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PGMJ Online First, published on October 10, 2017 as 10.1136/postgradmedj-2017-135212 Review

A systematic review of interventions to foster physician resilience Susan Fox,1 Sinéad Lydon,1 Dara Byrne,2 Caoimhe Madden,1 Fergal Connolly,1 Paul O’Connor1 ►► Additional material is published online only. To view please visit the journal online (http://d​ x.​doi.o​ rg/​10.​1136/​ postgradmedj-​2017-​135212). 1

Department of Primary Care and the Irish Centre for Applied Patient Safety and Simulation, School of Medicine, National University of Ireland, Galway, Ireland 2 Irish Centre for Applied Patient Safety, National University of Ireland, Galway, Ireland Correspondence to Dr Paul O’Connor, Department of Primary Care, NUI Galway, Distillery Road, Galway, Ireland; p​ aul.​oconnor@n​ uigalway.​ie Received 18 July 2017 Revised 19 September 2017 Accepted 24 September 2017

To cite: Fox S, Lydon S, Byrne D, et al. Postgrad Med J Published Online First: [please include Day Month Year]. doi:10.1136/ postgradmedj-2017-135212

Abstract This review aimed to synthesise the literature describing interventions to improve resilience among physicians, to evaluate the quality of this research and to outline the type and efficacy of interventions implemented. Searches were conducted in April 2017 using five electronic databases. Reference lists of included studies and existing review papers were screened. English language, peer-reviewed studies evaluating interventions to improve physician resilience were included. Data were extracted on setting, design, participant and intervention characteristics and outcomes. Methodological quality was assessed using the Downs and Black checklist. Twenty-two studies were included. Methodological quality was low to moderate. The most frequently employed interventional strategies were psychosocial skills training and mindfulness training. Effect sizes were heterogeneous. Methodologically rigorous research is required to establish best practice in improving resilience among physicians and to better consider how healthcare settings should be considered within interventions.

and external factors (eg, cultural and social factors), which may vary contextually and transiently.12 13 The preventative role of resilience in helping individuals to cope with adversity and protecting an individual from experiencing burnout has been demonstrated in the nursing literature.20 These data, combined with the knowledge of the negative impact of burnout on both physicians and their patients,14 have resulted in increased research interest in physician resilience. This has included the development and evaluation of interventions aiming to increase physician resilience and to reduce physician susceptibility to occupational stress and burnout.15 21 While previous reviews have evaluated educational interventions targeting resilience among healthcare profession populations,15 21 no review to date has evaluated interventions to improve physician resilience exclusively. The current review aimed to synthesise the literature describing interventions to improve resilience among physicians, to evaluate the quality of the extant research and to outline the type and efficacy of interventions implemented.

Introduction

Methods

Psychological resilience, as well as the use of resilience strategies, has been suggested to be the difference between doctors who experience burnout and doctors who thrive in the clinical environment.1 Physicians experiencing burnout are at an increased risk of suicidal ideation, clinical depression, substance misuse and poor quality of life.2–4 Physician burnout also has implications for patient safety and quality of care; burned out physicians have a higher incidence of medical error, exhibit poorer professional conduct and produce worse patient outcomes.5–8 The concept of psychological resilience, which has emerged from developmental psychology,9–12 can be defined as ‘the role of mental processes and behaviour in promoting personal assets and protecting an individual from the potential negative effect of stressors’ (Fletcher and Sarkar, p16).13 Given the negative impacts of burnout,14 research interest in physician resilience has grown.1 15 Resilience has traditionally been viewed as an intrinsic and/or innate quality rather than an attribute that can be developed or learnt.16 17 However, newly emerging theories of resilience have suggested that resilience is not static and may experience both amelioration and degeneration.13 18 19 These theories suggest that resilience is a product of adversity and its levels are determined by an array of internal (eg, presence or absence of psychiatric symptoms)

This review paper is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.22

Search strategy

Systematic searches were conducted in April 2017 within five electronic databases: MedLine, PsycINFO, CINAHL, Web of Science and Psychology and Behavioural Sciences. Our search protocol (see online supplementary digital content 1 for a sample search strategy from MedLine) consisted of Medical Subject Headings search terms including ‘health personnel’ and ‘resilience psychological’ and keywords including ‘resilienc*’ and ‘hardiness’. The search strategy was adapted as necessary for databases other than MedLine. Screening was conducted by the first author (SF). During the online searches, titles and abstracts were screened in order to determine each study’s suitability for inclusion. Where a study appeared eligible for inclusion at this point, its full text was reviewed and a decision regarding inclusion was made. In addition, the reference lists of all studies identified for inclusion were manually screened in order to identify other articles that were potentially suitable for inclusion. Further, the reference list of other recent reviews15 21 focusing on resilience among healthcare professionals was also examined.

Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence.

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Review Study selection Inclusion criteria

In order to be eligible for inclusion in the current review, studies had to: (a) be written in the English language; (b) be published in a peer-reviewed journal and; (c) describe original research focused on the development and/or evaluation of any intervention that was implemented with the stated intention of promoting resilience among physicians. Studies were eligible for inclusion if their participants were physicians who had completed undergraduate or postgraduate training and were practising medicine in any setting. Qualitative, quantitative and mixed-method research studies were eligible for inclusion.

Exclusion criteria

Studies were excluded if they did not report the participation of physicians or if the intervention described was delivered to individuals from multiple health professions and it was not possible to extract data concerning physician outcomes specifically. Studies that were focused on developing organisational or system resilience were also excluded. Other studies were excluded due to a focus on developing resilience in emergency situations or in order to mitigate trauma-induced stress or the consideration and/or measurement of resilience in the absence of intervention.

