Stelling, Brianna E. Vaa

Background There has been limited research on the positive aspects of physician wellness and to our knowledge there have been no validity studies on measures of resilience and grit among internal medicine (IM) residents. Objectives To investigate the validity of resilience (10 items Connor-Davidson Resilience Scale (CD-RISC 10)) and grit (Short Grit Scale (GRIT-S)) scores among IM residents at a large academic centre, and assess potential associations with previously validated measures of medical knowledge, clinical performance and professionalism. Methods We evaluated CD-RISC 10 and GRIT-S instrument scores among IM residents at the Mayo Clinic Rochester, Minnesota between July 2017 and June 2019. We analysed dimensionality, internal consistency reliability and criterion validity in terms of relationships between resilience and grit, with standardised measures of residents’ medical knowledge (in-training examination (ITE)), clinical performance (faculty and peer evaluations and Mini-Clinical Evaluation Examination (mini-CEX)) and professionalism/dutifulness (conference attendance and evaluation completion). Results A total of 213 out of 253 (84.2%) survey-eligible IM residents provided both CD-RISC 10 and GRIT-S survey responses. Internal consistency reliability (Cronbach alpha) was excellent for CD-RISC 10 (0.93) and GRIT-S (0.82) overall, and for the GRIT subscales of consistency of interest (0.84) and perseverance of effort (0.71). CD-RISC 10 scores were negatively associated with ITE percentile (β=−3.4, 95% CI −6.2 to −0.5, p=0.02) and mini-CEX (β=−0.2, 95% CI −0.5 to −0.02, p=0.03). GRIT-S scores were positively associated with evaluation completion percentage (β=2.51, 95% CI 0.35 to 4.67, p=0.02) and conference attendance (β=2.70, 95% CI 0.11 to 5.29, p=0.04). Conclusions This study revealed favourable validity evidence for CD-RISC 10 and GRIT-S among IM residents. Residents demonstrated resilience within a competitive training environment despite less favourable test performance and grittiness that was manifested by completing tasks. This initial validity study provides a foundation for further research on resilience and grit among physicians in training.

Purpose To evaluate the relationship between help-seeking concerns and attitudes and burnout among residents. Method In 2019, all residents across the 4 Mayo Clinic sites were surveyed. The survey included 2 items from the Maslach Burnout Inventory, an item from the National Comorbidity Survey Replication about likelihood of seeking professional help for a serious emotional problem, and items developed to explore residents’ help-seeking behaviors and concerns. Multivariable logistic regression was conducted for each outcome variable and included age, gender, specialty, postgraduate year, site, and burnout. Results Of the 1,146 residents to whom surveys were sent, 762 (66.5%) responded. Nearly half (342/747, 45.8%) were concerned about negative consequence to their career if they went on medical leave, and one-third (247/753, 32.8%) were reluctant to seek professional help for a serious emotional concern. Of the 437 residents who had never attended a personal health appointment during scheduled work, 34.6% (151) thought it would be difficult to tell a supervising physician they needed to miss work due to a scheduled appointment. On multivariable analysis, burnout was independently associated with reporting it would be difficult to tell a supervising physician of a need to attend an appointment (odds ratio [OR] 2.32; 95% confidence interval [CI] 1.46, 3.67; P < .001), being concerned about negative consequence to their career if they went on medical leave (OR 2.09; 95% CI 1.49, 2.93; P < .001), and reluctance to seek professional care for a serious emotional problem (OR 1.65; 95% CI 1.17, 2.34; P = .004). Conclusions Barriers to self-care and help-seeking are common among residents and may be worse among those with burnout. Strategies to reduce stigma and promote a culture of well-being are needed.

Purpose To explore the relationship between residents’ perceptions of residency program leadership team behaviors and resident burnout and satisfaction. Method In February 2019, the authors surveyed all residents across the 77 graduate medical education training programs at Mayo Clinic’s multiple sites. Survey items measured residents’ perceptions of program director and associate program director behaviors (using a composite residency program leadership team score), resident burnout, and resident satisfaction with the program and organization. Multivariable logistic regression was performed to evaluate relationships between these variables at the individual resident (adjusting for age, sex, postgraduate training year, program location, and specialty) and program (including only programs with at least 5 respondents) levels. Results Of the 1,146 residents surveyed, 762 (66.5%) responded. At the individual resident level, higher composite leadership team scores were associated with lower emotional exhaustion and depersonalization and higher overall satisfaction with the residency program and organization (all P < .001). In adjusted logistic regression models, each 1-point gain in composite leadership team score was associated with 9% lower odds of burnout, 20% higher odds of program satisfaction, and 19% higher odds of satisfaction with the organization (all P < .001). At the residency program level, higher mean composite leadership team scores were associated with a lower rate of burnout (r = −0.35, P = .03) and higher program and organization satisfaction (r = 0.67 and 0.74, respectively, both P < .001). Conclusions The behaviors of residency program leadership teams influence residents’ burnout and satisfaction. Additional studies are needed to determine if leadership training results in improved resident well-being and satisfaction.

Abstract Context Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training. Methods Using constructivist grounded theory, we conducted 23 semi‐structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de‐identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data. Results Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making ‘real decisions’ for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care. Conclusions This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.

