Issue: Burnout is reported to be epidemic among physicians and medical trainees, and wellness has been the predominant target for intervention in academic medicine over the past several years. However, both burnout and wellness suffer from a lack of standardized definition, often making interventions difficult to generalize and extrapolate to different sites. Although well-meaning, current frameworks surrounding wellness and burnout have limitations in fully addressing the challenges of improving physician mental health. Wellness as a framework does not inherently acknowledge the adversity inevitably experienced in the practice of medicine and in the lives of medical trainees. During a crisis such as the current pandemic, wellness curricula often do not offer adequate frameworks to address the personal, organizational, or societal crises that may ensue. This leaves academic institutions and their leadership ill-equipped to appropriately address the factors that contribute to burnout. More recently, resilience has been explored as another framework to positively influence physician wellness and burnout. Resilience acknowledges the inevitable adversity individuals encounter in their life and work, allowing for a more open discussion on the tensions and flexibility between facets of life. However, emphasizing personal resiliency without addressing organizational resiliency may leave physicians feeling alienated or marginalized from critical support and resources that organizations can and should provide. Evidence: Despite intense focus on wellness and burnout, there have not been significant positive changes in physicians' mental health. Many interventions have aimed at the individual level with mindfulness or other reflective exercises; unfortunately these have demonstrated only marginal benefit. Systems level approaches have demonstrated more benefit but the ability of organizations to carry out any specific intervention is likely to be limited by their own unique constraints and may limit the spread of innovation. We believe the current use of these conceptual lenses (wellness and burnout) has been clouded by lack of uniformity of definitions, an array of measurement tools with no agreed-upon standard, a lack of understanding of the complex interaction between the constructs involved, and an over-emphasis on personal rather than organizational interventions and solutions. Implications: If the frameworks of burnout and wellness are limited, and personal resilience by itself is inadequate, what framework would be helpful? We believe that focusing on organizational resilience and the connecting dimensions between organizations and their physicians could be an additional framework helpful in addressing physician mental health. An organization connects with its members along multiple dimensions, including communication, recognition of gifts, shared vision, and sense of belonging. By finding ways to positively affect these dimensions, organizations can create change in the culture and mental health of physicians and tr...

ObjectiveWe compared the conventional ‘one-bag protocol’ of management of diabetic ketoacidosis (DKA) with the ‘two-bag protocol’ which utilizes two bags of fluids, one containing saline and supplemental electrolytes and the other containing the same solution with the addition of 10% dextrose.Research design and methodsA retrospective chart review and analysis was done on adult patients admitted for DKA to the Riverside University Health System Medical Center from 2008 to 2015. There were 249 cases of DKA managed by the one-bag system and 134 cases managed by the two-bag system.ResultsThe baseline patient characteristics were similar in both groups. The anion gap closed in 13.56 hours in the one-bag group versus 10.94 hours in the two-bag group (p value <0.0002). None of the individual factors significantly influenced the anion gap closure time; only the two-bag system favored earlier closure of the anion gap. Plasma glucose levels improved to <250 mg/dL earlier with two-bag protocol (9.14 vs 7.82 hours, p=0.0241). The incidence of hypoglycemic events was significantly less frequent with the two-bag protocol compared with the standard one-bag system (1.49% vs 8.43%, p=0.0064). Neither the time to improve serum HCO3 level >18 mg/dL nor the hospital length of stay differed between the two groups.ConclusionsOur study indicates that the two-bag protocol closes the anion gap earlier than the one-bag protocol in adult patients with DKA. Blood glucose levels improved faster with the two-bag protocol compared with the one-bag protocol with fewer associated episodes of hypoglycemia. Prospective studies are needed to evaluate the clinical significance of these findings.

Background Discrepancies exist between what resident and attending physicians perceive as adequate supervision. We documented current practices in a university-based, categoric, internal medicine residency to characterize these discrepancies and the types of mixed messages that are communicated to residents, as well as to assess their potential effect on resident supervision and patient safety. Methods We surveyed residents and attending physicians separately about their current attitudes and behaviors regarding resident supervision. Both groups responded to 2 different measures of resident supervision: (1) 6 clinical vignettes that involved patient safety concerns, and (2) 9 frequently reported phrases communicated by attending physicians to residents before leaving the hospital during on-call admission days. Results There were clear and substantial differences between the perceptions of resident and attending physicians about when the supervising attending physician should be notified in each of the 6 vignettes. For example, 85% of attending physicians reported they wanted to be notified of an unexpected pneumothorax that required chest tube placement, but only 31% of resident physicians said they would call their attending physician during those circumstances. Common phrases, such as “page me if you need me,” resulted in approximately 50% of residents reporting they would “rarely” or “never” call and another 41% reporting they would only “sometimes” call their attending physicians. Conclusions Our study found that attending physicians reported they would want more frequent communication and closer supervision than routinely perceived by resident physicians. Although this discrepancy exists, commonly used phrases, such as “page me if you need me,” rarely resulted in a change in resident behavior, and attending physicians appeared to be aware of the ineffectiveness of these statements. These mixed messages may increase the difficulty of balancing the dual goals of appropriate attending supervision and progressive independence during residency training.

In most health care institutions, physician peer review is the primary method for maintaining and measuring physician competency and quality of care issues. However, many teaching hospitals do not have a method of tracking resident trainees' involvement in adverse cases. At the study institution, Code R was introduced as a measure to capture resident trainee involvement in the hospital-wide peer review process. The authors conducted a retrospective review of all peer review cases from January 2008 to December 2011 in an academic medical center and determined the quantity and type of resident errors that occurred compared to attending faculty. The Accreditation Council for Graduate Medical Education's core competencies served as a framework to categorize quality of care errors. The addition of Code R to the peer review process can be readily adopted by other institutions to help improve resident education, facilitate faculty supervision, and potentially improve patient safety.