Editorials 12. Amar J, Caranobe C, Sie P, et al: Antithrombotic potencies of heparins in relation to their antifactor Xa and antithrombin activities: An experimental study in two models of thrombosis in the rabbit. Br J Haematol 1990; 76:94–100 13. Rosenberg AF, Zumberg M, Taylor L, et al: The use of anti-Xa assay to monitor intravenous unfractionated heparin therapy. J Pharm Pract 2010; 23:210–216 14. Ryerson LM, Bauman ME, Kuhle S, et al: Antithrombin Concentrate in Pediatric Patients Requiring Unfractionated Heparin Anticoagulation: A Retrospective Cohort Study. Pediatr Crit Care Med 2014; 15:e340–e346 15. Bussey H, Francis JL, Heparin Consensus Group: Heparin overview and issues. Pharmacotherapy 2004; 24(8, Part 2):103S–107S 16. Ockelford PA, Carter CJ, Mitchell L, et al: Discordance between the anti-Xa activity and the antithrombotic activity in an ultra-low molecular weight heparin fraction. Thromb Res 1982; 28:401–409 17. Ofosu FA, Blajchman MA, Modi GJ, et al: The importance of thrombin inhibition for the expression of the anticoagulant activities of heparin, dermatan sulphate, low molecular weight heparin and pentosan polysulphate. Br J Haematol 1985; 60:695–704 18. Barrowcliffe TW, Mulloy B, Johnson EA, et al: The anticoagulant activity of heparin: Measurement and relationship to chemical structure. J Pharm Biomed Anal 1989; 7:217–226 19. ten Cate H, Lamping RJ, Henny CP, et al: Automated amidolytic method for determining heparin, a heparinoid, and a low-Mr heparin fragment, based on their anti-Xa activity. Clin Chem 1984; 30:860–864 20. Bara L, Mardiguian J, Samama M: In vitro effect on Heptest of low molecular weight heparin fractions and preparations with various antiIIa and anti-Xa activities. Thromb Res 1990; 57:585–592 21. Price EA, Jin J, Nguyen HM, et al: Discordant aPTT and anti-Xa values and outcomes in hospitalized patients treated with intravenous unfractionated heparin. Ann Pharmacother 2013; 47:151–158
22. Andrew M, Paes B, Johnston M: Development of the hemostatic system in the neonate and young infant. Am J Pediatr Hematol Oncol 1990; 12:95–104 23. Kher A, Al Dieri R, Hemker HC, et al: Laboratory assessment of antithrombotic therapy: What tests and if so why? Haemostasis 1997; 27:211–218 24. Spinler SA, Wittkowsky AK, Nutescu EA, et al: Anticoagulation monitoring part 2: Unfractionated heparin and low-molecular-weight heparin. Ann Pharmacother 2005; 39:1275–1285 25. Korte W, Jovic R, Hollenstein M, et al: The uncalibrated prothrombinase-induced clotting time test. Equally convenient but more precise than the aPTT for monitoring of unfractionated heparin. Hamostaseologie 2010; 30:212–216 26. Lind SE, Boyle ME, Fisher S, et al: Comparison of the aPTT with alternative tests for monitoring direct thrombin inhibitors in patient samples. Am J Clin Pathol 2014; 141:665–674 27. Maul TM, Wolff EL, Kuch BA, et al: Activated partial thromboplastin time is a better trending tool in pediatric extracorporeal membrane oxygenation. Pediatr Crit Care Med 2012; 13:e363–e371 28. Liveris A, Bello RA, Friedmann P, et al: Anti-factor Xa assay is a superior correlate of heparin dose than activated partial thromboplastin time or activated clotting time in pediatric extracorporeal membrane oxygenation. Pediatr Crit Care Med 2014; 15:e72–e79 29. Irby K, Swearingen C, Byrnes J, et al: Unfractionated heparin activity measured by anti-factor xa levels is associated with the need for extracorporeal membrane oxygenation circuit/membrane oxygenator change: A retrospective pediatric study. Pediatr Crit Care Med 2014; 15:e175–e182 30. Nguyen T, Musick M, Teruya J: Anticoagulation monitoring during extracorporeal membrane oxygenation: Is anti-factor Xa assay (heparin level) a better test? Pediatr Crit Care Med 2014; 15:178–179
Do You Smell Something Burning? Could It Be You?* Alan I. Fields, MD, MCCM Clinical Resource Management Children’s National Washington, DC
B
urnout is a state of chronic psychological stress with long-term exhaustion and diminished interest in work. Burnout may interfere with personal and job satisfaction and is associated with decreased job performance and dysfunctional professional relationships. For physicians, this may involve performance issues such as medical errors and relationships with patients and families (1, 2). Since the first publication on burnout in pediatric intensivists almost 2 decades ago (3), there has been a growing literature on physician burnout. *See also p. e347. Key Words: burnout; family conflict; pediatric intensivists; pediatricians; risk of burnout Dr. Fields consulted for The Coordinating Center, Millersville, MD (Medical Director), and Anchor Healthcare Services, Merrifield, VA (consultant). Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000241