Abstract Abstract 5154 Background Recent clinical trials with JAK or mTOR inhibitors in primary myelofibrosis (PMF) have identified pruritus as one of the most treatment-responsive disease traits. However, little is known about the prevalence of pruritus in PMF or its clinical and laboratory correlates. Methods The study population was selected among a consecutive series of patients with PMF seen at the Mayo Clinic and in whom bone marrow histologic and cytogenetic information was available for re-review. JAK2, MPL and IDH mutation status and plasma cytokine levels (IL-1b, IL-1RA, IL-2R, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, TNF-α, G-CSF, IFN-α, IFN-γ, MIP-1a, MIP-1b, HGF, IP-10, MIG, MCP-1 and VEGF) were recorded where available. Overall and leukemia-free survival analyses were performed from time of referral to the Mayo Clinic. Results I: Prevalence of pruritus and other baseline information Among 566 consecutive patients with PMF (median age 62 years; 368 males), the presence (n=90) or absence (n=146) of pruritus was documented in 236 patients. The prevalence of pruritus was 38% when considering only those patients in whom pruritus history was documented (n=236), and 16% when all study patients (n=566) were considered regardless of whether or not the absence of pruritus was documented in their history. Among the 90 patients with pruritus, it was severe enough to warrant specific therapy in 51 (57%) patients, was aquagenic in 29 (32%), and onset antedated PMF diagnosis in 15 (17%). All 236 patients had information on karyotype: 136 normal, 76 favorable and 24 unfavorable karyotype. Information on JAK2, MPL, and IDH mutations was available in 197 (125 positive), 147 (9 positive), and 131 (2 positive) patients, respectively. In addition, plasma levels of the aforementioned cytokines were available in 63 patients. Results II: Clinical correlates Parameters at diagnosis that were significantly associated with presence of pruritus included leukocytosis (p=0.03), absence of leukopenia (p=0.002), and absence of MPLW515 mutation (p=0.02). Borderline significance was noted for JAK2V617F positive status (p=0.08). The incidence of pruritus was 0% (0/9) vs. 41% (56/138) in MPL-mutated vs MPL-unmutated cases and 42% (52/125) vs. 29% (21/72) JAK2 mutated vs unmutated cases, respectively. No significant correlations were noted for age, DIPSS-plus scores, transfusion need, karyotype, or plasma cytokine levels. The association with leukocytosis/leukopenia was subsequently shown to be significant only in JAK2V617F-negative cases. To date, 124 deaths and 19 leukemic transformations have been documented. In JAK2-mutated cases (n=125), pruritus did not affect overall or leukemia-free survival. In JAK2-unmutated cases (n=72), a significant correlation between presence of pruritus and inferior leukemia-free survival was noted (p=0.04), and was independent of leukocytosis, thrombocytopenia or abnormal karyotype. Conclusions Pruritus accompanies PMF in a substantial proportion of patients and is more or less likely to occur in the presence of JAK2 or MPL mutations, respectively. In JAK2V617F-negative cases, PMF-associated pruritus clustered with leukocytosis and was independently associated with inferior leukemia-free survival. Disclosures: No relevant conflicts of interest to declare.

Transitional cell carcinoma of the bladder (TCC) represents nearly 90% of genitourinary malignancies and typically presents with locally invasive symptoms. Metastasis to the central nervous system (CNS) is uncommon occurring in <5% of patients. When present, metastatic lesions are typically solid, isolated and located in the cerebrum. We report a case of a patient with a history of TCC who presented with lethargy and ataxia and was found to have a solitary cystic cerebellar lesion consistent with metastatic disease. Unfortunately, the prognosis for patients with TCC and CNS metastases is poor. Treatment options include debulking surgery, whole brain radiation, stereotactic radiosurgery and chemotherapy. Unfortunately, treatment may not appreciably extend survival and care is often supportive in previously reported cases. Though uncommon, TCC can metastasise to the CNS and should be considered in the differential diagnosis of patients, particularly those who were treated with aggressive surgery or combination chemotherapy previously.

Aging is associated with reduced endothelial function. There is indirect evidence for reduced prostacyclin (PGI 2 )-mediated vasodilation with aging, but it is unknown whether this is because of reduced dilation to PGI 2 or altered production. In addition, the contribution of endothelial NO to PGI 2 -mediated dilation is unknown. Using plethysmography to determine forearm blood flow, we studied the effect of PGI 2 in 10 older (61 to 73 years) and 10 younger (19 to 45 years) subjects using 3 escalating intra-arterial doses of PGI 2 (epoprostenol). PGI 2 was also administered after NO synthase inhibition with N G -monomethyl- l -arginine acetate. The percent of change in forearm vascular conductance (mean±SEM) from baseline after PGI 2 was significantly lower ( P =0.002) in the aging individuals (52±11%, 164±23%, and 221±27% versus 115±20%, 249±19%, and 370±35%). In addition, the group-by-dose interaction was also significant ( P =0.018). After NO synthase inhibition, the dose-response curve to PGI 2 was blunted in the young subjects but unchanged in the older subjects; the difference between the groups was no longer significant. Our data suggest that the reduced dilator effects of PGI 2 in older individuals are attributable to a reduction in the contribution of endothelial-derived NO versus alterations in the direct effects of PGI 2 on vascular smooth muscle.