Data extraction

Data extraction was conducted independently by two of the authors. A structured tool was used to extract the following data from each study: year of publication, country in which the study had been conducted, participant characteristics (ie, medical specialty), intervention characteristics (ie, theoretical background, healthcare setting, duration and/or frequency of sessions, intervention agent and cost), experimental design, measurement of intervention outcomes, intervention outcome data, maintenance of intervention effects and methodological quality. In total, there were 657 opportunities for reviewers to agree or disagree during data extraction. The two reviewers were in agreement on 647 of these occasions (98.5% of opportunities). In cases of disagreement between reviewers, consensus was reached through discussion.

Methodological quality

The 27-item Downs and Black23 checklist was used to assess the methodological quality of the included studies. The checklist is suitable for use with both randomised and non-randomised studies of healthcare interventions and considers a study’s reporting, internal validity (bias and confounding), external validity and power. Four items were removed as they were not considered relevant to the type of studies in this systematic review (ie, blinding of participants to the intervention, reporting of adverse events, the representativeness of individuals asked to participate and compliance with the intervention). One additional change was made: power was scored as either sufficient power (1) or insufficient power (0), with the requisite number of participants calculated on the basis of an effect size 0.4, alpha of. 05, and the use of a two-tailed test. Total overall scores for the checklist could range from 0 to 24. For the purposes of this review, quality scores between 20 and 24 were considered to be excellent, scores between 16 and 19 were categorised as good, scores between 14 and 18 were considered fair and scores below 14 were considered to indicate poor quality. The quality assessment for each study was conducted independently by two 2

reviewers. Any disagreements were resolved through discussion until consensus was reached.

Quantification of intervention outcomes

Effect sizes were calculated in order to examine the impact of the interventions on the outcome measures (eg, changes in perceived stress from preintervention to postintervention; changes in perceived resilience from preintervention to postintervention). Effect sizes were calculated for outcomes that were measured within five or more studies. A meta-analysis of the impact of interventions targeting resilience among physicians was not conducted due to the myriad of different outcome measures used within the included studies and the inability to select just one, or a small number of, outcome measures.

Results

A total of 2751 articles were screened, of which 22 studies were determined to meet the inclusion criteria (see figure 1 for PRISMA diagram). Included studies were published between 2000 and 2016, with almost three-quarters (72.7%) published since 2014. While all included studies were interventional in nature, there were differences in experimental design: 17 studies used a quantitative design,24–40 4 studies used mixed-method designs41–44 and 1 study used a qualitative design.45 Table 1 provides an overview of the characteristics of the included studies including study location, physician specialty or setting, methodological and study design and intervention time (for a detailed summary of each individual study, see online supplementary digital content 2). Each included study explicitly stated an aim of improving physician resilience.

Participants

Within the included studies, less than half (n=9, 41%) delivered interventions exclusively to physicians with most delivering interventions to physicians in tandem with other healthcare professionals and/or health profession students. A summary of the specialty of the participants (where stated) is provided in table 1. Only one study reported the specific recruitment and inclusion of clinically depressed healthcare professionals.31 No other study specified mental or physical health status as a criterion for participation.

Interventions

A summary of included interventions to foster resilience in physicians is presented in table 2. Psychosocial skills and mindfulness-based interventions were the most common interventions reported by authors, all of which were delivered in group settings, with the exception of three interventions, which were delivered individually.38 45 46

Measurement of outcomes

All studies were focused on self-reported data collected via questionnaire or interview/focus group. A total of 13 included studies (59.1%) used 10 standardised measurement tools that were intended to measure resilience (see table 3). Only one study employed an unstandardised Likert-style questionnaire developed by the authors that was intended to measure resilience.36 Two studies used qualitative interviews45 and focus groups42 to assess the impact of the resilience intervention. The remaining six studies did not use explicit measures of resilience, instead assessing variables and constructs hypothesised to be related to resilience or vulnerability to mental ill-health,27 28 30 31 41 43 44 Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

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Review

Figure 1  Preferred Reporting Items for Systematic Review and Meta-Analysis flow chart of studies screened, excluded (with reasons) and included in the review.

such as perceived stress, anxiety and burnout. For further information on the outcomes achieved within individual studies, see online supplementary digital content 2.

Intervention costs Costs were not reported or considered in 18 (82%) of included studies. Two studies did not specify intervention costs but deemed the interventions to be ‘cost effective’.24 25 Only one study discussed intervention costs per participant (US$475),29 while another discussed the return on investments in terms of ‘employee cost reductions’ and estimated a per-employee cost reduction of US$1846 due to presenteeism.31 For further information, see online supplementary digital content 2.

Intervention maintenance effects The maintenance of intervention effects following intervention cessation was not considered in 14 (64%) studies. The remaining eight (36%) studies reported that intervention effects were maintained for variables and constructs relevant to resilience and burnout prevention for an average of 8 months (SD 9.2; with range 2–30).24–26 29 31 34 37 46 For further information, please see online supplementary digital content 2. Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

Intervention effect sizes

It was possible to calculate effect sizes for the interventions delivered in 15 of the 22 (68.2%) included studies. Effect sizes were calculated using Cohen’s d. Table 4 presents effect size calculations for psychological factors relevant to resilience, which were explored by five or more of the included studies (for all effect size calculations, see  online supplementary digital content 3).