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Since both work and lifestyle factors are associated with burnout, the risk for burnout differs for different specialties and work environments. Although factors associated with burnout have been investigated for many specialties, there have been few investigations of burnout in pediatric intensivists beyond the prevalence and basic demographic descriptors (4, 5). The components of burnout are incorporated into the domains of the Maslach Burnout Inventory (MBI) Scale, the methodology most commonly used in the evaluation of burnout (6). The MBI assesses the three basic domains of psychological functioning associated with burnout: emotional exhaustion (i.e., “I feel used up at the end of the workday”), depersonalization (i.e., “I feel I treat some patients as if they were impersonal objects”), and personal accomplishments (i.e., “I have accomplished many worthwhile things in this job”). Burnout represents a spectrum of severity of negative feelings in any of these domains and in the composite. In this issue of Pediatric Critical Care Medicine, Garcia et al (7) compared the prevalence of burnout and factors associated with burnout between intensivists and general pediatricians. The study population came from PICUs and outpatient departments in two regional hospitals in Brazil. Using the MBI Scale, burnout was much more frequent among pediatric intensivists October 2014 • Volume 15 • Number 8
Editorials
than general pediatricians (71% vs 29%, respectively; p < 0.01). Pediatric intensivists were more likely to develop the burnout syndrome involving all MBI domains, indicating a more severe state. The multivariate odds ratio for burnout in pediatric intensivists compared to general pediatricians was 5.7 (CI, 1.9–16.7; p < 0.01). The observation that pediatric intensivists have a higher prevalence of burnout than general pediatricians is not new (8). Since this is a study of only two sites in one country and we have little information about the working conditions in these locations, some of the effect could be parochial. Importantly, their data on personal accomplishments suggest the possibility that real or perceived factors in the workplace may be important in either mitigating burnout or protecting from the progression of the burnout syndrome. Unfortunately, there is insufficient detail to assess what these workplace factors may be. One possibility is that the intensivists worked more night and weekend shifts than the general pediatricians as this has been shown to be associated with increased burnout (9). What is the practical implication of a high burnout score? Is it a single snapshot in time? Was the scale administered after a very difficult week on call, or after a vacation? The authors did attempt to assess the chronic state by asking for frequency over the last 12 months, but this does not preclude undue influence of more recent experiences driving the participant responses. My initial national study of 474 pediatric intensivists on burnout used a different methodology, so it is not possible to make direct comparisons. However, I was always impressed by the outcomes of the two individuals with the highest scores. One, a fellow, was no longer practicing as an intensivist within a few years. The other, a very productive academic attending, continued with an extremely productive career for many more years. The latter example raises the possibility that burnout can wax and wane or that one can exist in a state of chronic burnout but with the right working conditions remain productive. What other factors may be important? The work-family conflict has received recent attention as a critical factor in the development of burnout. This conflict occurs when there are competing demands between the work and home roles of an individual, making participation in both roles more difficult. The work-family conflict occurs less in general pediatricians than pediatric subspecialists (10). Dyrbye et al (11) found that a recent work-family conflict was associated with a greater prevalence of burnout. Perhaps more importantly, resolving the work-family conflict in favor of work was associated with an increased risk for burnout. One could only wonder how these latter groups’ burnout scores may have been affected if the survey had been taken before the work-family conflict occurred. Roth et al (12) found that burnout was less in pediatric oncologists reporting satisfaction with their lives outside of work. The availability of a forum for debriefing, services for physicians affected by burnout, and less than 80% of time
Pediatric Critical Care Medicine
dedicated to clinical care were associated with lower rates of burnout. Similarly, Shanafelt et al (13) found less burnout in academic faculty who spent at least 20% of their time in “meaningful activity” as determined by the individual such as research, administration, and patient care. Further burnout research is needed. In particular, a longitudinal study of burnout would help define the onset and the ebb and flow of this state. Does the condition “wax and wane?” What are the work-related factors that are associated with the development, progression, or regression of the burnout state? What is the effectiveness of interventions aimed at preventing and treating work-related burnout? Currently, we should be aware of the known factors causing and mitigating burnout. Work-family conflict, control and autonomy in the workplace, and organizational programs for debriefing and other services for physicians may help decrease burnout. Burnout evaluations and discussions of burnout prevention, amelioration, and individual career alternatives starting early in one’s career should be included as part of the educational and workplace environment.
