two groups, and no moderators emerged as significant. Results suggest the guided discussion group improves the efficacy of Student Bodies in reducing weight/shape concerns in college students at high risk for an eating disorder.

  View details for DOI 10.1016/j.brat.2014.09.010

  View details for PubMedID 25461783

• Moderators and mediators of outcome in Internet-based indicated prevention for eating disorders. Behaviour research and therapy Völker, U., Jacobi, C., Trockel, M. T., Taylor, C. B. 2014; 63C: 114-121

  Abstract

  The objective of this study was to investigate moderators and mediators of the effect of an indicated prevention program for eating disorders (ED) on reduction of dysfunctional attitudes and specific ED symptoms. 126 women (M age = 22.3; range 18-33) reporting subthreshold ED symptoms were randomized to the Student Bodies™+ (SB+) intervention or an assessment-only control condition. Assessments took place at pre-intervention, mid-intervention (mediators), post-intervention, and 6-month follow-up. Mixed effects modeling including all available data from all time points were used for the data analysis. Intervention effects on the reduction of binge rate were weaker for participants with higher baseline BMI and for participants with a lower baseline purge rate. Intervention effects on reduction of eating disorder pathology were weaker for participants with higher baseline purge rate and with initial restrictive eating. No moderators of the intervention effect on restrictive eating were identified. An increase in knowledge mediated the beneficial effect of SB+ on binge rate. The results suggest that different moderators should be considered for the reduction of symptoms and change in attitudes of disturbed eating and that SB+ at least partially operates through psychoeducation.

  View details for DOI 10.1016/j.brat.2014.09.008

  View details for PubMedID 25461786

• A population-wide screening and tailored intervention platform for eating disorders on college campuses: the healthy body image program. Journal of American college health Jones, M., Kass, A. E., Trockel, M., Glass, A. I., Wilfley, D. E., Taylor, C. B. 2014; 62 (5): 351-356

  Abstract

  Abstract Objectives: This article presents a new approach to intervention for eating disorders and body image concerns on college campuses, using a model of integrated eating disorder screening and intervention. Formative data on implementation feasibility are presented. Participants: College students enrolled at 2 universities between 2011 and 2012. Methods: The Healthy Body Image program is an evidence-based screening and intervention platform, enacted via community and online resources. An online screen was used to identify students at varying levels of risk or eating disorder symptom status; responses were used to direct students to universal or targeted online interventions or further evaluation. Universal prevention programs to improve healthy weight regulation and body image culture were offered to all students. Results: Formative data from 1,551 students illustrates the application of this model. Conclusions: The Healthy Body Image program is feasible to deliver and provides a comprehensive system of screening, evidence-based intervention, and community culture change.

  View details for DOI 10.1080/07448481.2014.901330

  View details for PubMedID 24621000

  View details for PubMedCentralID PMC4031301

• An Internet-based positive psychology program: Strategies to improve effectiveness and engagement JOURNAL OF POSITIVE PSYCHOLOGY Redzic, N. M., Taylor, K., Chang, V., Trockel, M., Shorter, A., Taylor, C. B. 2014; 9 (6): 494-501

  View details for DOI 10.1080/17439760.2014.936966

  View details for Web of Science ID 000341882200005

• Validation of a Six-Item Male Body Image Concerns Scale (MBICS). Eating disorders Weisman, H. L., Patten, E., Montanez-Leaks, M., Yee, M., Darcy, A. M., Mazina, V., Zhang, A., Bailey, J. O., Jones, M., Trockel, M., Barr Taylor, C. 2014; 22 (5): 420-434

  Abstract

  Elevated body image concerns may be a risk factor for eating disorders among males and contribute to a range of other mental health problems. This study tested a 6-item measure of general male body image concerns in two studies with adolescent males ages 14-18 (total N = 122). The measure showed strong convergent validity, scale score reliability, and test-retest reliability, and was significantly correlated with the number of episodes of binge eating in the past month. A short scale will relieve participant burden and provide a useful research tool for studies with males at risk for or with eating disorders.