Methodological quality

Out of a potential score of 24 on the quality assessment measure,23 the mean (SD) score among the included studies was 11.6 out of 24 (3.2 with range 6–17). For the purposes of this review, quality scores between 20 and 24 were considered to be excellent, scores between 16 and 19 were categorised as good, scores between 14 and 18 were considered fair and scores below 14 were considered to indicate poor quality. Adjustment of the tool is commonplace in the literature.47–49 Studies typically scored highly on items relating to the reporting of hypotheses, aims, objectives and outcomes and appropriateness of statistical tests used. Studies typically scored poorly on items pertaining to intervention description, blinding of assessors and power. Quality assessment outcomes for individual studies are provided in online supplementary digital content 2. 3

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Review Table 1  Characteristics of the 22 included studies that detailed interventions to improve resilience among physicians Characteristics

Studies, n (%)

Study location   USA

18 (81.8)

  Germany

3 (13.6)

  Israel

1 (4.5)

Participants  Physicians and healthcare professionals and/or medical students

13 (59.1)

 Physicians only

9 (40.9)

Physician specialty/setting  Unspecified

9 (40.9)

 Multiple medical specialties

2 (9.1)

 Palliative care

2 (9.1)

 Primary care

2 (9.1)

 Gynaecology

1 (4.5)

 ICU

1 (4.5)

 Paediatric oncology

1 (4.5)

 Paediatrics

1 (4.5)

 Psychiatry

1 (4.5)

 Radiology

1 (4.5)

 Surgery

1 (4.5)

Methodological design  Quantitative

17 (77.3)

  Pretest–post-test design

11 (64.7)

  Randomised controlled trial

6 (35.3)

 Mixed methods

4 (18.2)

 Qualitative

1 (4.5)

Intervention  Psychosocial skills training intervention

5 (22.7)

 Mindfulness-based intervention

5 (22.7)

 Mindfulness-Based Stress Reduction type intervention

3 (13.6)

 Self-directed Stress Management and Resiliency Training Intervention

3 (13.6)

 Relaxation Response Resiliency Program for palliative care clinicians intervention

1 (4.5)

 Aware Compassionate Communication: an Experiential Provider Training Series Intervention

1 (4.5)

 Coaching training intervention

1 (4.5)

 Narrative training intervention

1 (4.5)

 Resilience in Stressful Events intervention

1 (4.5)

 Simulation training intervention

1 (4.5)

ICU, intensive care unit.

Discussion Psychological resilience, as well as the use of resilience strategies, has been suggested to be the difference between doctors who experience burnout and doctors who thrive in the clinical environment.1 Given the negative impact of burnout on both the physician and patient,14 there is a growing research interest in promoting psychological resilience among physicians.1 15 The current review aimed to synthesise the literature describing interventions to improve resilience among physicians, to evaluate the quality of the extant research and to outline the type and efficacy of interventions implemented. The timeliness of this review is evident, with over two-thirds of the included studies published in the past 3 years. However, difficulties determining the true efficacy of interventions implemented were noted due to the low methodological rigour of the included studies and a lack of clarity surrounding the concept and definition of psychological 4

resilience, which impacts negatively on its measurement within the included research studies. Our review highlights a lack of consensus concerning the conceptual understanding of resilience. This is apparent from the variability in outcome measures employed across the included studies and the diversity of the types of interventions implemented. Interventions included psychosocial skills training interventions, mindfulness-based interventions, coaching interventions and simulation-based interventions (see table 2). Issues pertaining to the content, construct and criterion validity of measures of resilience50 51 and difficulties with operationalising psychological resilience have been identified in other studies.13 50 52 A critical review of resilience theory52 53 notes that the theoretical issues raised are reminiscent of concerns previously raised about many other psychological constructs such as wellness or empowerment.54 The review notes that ‘clarification… in this area must proceed firstly by conceptual unification’ (p. 479).52 This concern is echoed elsewhere.55 Future research focused on improving the conceptualisation and operationalisation of psychological resilience would yield an improved quality of research focused on psychological resilience among physicians and allow stakeholders to best proceed with initiatives to measure and improve resilience and well-being among physicians. Similarly, research pertaining to the development of specialised measures of resilience for use with physicians may also be necessary and could facilitate the measurement of intervention outcomes. This is not a unique suggestion; other scholars have emphasised that specialised measures of resilience are required for specific populations, making the case for the development, evaluation and utilisation of a physician-specific measure of resilience.13 50 56 Given the unique environment and responsibilities of physicians, which create a high risk of burnout,14 a physician-specific measure of resilience may yield more valid and reliable data. A key finding of this review was the low methodological rigour of the included studies; 72.7% of studies were deemed ‘poor’, 9.1% ‘fair’, 18.2% ‘good’ and no study achieved a score indicative of ‘excellent’ methodological rigour. Frequent methodological shortcomings included the use of weak experimental designs (eg, pretest–post-test designs), small sample sizes that resulted in studies being insufficiently powered to detect intervention effects and the insufficient description of the interventions implemented. This lack of procedural detail precludes replication or the repetition of experimental procedures.57 This issue is commonplace within research describing behavioural and public health interventions58–60 and within resilience interventions in general populations.61 However, without comprehensive description and explication, interventions cannot be reliably implemented.60 Researchers have developed guidelines for improved reporting of intervention description and replication.60 It is imperative that future research describes interventional procedures in sufficient detail that they may be replicated and the reproducibility of outcomes can be determined. To advance our knowledge of resilience and means of improving it within physician populations, future research studies that are well planned and methodologically rigorous are required.15 61 A key aim of this review was to examine the efficacy of interventions implemented to improve physician resilience. This endeavour was complicated by the myriad of different outcome measures used within the included studies, as described above, which precluded the conduct of a meta-analysis. This challenge has been previously noted in the psychological resilience literature.55 However, within and across studies in which it was possible to compute effect sizes (68.2% of included studies), Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

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Review Table 2  Summary of intervention characteristics Intervention type

Studies, n (%)

Author description

Psychosocial skills training intervention

5 (22.7)24–26 35 37

Psychosocial skill training combined with cognitive–behavioural and solution-focused counselling; coping skills training; psychosocial skill training combined with cognitive–behavioural and solution-focused counselling; coping skills training; stress management/adaptive coping training

Mindfulness-based intervention

5 (22.7)27 30 31 41 44

Wellness curriculum emphasising competencies around leadership, focused on teaching skills to cultivate mindfulness and self-compassion; mindfulness-based resilience intervention to cultivate mindful awareness and resilience; mindfulness-based resilience self-care training; mind-body medicine skills and interactive reflective writing programme; mindfulness and mindful movement programme

MBSR type intervention

3 (13.6)29 33 46

Abbreviated versions of the MBSR programme47

38–40

SMART intervention

3 (13.6)