REFERENCES
1. Krasner MS, Epstein RM, Beckman H, et al: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009; 302:1284–1293 2. Spickard A Jr, Gabbe SG, Christensen JF: Mid-career burnout in generalist and specialist physicians. JAMA 2002; 288:1447–1450 3. Fields AI, Cuerdon TT, Brasseux CO, et al: Physician burnout in pediatric critical care medicine. Crit Care Med 1995; 23:1425–1429 4. Bustinza AA, López-Herce CJ, Carrillo ÁA, et al: Burnout among Spanish pediatricians specialized in intensive care. An Esp Pediatr 2000; 52:418–423 5. Galván ME, Vassallo JC, Rodríguez SP, et al; Members of Clinical and Epidemiological Research Group in Pediatric Intensive Care Units— Sociedad Argentina de Pediatría: Professional burnout in pediatric intensive care units in Argentina. Arch Argent Pediatr 2012; 110:466–473 6. Maslach C, Jackson SE, Leiter MP: The Maslach Burnout Inventory: Manual. Palo Alto, Consulting Psychologists Press, 1996 7. Garcia TT, Garcia PCR, Molon ME, et al: Prevalence of Burnout in Pediatric Intensivists: An Observational Comparison With General Pediatricians. Pediatr Crit Care Med 2014; 15:e347–e353 8. Shugerman R, Linzer M, Nelson K, et al; Career Satisfaction Study Group: Pediatric generalists and subspecialists: Determinants of career satisfaction. Pediatrics 2001; 108:E40 9. Rehder KJ, Cheifetz IM, Markovitz BP, et al; Pediatric Acute Lung Injury and Sepsis Investigators Network: Survey of in-house coverage by pediatric intensivists: Characterization of 24/7 in-hospital pediatric critical care faculty coverage. Pediatr Crit Care Med 2014; 15:97–104 10. Shanafelt TD, Boone S, Tan L, et al: Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; 172:1377–1385 11. Dyrbye LN, West CP, Satele D, et al: Work/home conflict and burnout among academic internal medicine physicians. Arch Intern Med 2011; 171:1207–1209 12. Roth M, Morrone K, Moody K, et al: Career burnout among pediatric oncologists. Pediatr Blood Cancer 2011; 57:1168–1173 13. Shanafelt TD, West CP, Sloan JA, et al: Career fit and burnout among academic faculty. Arch Intern Med 2009; 169:990–995
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22. Andrew M, Paes B, Johnston M: Development of the hemostatic system in the neonate and young infant. Am J Pediatr Hematol Oncol 1990; 12:95–104 23. Kher A, Al Dieri R, Hemker HC, et al: Laboratory assessment of antithrombotic therapy: What tests and if so why? Haemostasis 1997; 27:211–218 24. Spinler SA, Wittkowsky AK, Nutescu EA, et al: Anticoagulation monitoring part 2: Unfractionated heparin and low-molecular-weight heparin. Ann Pharmacother 2005; 39:1275–1285 25. Korte W, Jovic R, Hollenstein M, et al: The uncalibrated prothrombinase-induced clotting time test. Equally convenient but more precise than the aPTT for monitoring of unfractionated heparin. Hamostaseologie 2010; 30:212–216 26. Lind SE, Boyle ME, Fisher S, et al: Comparison of the aPTT with alternative tests for monitoring direct thrombin inhibitors in patient samples. Am J Clin Pathol 2014; 141:665–674 27. Maul TM, Wolff EL, Kuch BA, et al: Activated partial thromboplastin time is a better trending tool in pediatric extracorporeal membrane oxygenation. Pediatr Crit Care Med 2012; 13:e363–e371 28. Liveris A, Bello RA, Friedmann P, et al: Anti-factor Xa assay is a superior correlate of heparin dose than activated partial thromboplastin time or activated clotting time in pediatric extracorporeal membrane oxygenation. Pediatr Crit Care Med 2014; 15:e72–e79 29. Irby K, Swearingen C, Byrnes J, et al: Unfractionated heparin activity measured by anti-factor xa levels is associated with the need for extracorporeal membrane oxygenation circuit/membrane oxygenator change: A retrospective pediatric study. Pediatr Crit Care Med 2014; 15:e175–e182 30. Nguyen T, Musick M, Teruya J: Anticoagulation monitoring during extracorporeal membrane oxygenation: Is anti-factor Xa assay (heparin level) a better test? Pediatr Crit Care Med 2014; 15:178–179
Do You Smell Something Burning? Could It Be You?* Alan I. Fields, MD, MCCM Clinical Resource Management Children’s National Washington, DC
B