  View details for DOI 10.1080/10640266.2014.925768

  View details for PubMedID 24964387

• National Dissemination of Cognitive Behavioral Therapy for Insomnia in Veterans: Therapist- and Patient-Level Outcomes JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Karlin, B. E., Trockel, M., Taylor, C. B., Gimeno, J., Manber, R. 2013; 81 (5): 912-917

  Abstract

  Objective: To evaluate the effects of national training in and implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I) in the U.S. Department of Veterans Affairs (VA) health care system on clinicians' competency and patients' insomnia severity, symptoms of depression, and quality of life. Method: A prospective cohort of 102 VA clinicians (including mental health staff in various mental health and primary care settings) participated in the VA CBT-I Training Program during 2011 and 2012. Patients included 182 veterans treated by clinicians enrolled in the training. Clinicians were rated on taped therapy sessions, using a standardized competency rating form. Patients' symptoms were assessed using the Insomnia Severity Index (ISI) and standardized measures of depression and quality of life. Results: Of 102 clinicians attending workshop training, 94 (92%) met all training requirements, including minimum competency score criteria. Of 182 patients, 122 (67%) completed treatment. The mixed effects model revealed significant reductions in average patient ISI score (from 19.9 to 10.2, standard error = 3.0). Patients also improved on measures of depression and quality of life. Conclusion: National training in and implementation of CBT-I resulted in a significant increase in therapist competency to deliver CBT-I for almost all clinicians and in a large reduction in insomnia severity and improvement in depression and quality of life among veterans. Observed effect sizes are comparable to results of randomized clinical trials. These results suggest CBT-I can be feasibly and effectively disseminated to routine clinical settings, with very favorable patient outcomes. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

  View details for DOI 10.1037/a0032554

  View details for Web of Science ID 000324780500017

  View details for PubMedID 23586730

• Training in and implementation of Acceptance and Commitment Therapy for depression in the Veterans Health Administration: Therapist and patient outcomes BEHAVIOUR RESEARCH AND THERAPY Walser, R. D., Karlin, B. E., Trockel, M., Mazina, B., Taylor, C. B. 2013; 51 (9): 555-563

  View details for DOI 10.1016/j.brat.2013.05.009

  View details for Web of Science ID 000324007300006

• Effectiveness of acceptance and commitment therapy for depression: Comparison among older and younger veterans AGING & MENTAL HEALTH Karlin, B. E., Walser, R. D., Yesavage, J., Zhang, A., Trockel, M., Taylor, C. B. 2013; 17 (5): 555-563

  Abstract

  Limited data exist on outcomes of older adults receiving psychotherapy for depression in real-world settings. Acceptance and Commitment Therapy for depression (ACT-D) offers potential utility for older individuals who may experience issues of loss, reduced control, and other life changes. The present article examines and compares outcomes of older and younger Veterans receiving ACT-D nationally in the U.S. Department of Veterans Affairs health care system.Patient outcomes were assessed using the Beck Depression Inventory-Second Edition and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.Six hundred fifty-five Veterans aged 18-64 and 76 Veterans aged 65+ received ACT-D. Seventy-eight percent of older and 67% of younger patients completed all sessions or finished early. Mean depression scores declined from 28.4 (SD = 11.4) to 17.5 (SD = 12.0) in the older group and 30.3 (SD = 10.6) to 19.1 (SD = 14.3) in the younger group. Within-group effect sizes were d = .95 and d = 1.06 for the two age groups, respectively. Quality of life and therapeutic alliance also increased during treatment.The findings suggest that ACT-D is an effective and acceptable treatment for older Veterans treated in routine clinical settings, including those with high levels of depression.

  View details for DOI 10.1080/13607863.2013.789002

  View details for Web of Science ID 000320913300005

  View details for PubMedID 23607328

• What constitutes clinically significant binge eating? Association between binge features and clinical validators in college-age women INTERNATIONAL JOURNAL OF EATING DISORDERS Vannucci, A., Theim, K. R., Kass, A. E., Trockel, M., Genkin, B., Rizk, M., Weisman, H., Bailey, J. O., Sinton, M. M., Aspen, V., Wilfley, D. E., Taylor, C. B. 2013; 46 (3): 226-232

  Abstract

  To investigate the association between binge features and clinical validators.The Eating Disorder Examination assessed binge features in a sample of 549 college-age women: loss of control (LOC) presence, binge frequency, binge size, indicators of impaired control, and LOC severity. Clinical validators were self-reported clinical impairment and current psychiatric comorbidity, as determined via a semistructured interview.Compared with women without LOC, those with LOC had significantly greater odds of reporting clinical impairment and comorbidity (ps < 0.001). Among women with LOC (n = 252), the indicators of impaired control and LOC severity, but not binge size or frequency, were associated with greater odds of reporting clinical impairment and/or comorbidity (ps < 0.05). DICUSSION: Findings confirm that the presence of LOC may be the hallmark feature of binge eating. Further, dimensional ratings about the LOC experience--and possibly the indicators of impaired control--may improve reliable identification of clinically significant binge eating.