A SMART programme, adapted from Attention and Interpretation Therapy, with brief structured relaxation intervention (paced breathing meditation)

3RP-PCC intervention

1 (4.5)34

A 3RP-PCC programme adapted from the MGH Benson-Henry Institute for Mind–Body Medicine manualised 3RP programme,48 based on the principles of cognitive–behavioural therapy and positive psychology

ACCEPTS intervention

1 (4.5)28

ACCEPTS programme informed by Mindfulness-Based Interventions and principles of Psychological Flexibility Theory

Coaching training intervention

1 (4.5)45

Physician well-being coaching

Narrative training intervention

1 (4.5)42

Narrative medical training

RISE intervention

1 (4.5)43

Peer-led PFA and emotional support

Simulation training intervention

1 (4.5)36

Obstetrical and gynaecological boot camp simulation training

3RP-PCC, Relaxation Response Resiliency Program for palliative care clinicians; ACCEPTS, Aware Compassionate Communication: An Experiential Provider Training Series; MBSR, Mindfulness-Based Stress Reduction; MGH, Massachusetts General Hospital; PFA, psychological first aid; RISE, Resilience in Stressful Events; SMART, Self-directed Stress Management and Resiliency Training.

treatment effects were inconsistent. A previous review of resilience interventions in the general population has similar challenges and subsequently removed studies at a high risk of bias from the meta-analysis.61 The review reported low to moderate effect sizes for interventions, with poor confidence. Future research on interventions to improve physician resilience that makes consistent use of specific outcome measures and supplies the information necessary to compute measures of intervention effect size would therefore be of much use in elucidating intervention outcomes. However, it is important to note that effect size classifications (ie, small, medium and large) can be considered to be rather arbitrary, rather than reflecting true and meaningful differences.62 Further research would be required using the various measures of resilience in order to determine what constitutes a true and meaningful difference on each. Nonetheless, future research reporting effect sizes would be useful and would allow for a meta-analysis of intervention research, which may identify specific participant, organisation or intervention characteristics that are predictive of treatment failure or success or predictive of the persistence of intervention effects postintervention cessation.63 64

Strengths and limitations This review paper had a number of demonstrable strengths. These strengths include the adherence to the PRISMA reporting guidelines,22 the broad and comprehensive nature of the search strategy, the assessment of methodological quality using a well-regarded65 66 quality assessment tool,23 the completion of data extraction and quality appraisal by two Masters-level psychologists independently and the quantification of treatment outcomes through the computation of effect sizes. However, it is important that a number of limitations to the review’s methodology are acknowledged. First, the fact that only those studies in which the authors explicitly stated that the aim was to increase physician resilience were included in this review could be considered to be a weakness of this study. For example, interventions aiming to promote physician well-being or decrease burnout without discussing resilience were excluded, although many of the included studies did include measurement of such constructs. The reliance on study authors’ description of research aims increased objectivity around inclusion/exclusion meant that the review authors were not making inferences

Table 3  Overview of standardised scales employed within studies to measure resilience Tool

Use

Items (n)

Author-reported purpose

Brief Resilient Coping Scale (BRCS)

Used in three studies24–26

4

Measure of adaptive stress coping

Connor-Davidson Resilience Scale

Used in three studies38–40

25

Measure of psychological resilience

Cognitive Hardiness Scale

Used in one study37

30

Measure of psychological hardiness

Connor-Davidson Resiliency Scale - 10-items version (CD-RISC)

Used in one study33

10

Measure of psychological resilience

General Self-Efficacy Scale

Used in one study34

10

Measure of optimistic self-beliefs to cope life demands

Interpersonal Reactivity Index (IRI)

Used in one study42

28

Measure of empathy

Personal and Organisational Quality Assessment‐Revised Used in one study35

80

Measure of physical stress symptoms, psychological health, resilience, emotional competencies, organisational climate and work performance

Smith’s Brief Resilience Scale (BRS)

Used in one study46

6

Measure of psychological resilience

The 14-item Resilience Scale (RS-14)

Used in one study29

14

Measure of psychological resilience

Ways of Coping Scale

Used in one study37

123

Measure of coping style

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Review Table 4  Magnitude of changes (Cohen’s d) from preintervention to postintervention across the various types of outcomes measured Category and measurement tools

n

Effect size (% of studies) Small

Medium

Large

   Emotional exhaustion

1 (16.7)

3 (50)

1 (16.7)

   Depersonalisation

1 (16.7)

UTD*

Burnout/fatigue Maslach’s Burnout Inventory

6

   Personal accomplishment Oldenburg Burnout Inventory

2 (33.3) 3

1 (16.7) 5 (83.3)

1 (16.7)

1 (16.7)

1 (33.3)

2 (33.3) 2 (66.7)

Personal and Organisational Quality Assessment‐ Revised Visual Analog Scale-Fatigue (VAS-Fatigue) Depression/anxiety/stress Depression Anxiety Stress Scale, 21-question version (DASS-21)

2

Anxiety

6

2 (100) 1 (16.7)

3 (50)

2 (33.3)

Smith Anxiety Scale State-Trait Anxiety Inventory (STAI) Stress

18

7 (38.8)

3 (16.7)

3 (16.7)

5 (27.8)

13

3 (23.1)

2 (15.4)

2 (15.4)

6 (46.1)

The Perceived Stress Scale (PSS) Perceived Stress Questionnaire (PSQ) CESD-1042 Scale and the Patient Health Questionnaire (PHQ-9) Stressor Scale for Paediatric Oncology Nurses (SSPON) The Positive and Negative Affect Schedule Stress Assessment Inventory The Beck Depression Inventory The Post-Traumatic Stress Disorder Symptom Checklist Ruminative Responses Scale Resilience/adaptive coping/coping style The 14-item Resilience Scale (RS-14) Smith’s Brief Resilience Scale 10-items version of the Connor-Davidson Resiliency Scale (CD-RISC) Brief Resilient Coping Scale (BRCS) Perspective taking subscale of the Interpersonal Reactivity Index (IRI) General Self-Efficacy Scale Cognitive Hardiness Scale Ways of Coping Scale Connor-Davidson Resiliency Scale (CD-RISC) Compassion

