Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

There are few articles that describe the clinical or educational effectiveness of residents' participation in QI efforts; the authors describe barriers that may be partly responsible. They conclude that there is a great need for additional research on the effectiveness of residents' participation in QI initiatives, particularly as they affect patient health outcomes.

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Although the published literature on this topic is limited, those articles that exist identify barriers that make residents reluctant to engage in institutional error identification and/or reduction. Key factors identified included a fear of retribution and the perception of residents as transient care providers. Whereas several countermeasures have been promulgated, the literature reveals scant evidence of their effectiveness. Institutions should recognize and capitalize on the unique experiences of residents and their potential to become owners in patient safety initiatives.

Background: Clinician burnout in hospice and palliative care (HPC) has potentially widespread negative consequences including increased clinical errors, decreased professionalism, decreased staff retention, and decreased empathy. Reading non-medical literature has been associated with increased empathy, but no studies on the effect of reading on burnout have previously been conducted. We wished to assess reading patterns of practicing HPC clinicians and determine associations between non-medical reading and burnout.Methods: Sixteen-item electronic survey regarding reading practices, exposure to non-medical literature, fatigue, quality of life, and burnout symptoms was administered to members of the American Academy of Hospice and Palliative Medicine. Burnout measures of emotional exhaustion and depersonalization were assessed by the validated 2-item Maslach Burnout Inventory. Data were analyzed using descriptive statistics and multivariate regression.Results: Seven hundred nine members responded (15.2% response rate), of which 129 (18.2%) met the criteria for burnout, with 117 (16.6%) meeting the criteria for high emotional exhaustion and 45 (6.3%) meeting the criteria for high depersonalization. On univariate analysis, burnout was associated with age, reading habits, and fatigue, but not years in practice. On multivariable logistic regression consistent readers had decreased odds of overall burnout compared to inconsistent readers (OR 0.61; 95% CI, 0.39-0.97, P=0.036). This was true across the depersonalization (OR 0.58; 95% CI, 0.36-0.93, P=0.025), but not the emotional exhaustion domain. Conclusions:Reading non-medical literature on a consistent basis may be associated with a significantly decreased likelihood of burnout, specifically across the depersonalization domain.

Portfolios have emerged in graduate medical education despite lack of consensus on their definition, purpose, or usefulness. Portfolios can be used as a tool for residents to record their accomplishments, reflect on their experiences, and gain formative feedback. This exercise may help prepare physicians for lifelong learning as well as enhance patient care. The Accreditation Council for Graduate Medical Education has endorsed and may soon require the use of portfolios as an assessment tool to evaluate resident competence. However, using portfolios for summative evaluation purposes such as making high-stakes decisions on resident promotion or matriculation may deter resident candidness. In addition, the use of portfolios in clinical settings raises issues unique to the health care setting such as patient privacy, disclosure of clinical information, and professional liability exposure of physicians. It is not clear that peer-review statutes that sometimes protect educational materials used in teaching and evaluation of residents would also bar disclosure and/or evidentiary use of portfolio contents. Is the teaching institution, resident, or graduate vulnerable to requests and subpoenas for the portfolio contents? If so, then a resident's documentation of insecurities, suboptimal performance, or bad outcomes would be ripe for discovery in a medical malpractice lawsuit. If embraced too quickly and without sufficient reflection on the nuances of implementation, this well-intentioned initiative may present unintended legal consequences.

The high prevalence of physician burnout is of great concern and may begin with observed declines in empathy and increases in stress and burnout in medical and health professions students. While underlying causes have been described, there is less certainty on how to create effective interventions in curricula and workplace. In October 2015, The Center for Innovation and Leadership in Education (CENTILE) at Georgetown University, together with MedStar Health, Georgetown's clinical partner, and six academic institutions sponsored a conference in Washington, DC. The goal was to discuss the current state of stress and burnout in the health professions, and to share best practices on strategies to promote resilience, empathy and well-being in students, residents, faculty and practitioners across health professions. In this issue of Medical Teacher, three articles address pertinent themes of the conference. Maslach and Leiter provide insights into burnout and strategies to alleviate it. Ekman and Krasner discuss various types of empathy and how neuroscience can be used to effectively cultivate empathy. In the third paper, Kreitzer and Klatt highlight three successful curricular interventions that foster self-awareness and boost resilience. Ultimately, effective strategies will be needed to address this issue at both the individual and organizational levels.

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