urnout is a state of chronic psychological stress with long-term exhaustion and diminished interest in work. Burnout may interfere with personal and job satisfaction and is associated with decreased job performance and dysfunctional professional relationships. For physicians, this may involve performance issues such as medical errors and relationships with patients and families (1, 2). Since the first publication on burnout in pediatric intensivists almost 2 decades ago (3), there has been a growing literature on physician burnout. *See also p. e347. Key Words: burnout; family conflict; pediatric intensivists; pediatricians; risk of burnout Dr. Fields consulted for The Coordinating Center, Millersville, MD (Medical Director), and Anchor Healthcare Services, Merrifield, VA (consultant). Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000241
788
www.pccmjournal.org
Since both work and lifestyle factors are associated with burnout, the risk for burnout differs for different specialties and work environments. Although factors associated with burnout have been investigated for many specialties, there have been few investigations of burnout in pediatric intensivists beyond the prevalence and basic demographic descriptors (4, 5). The components of burnout are incorporated into the domains of the Maslach Burnout Inventory (MBI) Scale, the methodology most commonly used in the evaluation of burnout (6). The MBI assesses the three basic domains of psychological functioning associated with burnout: emotional exhaustion (i.e., “I feel used up at the end of the workday”), depersonalization (i.e., “I feel I treat some patients as if they were impersonal objects”), and personal accomplishments (i.e., “I have accomplished many worthwhile things in this job”). Burnout represents a spectrum of severity of negative feelings in any of these domains and in the composite. In this issue of Pediatric Critical Care Medicine, Garcia et al (7) compared the prevalence of burnout and factors associated with burnout between intensivists and general pediatricians. The study population came from PICUs and outpatient departments in two regional hospitals in Brazil. Using the MBI Scale, burnout was much more frequent among pediatric intensivists October 2014 • Volume 15 • Number 8
Editorials
than general pediatricians (71% vs 29%, respectively; p < 0.01). Pediatric intensivists were more likely to develop the burnout syndrome involving all MBI domains, indicating a more severe state. The multivariate odds ratio for burnout in pediatric intensivists compared to general pediatricians was 5.7 (CI, 1.9–16.7; p < 0.01). The observation that pediatric intensivists have a higher prevalence of burnout than general pediatricians is not new (8). Since this is a study of only two sites in one country and we have little information about the working conditions in these locations, some of the effect could be parochial. Importantly, their data on personal accomplishments suggest the possibility that real or perceived factors in the workplace may be important in either mitigating burnout or protecting from the progression of the burnout syndrome. Unfortunately, there is insufficient detail to assess what these workplace factors may be. One possibility is that the intensivists worked more night and weekend shifts than the general pediatricians as this has been shown to be associated with increased burnout (9). What is the practical implication of a high burnout score? Is it a single snapshot in time? Was the scale administered after a very difficult week on call, or after a vacation? The authors did attempt to assess the chronic state by asking for frequency over the last 12 months, but this does not preclude undue influence of more recent experiences driving the participant responses. My initial national study of 474 pediatric intensivists on burnout used a different methodology, so it is not possible to make direct comparisons. However, I was always impressed by the outcomes of the two individuals with the highest scores. One, a fellow, was no longer practicing as an intensivist within a few years. The other, a very productive academic attending, continued with an extremely productive career for many more years. The latter example raises the possibility that burnout can wax and wane or that one can exist in a state of chronic burnout but with the right working conditions remain productive. What other factors may be important? The work-family conflict has received recent