  View details for DOI 10.1002/eat.22115

  View details for Web of Science ID 000316216100004

  View details for PubMedID 23386591

• Motivation and Changes in Depression COGNITIVE THERAPY AND RESEARCH Burns, D., Westra, H., Trockel, M., Fisher, A. 2013; 37 (2): 368-379

  View details for DOI 10.1007/s10608-012-9458-3

  View details for Web of Science ID 000316353700016

• National Dissemination of Cognitive Behavioral Therapy for Depression in the Department of Veterans Affairs Health Care System: Therapist and Patient-Level Outcomes JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Karlin, B. E., Brown, G. K., Trockel, M., Cunning, D., Zeiss, A. M., Taylor, C. B. 2012; 80 (5): 707-718

  Abstract

  The Department of Veterans Affairs (VA) health care system is nationally disseminating and implementing cognitive behavioral therapy for depression (CBT-D). The current article evaluates therapist and patient-level outcomes associated with national training in and implementation of CBT-D in the VA health care system.Therapist competencies were assessed with the Cognitive Therapy Rating Scale (CTRS). Patient outcomes were assessed with the Beck Depression Inventory-II and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed with the Working Alliance Inventory-Short Revised. Two-hundred twenty-one therapists have received training, and 356 veteran patients have received treatment through the VA CBT-D Training Program.Of therapists who have participated in the program, 182 (82%) completed all training requirements and achieved competency, reflected by a score of 40 on the CTRS. Of 356 patients, nearly 70% completed 10 or more sessions or improved sufficiently to stop therapy before the 10th session. Mean depression scores decreased by approximately 40% from initial to later treatment phase. Effect sizes of changes ranged from d = 0.39 to d = 0.74 for quality of life and from d = 0.47 to d = 0.66 for therapeutic alliance measures.National training in and implementation of CBT-D within the VA health care system is associated with significant, positive therapist training outcomes, as evidenced by increases in CBT core competencies. The implementation of the protocol by newly trained CBT-D therapists is associated with significantly improved patient outcomes, as evidenced by large decreases in depression and improvements in quality of life.

  View details for DOI 10.1037/a0029328

  View details for Web of Science ID 000309312400001

  View details for PubMedID 22823859

• Effects of an Internet-based intervention for subthreshold eating disorders: A randomized controlled trial 15th Annual Meeting of the Eating-Disorders-Research-Society Jacobi, C., Voelker, U., Trockel, M. T., Taylor, C. B. PERGAMON-ELSEVIER SCIENCE LTD. 2012: 93–99

  Abstract

  Women reporting initial eating disorder (ED) symptoms are at highest risk for the development of an eating disorder. Preventive interventions should, therefore, be specifically tailored for this subgroup.To adapt and evaluate the effects of the Internet-based prevention program "Student Bodies™" for women with symptoms of disordered eating and/or subthreshold eating disorder (ED) syndromes.126 women, reporting subthreshold ED symptoms (high weight and shape concerns and below threshold bingeing, purging, chronic dieting or several of these symptoms) were randomly assigned to a Student Bodies™+ (SB+) intervention or a wait-list control group and assessed at pre-intervention, post-intervention, and 6-month follow-up. "Student Bodies™" was adapted to be suitable for subthreshold EDs. Main outcome measures were attitudes and symptoms of disordered eating. Pre-follow-up data were analyzed by ANCOVAS with mixed effects.At 6-month follow-up, compared to participants in the control group, participants in the intervention group showed significantly greater improvements on ED-related attitudes. Intervention participants also showed 67% (95% CI = 20-87%) greater reductions in combined rates of subjective and objective binges, and 86% (95% CI = 63-95%) greater reduction in purging episodes. Also, the rates of participants abstinent from all symptoms of disordered eating (restrictive eating, binge eating and any compensatory behavior) were significantly higher in the intervention group (45.1% vs. 26.9%). Post-hoc subgroup analyses revealed that for participants with binge eating the effect on EDE-Q scores was larger than in the pure restricting subgroup.The adapted "SB+" program represents an effective intervention for women with subthreshold EDs of the binge eating subtype.