5

5 (100)

The Santa Clara Brief Compassion Scale (SCBC) Neff’s Self-Compassion Scale Professional Quality of Life Self-Compassion Scale Workplace productivity/work engagement/job satisfaction

5

3 (60)

5

3 (60)

2 (40)

Copenhagen Psychosocial Questionnaire (COPSOQ) Workplace Productivity and Impairment General Health 49 Questionnaire (WPAI: GH) Utrecht Work Engagement Scale (UWES) Satisfaction with life/quality of life/life context

1 (20)

1 (20)

Linear Analog Self-Assessment Scale Professional Quality of Life measure Brief Satisfaction with Life Scale *UTD, unable to determine: sufficient data were not provided in order to determine the effect size of the intervention; Cohen d: 0.2, small effect size; 0.5, medium effect size; 0.8, large effect size.

concerning study aims or the suitability of studies for inclusion. However, future research could conduct a more expansive review of all literature, encompassing all intervention research focused on improving physician well-being. Second, searches of the grey literature were not carried out. This may be considered a weakness of the review as it is known that interventions with positive results are more likely to be published so the review may offer an overestimation of the efficacy of resilience interventions 6

for physicians.67 68 However, there are issues with including grey literature searches within a systematic review such as compromised methodological reproducibility and difficulties in interpreting these publications due to the low methodological quality and poor reporting.69–71 Third, the exclusion of other health professions reduces the generalisability of the review. However, the unique working conditions and responsibilities of physicians72 73 suggest that they should be considered separately from Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

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Review other healthcare professionals. Finally, limiting the search to the English language may have resulted in the exclusion of some pertinent studies published in other languages.74–76

Future research

Our findings may assist researchers in improving the rigour and guiding the focus of future research studies examining interventions to improve psychological resilience among physicians. The relatively infrequent (36% of included studies) assessment of the maintenance of intervention effects within the included studies negatively impacts on our understanding of intervention outcomes. Initial data are promising and suggest that reductions in burnout and stress symptoms and increases in resilience may persist over time. Previous reviews pertaining to psychological resilience have not typically reported the exploration of longterm maintenance of intervention effects (≥6 months).15 21 61 However, notably, one review of burnout prevention interventions previously reported long-lasting positive effects (≥12 months) in interventions that incorporate both a person-directed and organisational-directed approach.77 Future research on physician resilience must therefore consider and report the maintenance of intervention effects, which will further our understanding of the true efficacy of such interventions. There is also a need for the greater consideration of theories of psychological resilience within the development and evaluation of interventions to promote psychological resilience in future research. Consideration of theory during intervention development can guide outcome measurement, may result in stronger intervention effects, can facilitate the determination of why an intervention is or is not effective and makes comparison across studies more feasible or appropriate.64 The use of theory coding schemes78 within future research would ensure full and reliable reporting of the theoretical foundation of interventions, in addition to guiding intervention content and the evaluation tools used to measure the effectiveness of the interventions. It is essential that reporting within studies is comprehensive and allows for the determination of positive or null or potentially adverse effects. Selective reporting was noted within a number of the included studies,37 41 whereby findings were not reported across all of the described outcome measures post-test. Such biases in reporting are a substantive problem79 80 and raise concerns about possibly unreported undesirable research findings and potential harm caused by interventions.81 82 Researchers should be vigilant regarding the potential of unintentionally harmful interventions and report all research findings to best inform future research.83 Registration of trial protocols for studies targeting the improvement of physician resilience would increase transparency and may also help ensure appropriate subsequent conduct in analysis and reporting.80 All included studies were focused exclusively on self-reported outcome measures, such as perceived stress, burnout, anxiety and depression. The sole reliance on participant self-reports within the existing literature is limiting. The weaknesses of self-reported data are well established84–86 and include social desirability and acquiescence response biases.86 87 Future research should supplement self-reported data with physiological measures of stress and health (eg, cortisol, alpha amylase)88 in order to further our knowledge of resilience, well-being and health in this population.89 The comparison of self-reported and objective physiological data can result in differences or discrepancies between subjective and objective measures90–92 and thus may further our knowledge of psychological resilience and wellbeing among physicians or may contribute to the validation of Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

the existing literature.93 Thus, research exploring the effects of resilience interventions on physicians’ physiological functioning, such as stress as measured by cortisol or immune functioning as measured through salivary cytokines, would be of much interest. Despite the diversity in the nature of interventions implemented to improve psychological resilience across the included studies, all were focused on building resilience at an individual level, with the exception of one peer-led first-aid programme, which made secondary resources (ie, a telephone support system) available to participants.43 As such, the interventions implemented uniformly fail to consider or address the impact of the work environment on the individual, in spite of previous research suggesting that burnout is an almost certain outcome of the organisational systems in place across many medical education and healthcare settings.94 95 Interventions that fail to address the organisational and social contexts of healthcare therefore inappropriately place the burden of wellness and/or burnout on the individual.94 96 97 It is recommended that future research considers how to foster or ameliorate resilience using a more holistic, system-wide model that targets both the individual and the characteristics of the healthcare setting that may have contributed to reduced well-being or health. Such interventions could incorporate primary prevention strategies at the organisational level (ie, changing the work environment), secondary prevention techniques (ie, teaching personnel how to be resilient) and tertiary prevention (ie, treating those individuals who have become burned out).57 98 99

Conclusions

The high prevalence, as well as negative impact, of burnout within the medical profession, has prompted research interest in psychological resilience and how to foster it among physicians. This review indicates that this research area is in its infancy and currently suffers from the lack of consideration or use of pertinent theory, a lack of consistency in outcome measurement and substantive methodological weaknesses. In the absence of theoretically valid, evidence-based interventions, it is not possible to provide best practice guidance on how to improve resilience among physicians. There is a need for methodologically rigorous future research to consider the place of psychological resilience within the context of challenging healthcare contexts, rather than the current focus on seeking a ‘fix’ for the individual without consideration of the system’s impact.