attention as a critical factor in the development of burnout. This conflict occurs when there are competing demands between the work and home roles of an individual, making participation in both roles more difficult. The work-family conflict occurs less in general pediatricians than pediatric subspecialists (10). Dyrbye et al (11) found that a recent work-family conflict was associated with a greater prevalence of burnout. Perhaps more importantly, resolving the work-family conflict in favor of work was associated with an increased risk for burnout. One could only wonder how these latter groups’ burnout scores may have been affected if the survey had been taken before the work-family conflict occurred. Roth et al (12) found that burnout was less in pediatric oncologists reporting satisfaction with their lives outside of work. The availability of a forum for debriefing, services for physicians affected by burnout, and less than 80% of time
Pediatric Critical Care Medicine
dedicated to clinical care were associated with lower rates of burnout. Similarly, Shanafelt et al (13) found less burnout in academic faculty who spent at least 20% of their time in “meaningful activity” as determined by the individual such as research, administration, and patient care. Further burnout research is needed. In particular, a longitudinal study of burnout would help define the onset and the ebb and flow of this state. Does the condition “wax and wane?” What are the work-related factors that are associated with the development, progression, or regression of the burnout state? What is the effectiveness of interventions aimed at preventing and treating work-related burnout? Currently, we should be aware of the known factors causing and mitigating burnout. Work-family conflict, control and autonomy in the workplace, and organizational programs for debriefing and other services for physicians may help decrease burnout. Burnout evaluations and discussions of burnout prevention, amelioration, and individual career alternatives starting early in one’s career should be included as part of the educational and workplace environment.
REFERENCES
1. Krasner MS, Epstein RM, Beckman H, et al: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009; 302:1284–1293 2. Spickard A Jr, Gabbe SG, Christensen JF: Mid-career burnout in generalist and specialist physicians. JAMA 2002; 288:1447–1450 3. Fields AI, Cuerdon TT, Brasseux CO, et al: Physician burnout in pediatric critical care medicine. Crit Care Med 1995; 23:1425–1429 4. Bustinza AA, López-Herce CJ, Carrillo ÁA, et al: Burnout among Spanish pediatricians specialized in intensive care. An Esp Pediatr 2000; 52:418–423 5. Galván ME, Vassallo JC, Rodríguez SP, et al; Members of Clinical and Epidemiological Research Group in Pediatric Intensive Care Units— Sociedad Argentina de Pediatría: Professional burnout in pediatric intensive care units in Argentina. Arch Argent Pediatr 2012; 110:466–473 6. Maslach C, Jackson SE, Leiter MP: The Maslach Burnout Inventory: Manual. Palo Alto, Consulting Psychologists Press, 1996 7. Garcia TT, Garcia PCR, Molon ME, et al: Prevalence of Burnout in Pediatric Intensivists: An Observational Comparison With General Pediatricians. Pediatr Crit Care Med 2014; 15:e347–e353 8. Shugerman R, Linzer M, Nelson K, et al; Career Satisfaction Study Group: Pediatric generalists and subspecialists: Determinants of career satisfaction. Pediatrics 2001; 108:E40 9. Rehder KJ, Cheifetz IM, Markovitz BP, et al; Pediatric Acute Lung Injury and Sepsis Investigators Network: Survey of in-house coverage by pediatric intensivists: Characterization of 24/7 in-hospital pediatric critical care faculty coverage. Pediatr Crit Care Med 2014; 15:97–104 10. Shanafelt TD, Boone S, Tan L, et al: Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; 172:1377–1385 11. Dyrbye LN, West CP, Satele D, et al: Work/home conflict and burnout among academic internal medicine physicians. Arch Intern Med 2011; 171:1207–1209 12. Roth M, Morrone K, Moody K, et al: Career burnout among pediatric oncologists. Pediatr Blood Cancer 2011; 57:1168–1173 13. Shanafelt TD, West CP, Sloan JA, et al: Career fit and burnout among academic faculty. Arch Intern Med 2009; 169:990–995
www.pccmjournal.org
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