  View details for DOI 10.1016/j.brat.2011.09.013

  View details for Web of Science ID 000301019200002

• Depressive symptom dimensions and cardiac prognosis following myocardial infarction: results from the ENRICHD clinical trial PSYCHOLOGICAL MEDICINE Bekke-Hansen, S., Trockel, M., Burg, M. M., Taylor, C. B. 2012; 42 (1): 51-60

  Abstract

  Depression following myocardial infarction (MI) independently increases risk for early cardiac morbidity and mortality. Studies suggest that somatic, but not cognitive, depressive symptoms are responsible for the increased risk. However, the effects of somatic depressive symptoms at follow-up, after sufficient time has elapsed to allow for physical recovery from the initial infarction, are not known. Our aim was to examine the relationship between cognitive and somatic depressive symptom dimensions at baseline and 12 months post-MI and subsequent mortality and cardiovascular morbidity.Patients were 2442 depressed and/or socially isolated men and women with acute MI included in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial. We used principal components analysis (PCA) of the Beck Depression Inventory (BDI) items to derive subscales measuring cognitive and somatic depressive symptom dimensions, and Cox regression with Bonferroni correction for multiple testing to examine the contribution of these dimensions to all-cause mortality, cardiovascular mortality, and first recurrent non-fatal MI.After adjusting for medical co-morbidity and Bonferroni correction, the somatic depressive symptom dimension assessed proximately following MI did not significantly predict any endpoints. At 12 months post-MI, however, this dimension independently predicted subsequent all-cause [hazard ratio (HR) 1.43, 95% confidence interval (CI) 1.13-1.81] and cardiovascular mortality (HR 1.60, 95% CI 1.17-2.18). No significant associations were found between the cognitive depressive symptom dimension and any endpoints after Bonferroni correction.Somatic symptoms of depression at 12 months post-MI in patients at increased psychosocial risk predicted subsequent mortality. Psychosocial interventions aimed at improving cardiac prognosis may be enhanced by targeting somatic depressive symptoms, with particular attention to somatic symptom severity at 12 months post-MI.

  View details for DOI 10.1017/S0033291711001000

  View details for Web of Science ID 000298961600005

  View details for PubMedID 21682949

• Dissemination of CBTI to the Non-Sleep Specialist: Protocol Development and Training Issues JOURNAL OF CLINICAL SLEEP MEDICINE Manber, R., Carney, C., Edinger, J., Epstein, D., Friedman, L., Haynes, P. L., Karlin, B. E., Pigeon, W., Siebern, A. T., Trockel, M. 2012; 8 (2): 209-218

  Abstract

  Strong evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI). A significant barrier to wide dissemination of CBTI is the lack of qualified practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and flexibility of the treatment protocol. We developed a case conceptualization-driven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.

  View details for DOI 10.5664/jcsm.1786

  View details for Web of Science ID 000302862200017

  View details for PubMedID 22505869

  View details for PubMedCentralID PMC3311421

• Binge Drinking in Women at Risk for Developing Eating Disorders INTERNATIONAL JOURNAL OF EATING DISORDERS Khaylis, A., Trockel, M., Taylor, C. B. 2009; 42 (5): 409-414

  Abstract

  To determine binge drinking rates in college-age women at risk for eating disorders and to examine factors related to binge drinking over time.Participants were 480 college-age women who were at high risk for developing an eating disorder (ED) and who had a body mass index (BMI) between 18 and 32. Participants were assessed annually for 4 years.Participants reported high rates of binge drinking and frequent binge drinking throughout college. Binge drinking was positively correlated with dietary restraint, coping using substances, coping using denial, and life events.The study's findings suggest that binge drinking is highly prevalent in women at high risk for developing eating disorders. Results also indicated that binge drinking was related to dieting and maladaptive coping patterns. Intervention for women with strong weight and shape concerns should also address problematic alcohol use.

  View details for Web of Science ID 000267299100005

  View details for PubMedID 19115362