Main messages ►► There is a need for methodologically rigerous research to

identify interventions to improve resiliance.

►► Interventions have tend to focus on building resilence only at

an individual level.

►► There is a need to take a systems-wide approach to resiliance

that targets both the individual and organisation.

Current research questions ►► What are the interventions that have been used with doctors

to foster resilience?

►► What is the efficacy of resilience interventions for doctors? ►► What is the quality of the literature reporting evaluations of

resilience interventions for doctors?

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Review Key references ►► Launer J. Resilience: for and against. Postgrad Med J

2015;91:721–2.

►► Zwack J, Schweitzer J. If every fifth physician is affected by

burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med. 2013;88:382–9. ►► Fletcher D, Sarkar M. Psychological resilience. Eur Psychol 2013;18, 12–23. ►► Davydov DM, Stewart R, Ritchie K, et al. Resilience and mental health. Clin Psychol Rev 2010;30:479–95. ►► O’Connor P, Lydon S, O’Dea A, et al. A longitudinal and multicentre study of burnout and error in Irish junior doctors. Postgraduate Medical Journal. 2017: doi: 10.1136/ postgradmedj-2016–134626.

Self assessment questions Please answer true or false to the below statements. 1. The concept of psychological resilience has its origins in developmental psychology. 2. Resilience has traditionally been viewed as something that can be developed or learnt. 3. Research interest in psychological resilience has increased in recent years. 4. The resilience interventions included in the systematic review tended to focus on the individual level. 5. In the absence of theoretically valid, evidence-based interventions, it is not possible to provide best practice guidance on how to improve resilience among physicians.

Contributors SF, SL, DB and POC were all involved in the design and planning of the study. SF conducted the searches. SF, CM and FC were responsible for completing the data extraction, quality assessment and data analysis. SF drafted the initial manuscript with all other authors assisting with redrafting it. All authors reviewed and approved the manuscript prior to submission. Funding This research was supported through funding from the Health Service Executive National Doctors Training and Planning. Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Authors are happy to share the data, and these are available in the supplemental materials. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

References

1 Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? resilience strategies of experienced physicians. Acad Med 2013;88:382–9. 2 Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry 2013;35:45–9. 3 Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: the EGPRN study. Fam Pract 2008;25:245–65. 4 Linzer M, Visser M, Oort F, et al. Society of General Internal Medicine (SGIM) Career Satisfaction Study Group (CSSG) predicting and preventing physician burnout: results from the United States and The Netherlands. Am J Med 2001;111:170–5. 5 Hall LH, Johnson J, Watt I, et al. Healthcare staff wellbeing, burnout, and patient safety: a systematic review. PLoS One 2016;11:e0159015. 6 Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995–1000. 7 Williams ES, Manwell LB, Konrad TR, et al. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev 2007;32:203–12.

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8 de Oliveira GS, Chang R, Fitzgerald PC, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg 2013;117:182–93. 9 Garmezy N, Nuechterlein K. Invulnerable children-fact and fiction of competence and disadvantage. Am J Orthopsychiatry 1972;42:328. 10 Kagan J. New views on cognitive development. J Youth Adolesc 1976;5:113–29. 11 Kagan J, Klein RE. Cross-cultural perspectives on early development. Am Psychol 1973;28:947–61. 12 Rutter M. Protective factors in children’s responses to stress and disadvantage. Ann Acad Med Singapore 1979;8:324–38. 13 Fletcher D, Sarkar M. Psychological resilience. Eur Psychol 2013;18:12–23. 14 Dewa CS, Loong D, Bonato S, et al. How does burnout affect physician productivity? a systematic literature review. BMC Health Serv Res 2014;14:325. 15 Rogers D. Which educational interventions improve healthcare professionals’ resilience? Med Teach 2016;38:1236–41. 16 Mahoney JL, Bergman LR. Conceptual and methodological considerations in a developmental approach to the study of positive adaptation. J Appl Dev Psychol 2002;23:195–217. 17 Ungar M. Resilience across cultures. Br J Soc Work 2008;38:218–35. 18 Maddi SR, Harvey RH, Khoshaba DM, et al. The personality construct of hardiness, III: relationships with repression, innovativeness, authoritarianism, and performance. J Pers 2006;74:575–98. 19 Steinhardt M, Dolbier C. Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology. J Am Coll Health 2008;56:445–53. 20 Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J Adv Nurs 2007;60:1–9. 21 Kreitzer MJ, Klatt M. Educational innovations to foster resilience in the health professions. Med Teach 2017;39:153–9. 22 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9. 23 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377–84. 24 Mache S, Baresi L, Bernburg M, et al. Being prepared to work in gynecology medicine: evaluation of an intervention to promote junior gynecologists professionalism, mental health and job satisfaction. Arch Gynecol Obstet 2017;295:153–62. 25 Mache S, Bernburg M, Baresi L, et al. Evaluation of self-care skills training and solution-focused counselling for health professionals in psychiatric medicine: a pilot study. Int J Psychiatry Clin Pract 2016;20:239–44. 26 Mache S, Danzer G, Klapp B, et al. An evaluation of a multicomponent mental competency and stress management training for entrants in surgery medicine. J Surg Educ 2015;72:1102–8. 27 Runyan C, Savageau JA, Potts S, et al. Impact of a family medicine resident wellness curriculum: a feasibility study. Med Educ Online 2016;21:30648. 28 Gerhart J, O’Mahony S, Abrams I, et al. A pilot test of a mindfulness-based communication training to enhance resilience in palliative care professionals. J Contextual Behav Sci 2016;5:89–96. 29 Fortney L, Luchterhand C, Zakletskaia L, et al. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med 2013;11:412–20. 30 Goldhagen BE, Kingsolver K, Stinnett SS, et al. Stress and burnout in residents: impact of mindfulness-based resilience training. Adv Med Educ Pract 2015;6:525–32. 31 Johnson JR, Emmons HC, Rivard RL, et al. Resilience training: a pilot study of a mindfulness-based program with depressed healthcare professionals. Explore 2015;11:433–44. 32 Barrios-Choplin B, Atkinson M. Personal and organizational quality assessment. Boulder Creek, CA: HeartMath Research Center, Institute of HeartMath, 1996. 33 Klatt M, Steinberg B, Duchemin AM. Mindfulness in Motion (MIM): an onsite mindfulness based intervention (MBI) for chronically high stress work environments to increase resiliency and work engagement. J Vis Exp 2015;101:e52359. 34 Mehta DH, Perez GK, Traeger L, et al. Building resiliency in a palliative care team: a pilot study. J Pain Symptom Manage 2016;51:604–8. 35 Pipe TB, Buchda VL, Launder S, et al. Building personal and professional resources of resilience and agility in the healthcare workplace. Stress Health 2012;28:11–22. 36 Pliego JF, Wehbe-Janek H, Rajab MH, et al. OB/GYN boot cAMP using high-fidelity human simulators: enhancing residents’ perceived competency, confidence in taking a leadership role, and stress hardiness. Simul Healthc 2008;3:82–9. 37 Rowe MM. Skills training in the long-term management of stress and occupational burnout. Curr Psychol 2000;19:215–28. 38 Sharma V, Sood A, Prasad K, et al. Bibliotherapy to decrease stress and anxiety and increase resilience and mindfulness: a pilot trial. Explore 2014;10:248–52. 39 Sood A, Prasad K, Schroeder D, et al. Stress management and resilience training among Department of Medicine faculty: a pilot randomized clinical trial. J Gen Intern Med 2011;26:858–61.

Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

Downloaded from http://pmj.bmj.com/ on October 10, 2017 - Published by group.bmj.com

Review 40 Sood A, Sharma V, Schroeder DR, et al. Stress Management and Resiliency Training (SMART) program among Department of Radiology faculty: a pilot randomized clinical trial. Explore 2014;10:358–63. 41 Wald HS, Haramati A, Bachner YG, et al. Promoting resiliency for interprofessional faculty and senior medical students: outcomes of a workshop using mind-body medicine and interactive reflective writing. Med Teach 2016;38:525–8. 42 Sands SA, Stanley P, Charon R. Pediatric narrative oncology: interprofessional training to promote empathy, build teams, and prevent burnout. J Support Oncol 2008;6:307–12. 43 Edrees H, Connors C, Paine L, et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open 2016;6:e011708. 44 Kinser P, Braun S, Deeb G, et al. "Awareness is the first step": an interprofessional course on mindfulness & mindful-movement for healthcare professionals and students. Complement Ther Clin Pract 2016;25:18–25. 45 Schneider S, Kingsolver K, Rosdahl J. Physician coaching to enhance well-being: a qualitative analysis of a pilot intervention. Explore 2014;10:372–9. 46 Kemper KJ, Lynn J, Mahan JD. What is the impact of online training in mind-body skills? J Evid Based Complementary Altern Med 2015;20:275–82. 47 Connor Gorber S, Tremblay M, Moher D, et al. A comparison of direct vs. self-report measures for assessing height, weight and body mass index: a systematic review. Obes Rev 2007;8:307–26. 48 Prince SA, Adamo KB, Hamel ME, et al. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. Int J Behav Nutr Phys Act 2008;5:56. 49 Monteiro PO, Victora CG. Rapid growth in infancy and childhood and obesity in later life-a systematic review. Obes Rev 2005;6:143–54. 50 Windle G. What is resilience? a review and concept analysis. Rev Clin Gerontol 2011;21:152–69. 51 Polit DF, Beck CT. The content validity index: are you sure you know what’s being reported? critique and recommendations. Res Nurs Health 2006;29:489–97. 52 Davydov DM, Stewart R, Ritchie K, et al. Resilience and mental health. Clin Psychol Rev 2010;30:479–95. 53 Luthar SS, Cicchetti D, Becker B. The construct of resilience: a critical evaluation and guidelines for future work. Child Dev 2000;71:543–62. 54 Cowen EL. The enhancement of psychological wellness: challenges and opportunities. Am J Community Psychol 1994;22:149–79. 55 Launer J. Resilience: for and against. Postgrad Med J 2015;91:721–2. 56 Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry 2008;32:44–53. 57 Johnston JM, Pennypacker HS, Green G. Strategies and tactics of behavioral research. New York, NY: Routledge, 2010. 58 Wells M, Williams B, Treweek S, et al. Intervention description is not enough: evidence from an in-depth multiple case study on the untold role and impact of context in randomised controlled trials of seven complex interventions. Trials 2012;13:95. 59 Des Jarlais DC, Lyles C, Crepaz N; TREND Group. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health 2004;94:361–6. 60 Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014;348:g1687. 61 Leppin AL, Bora PR, Tilburt JC, et al. The efficacy of resiliency training programs: a systematic review and meta-analysis of randomized trials. PLoS One 2014;9:e111420. 6 2 Cohen J. Statistical power analysis for the behavioral sciences. New York, NY: Routledge, 1988. 63 Shadish WR, Sweeney RB. Mediators and moderators in meta-analysis: there’s a reason we don’t let dodo birds tell us which psychotherapies should have prizes. J Consult Clin Psychol 1991;59:883–93. 64 Edwards JR, Lambert LS. Methods for integrating moderation and mediation: a general analytical framework using moderated path analysis. Psychol Methods 2007;12:1–22. 65 Deeks JJ, Dinnes J, D’Amico R, et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003;7:1–73. 66 Saunders LD, Soomro GM, Buckingham J, et al. Assessing the methodological quality of nonrandomized intervention studies. West J Nurs Res 2003;25:223–37. 67 Dickersin K. Publication bias: recognizing the problem, understanding its origins and scope, and preventing harm. In: Rothstein H, Sutton A, Borenstein M, eds. Publication bias in meta-analysis: Prevention, assessment and adjustments. Hoboken,NJ: Wiley, 2005:11–33. 68 Scherer RW, Langenberg P, Elm E. The Cochrane Library. Full publication of results initially presented in abstracts. Hoboken,NJ: Wiley, 2005. 69 Mahood Q, Van Eerd D, Irvin E. Searching for grey literature for systematic reviews: challenges and benefits. Res Synth Methods 2014;5:221–34. 70 Egger M, Juni P, Bartlett C, et al. How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? empirical study. Health Technol Assess 2003;7:1-76. 71 Martin JL, Pérez V, Sacristán M, et al. Is grey literature essential for a better control of publication bias in psychiatry? an example from three meta-analyses of schizophrenia. Eur Psychiatry 2005;20:550–3.

