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首页> 外文期刊>The Journal of Graduate Medical Education >Wellness in Graduate Medical Education: Is It Time to Pull the Andon Cord?
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Wellness in Graduate Medical Education: Is It Time to Pull the Andon Cord?

机译：毕业生医学教育的健康：是时候拉onon绳子了吗？

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An Andon is a traditional Japanese lantern. Japanese lore recounts tales of fishermen, returning to their villages at night, who would light the Andon aboard their boats to signal the need for help. Originating within Japanese manufacturing and today's continuous improvement lexicon, “pulling the Andon cord” refers to a call for help to say “I can't do my job.” It is meant to authorize and empower the individual to immediately stop processes, activate management to investigate and intervene on the problem, and thus allow the individual to function optimally. As mentioned in the article by Ey et al1 in this issue of the Journal of Graduate Medical Education, prevalence of depression, burnout, and suicidality among medical students and resident trainees continues to outpace the general population, with nearly 50% to 70% of residents exhibiting burnout symptoms and 6% to 12% reporting suicidal ideation. Emotional exhaustion and increased depersonalization are rising among faculty in their first few years of practice as well.2 We need to shift from building resilience, an attempt to mitigate the effects of a chaotic and depleting clinical environment, toward improving the clinical learning environment for faculty, patients, and trainees alike. The MEMO (Minimizing Error, Maximizing Outcome) Investigators first described the need for the creation of “healthy workplaces”—the type of environment that can sustain providers and patients—to mitigate burnout in primary care settings.3 Although the study focused on 119 primary care clinics in 5 regions, the results may be generalizable to the larger graduate medical education environment. The MEMO team identified several themes that were associated with increasing emotional exhaustion in providers: (1) adverse work conditions (eg, work intensity); (2) autonomy and control; and (3) unfavorable culture (eg, trust, alignment of values with leadership, cohesiveness). Although these key triggers were associated with faculty burnout, they also may serve as a starting place for burnout in trainees.;Adverse Work Conditions The enactment of the duty hour limits has reduced hours, but has also contributed to increasing work intensity during work hours. More and more complex patient conditions, with shorter lengths of stay, stringent documentation requirements, and complex electronic health record systems, contribute to high work intensity. The demand for trainees to populate patient data for regulatory requirements or reimbursement rather than for clinical decision making, in tightly controlled shifts or clinic visits, leaves little time for connecting with patients, synthesizing information, and reflection. Cognitive overload and subsequent decision fatigue are likely contributors to burnout and emotional exhaustion.4 Redesign of workflows that incorporate the entire care team, rather than placing work primarily on the shoulders of the provider, is critical. Emphasizing education over service may also result in a different prioritization and delegation of tasks.;Autonomy and Control Early research from the social sciences has introduced the “demand control” model of job stress, which has shown convincingly that lack of control leads to high stress and adverse outcomes for workers.5 In the review article in this issue, Raj2 notes that a sense of control and autonomy, as well as pursuit and achievement of goals, correlates with greater resident well-being. The adoption of competency-based medical education and entrustable professional activities allows for individualized growth and development. However, the trainee role within the health care system or local clinical environment often lacks control. Institutional metrics, workflows, and standard processes are often prescriptive and rigid. This careful balance between standardization and autonomy must be sensitive to trainees' need to learn and develop. Careful attention to what work should be discontinued, or shifted to other members of the care tea
机译：安通是传统的日本灯笼。日本幽默叙述了渔民的故事，晚上回到了他们的村庄，谁会照亮安蒙船，以发出帮助的需求。起源于日本制造业和今天的持续改进词典，“拉动安乐绳”是指帮助说“我不能完成工作”。它旨在授权和授权个人立即停止流程，激活管理以调查和干预问题，从而让个人最佳地运作。如本问题在此问题上提到的研究生医学教育杂志，医学生和居民学员的抑郁症，倦怠和自杀的患病率继续超过一般人群，近50％至70％的居民表现出倦怠症状和6％至12％报告的自杀式思想。在他们的前几年的实践中，情感疲惫和额外的职位化在教职员工中升起.2我们需要从建筑恢复力转向，试图减轻混乱和消耗临床环境的影响，从而改善教师的临床学习环境，患者和学员都一样。备忘录（最小化错误，最大化结果）调查人员首先介绍了创建“健康工作场所”的必要性 - 可以维持提供者和患者的环境类型 - 在初级保健设置中减轻倦怠.3虽然该研究专注于119主要在5个地区的护理诊所，结果可能是普遍的毕业生医学教育环境。备忘录团队确定了几个与提供者中情绪耗尽相关的主题：（1）不利的工作条件（例如，工作强度）; （2）自治和控制; （3）不利的文化（例如，信任，与领导，凝聚力的值对齐）。虽然这些关键触发器与教师有关，但它们也可以作为培训人员的起始地点。;不利的工作条件，税率限制的制定减少了数小时，但也有助于增加工作时间的工作强度。越来越复杂的患者条件，具有较短的住宿时间，严格的文档要求和复杂的电子健康记录系统，有助于高工作强度。对学员的需求填充监管要求或报销的患者数据，而不是用于临床决策，在紧密控制的班次或临床访问中，留下与患者连接的时间很少，合成信息和反思。认知过载和随后的决策疲劳是倦怠和情感疲惫的贡献者.4重新设计整个护理团队的工作流程，而不是主要在提供者的肩膀上放置工作至关重要。强调服务教育也可能导致各种优先级和任务授权。;社会科学的自治和控制早期研究介绍了“需求控制”的工作压力模型，这表明缺乏控制导致高压力导致高压力对于工人的不利结果.5在本期审查文章中，RAJ2注意到控制和自主权，以及追求和实现目标，与更大的居民福祉相关联。采用基于能力的医学教育和委托的专业活动允许个性化的增长和发展。然而，医疗保健系统或地方临床环境中的实习角色往往缺乏控制。机构指标，工作流程和标准流程通常是规范性和刚性的。标准化和自主性之间的仔细平衡必须对学员的学习和发展需要敏感。仔细注意应该停止的工作，或转移到照顾茶的其他成员

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