Fox S, et al. Postgrad Med J 2017;0:1–9. doi:10.1136/postgradmedj-2017-135212

72 Harrison R, Lawton R, Stewart K. Doctors’ experiences of adverse events in secondary care: the professional and personal impact. Clin Med 2014;14:585–90. 73 Working Party of the Royal College of Physicians. Doctors in society. Medical professionalism in a changing world. Clin Med 2005;5(6 Suppl 1):S5–40. 74 Egger M, Zellweger-Zähner T, Schneider M, et al. Language bias in randomised controlled trials published in English and German. Lancet 1997;350:326–9. 75 Sterne JA, Egger M, Smith GD. Investigating and dealing with publication and other biases in meta-analysis. BMJ 2001;323:101. 76 Galandi D, Schwarzer G, Antes G. The demise of the randomised controlled trial: bibliometric study of the German-language health care literature, 1948 to 2004. BMC Med Res Methodol 2006;6:30. 77 Awa WL, Plaumann M, Walter U. Burnout prevention: a review of intervention programs. Patient Educ Couns 2010;78:184–90. 78 Michie S, Prestwich A. Are interventions theory-based? development of a theory coding scheme. Health Psychology 2010;29:1–8. 79 Dwan K, Altman DG, Arnaiz JA, et al. Systematic review of the empirical evidence of study publication bias and outcome reporting bias. PLoS One 2008;3:e3081. 80 Chan AW. Bias, spin, and misreporting: time for full access to trial protocols and results. PLoS Med 2008;5:e230. 81 Chan AW, Hróbjartsson A, Haahr MT, et al. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles. JAMA 2004;291:2457–65. 82 Hahn S, Williamson PR, Hutton JL, et al. Assessing the potential for bias in metaanalysis due to selective reporting of subgroup analyses within studies. Stat Med 2000;19:3325–36. 83 Lilienfeld SO. Psychological treatments that cause harm. Perspect Psychol Sci 2007;2:53–70. 84 Jürges H. True health vs response styles: exploring cross-country differences in selfreported health. Health Econ 2007;16:163–78. 85 Brutus S, Aguinis H, Wassmer U. Self-reported limitations and future directions in scholarly reports: analysis and recommendations. J Manag 2013;39:48–75. 86 Razavi T. Self-report measures: an overview of concerns and limitations of questionnaire use in occupational stress research. 2001. https://​eprints.​soton.​ac.​uk/​ 35712/​1/​01-​175.​pdf (accessed 4 Jul 2017). 87 Randall DM, Fernandes MF. The social desirability response bias in ethics research. J Bus Ethics 1991;10:805–17. 88 McLeod DR, Hoehn-Saric R, Stefan RL. Somatic symptoms of anxiety: comparison of self-report and physiological measures. Biol Psychiatry 1986;21:301–10. 89 Schaufeli WB, Bakker AB. Job demands, job resources, and their relationship with burnout and engagement: a multi-sample study. J Organ Behav 2004;25:293–315. 90 Harrison LD. The validity of self-reported data on drug use. J Drug Issues 1995;25:91–111. 91 Kuczmarski MF, Kuczmarski RJ, Najjar M. Effects of age on validity of self-reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Diet Assoc 2001;101:28–34. 92 Niedhammer I, Bugel I, Bonenfant S, et al. Validity of self-reported weight and height in the French GAZEL cohort. Int J Obes Relat Metab Disord 2000;24:1111–8. 93 Semmer NK, Grebner S, Elfering A. Beyond self-report: using observational, physiological, and situation-based measures in research on occupational stress. In: Perrewe PL, Ganster DC, eds. Emotional and physiological processes and positive intervention strategies Research in Occupational Stress and Well-being, Volume 3): Emerald Group Publishing Limited, 2003:205–63. 94 Montgomery A. The inevitability of physician burnout: implications for interventions. Burn Res 2014;1:50–6. 95 Montgomery A, Georganta K, Doulougeri K, et al. Burnout: why interventions fail and what can we do differently. In: Karanika-Murray M, Biron C, eds. Derailed organizational interventions for stress and well-geing. Dordrecht: Springer, 2015:37–43. 96 Dunn PM, Arnetz BB, Christensen JF, et al. Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med 2007;22:1544–52. 97 Kompier MA, Kristensen TS. Organizational work stress interventions in a theoretical,methodological and practical context, 2001. 98 O’Connor P, Lydon S, O’Dea A, et al. A longitudinal and multicentre study of burnout and error in Irish junior doctors. Postgrad Med J 2017:postgradmedj-2016-134626. 99 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714–21.

Answers 1. 2. 3. 4. 5.

True False True True True 9

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A systematic review of interventions to foster physician resilience Susan Fox, Sinéad Lydon, Dara Byrne, Caoimhe Madden, Fergal Connolly and Paul O'Connor Postgrad Med J published online October 10, 2017

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