Working conditions in primary care: physician reactions and care quality.

BACKGROUND: Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. OBJECTIVE: To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care. DESIGN: Cross-sectional analysis. SETTING: 119 ambulatory clinics in New York, New York, and in the upper Midwest. PARTICIPANTS: 422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure. MEASUREMENTS: Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits). RESULTS: More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors. LIMITATION: The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician. CONCLUSION: Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.

Physician perspectives on quality and error in the outpatient setting.

CONTEXT: Little is known about the influence of the primary care workplace on patient care. Assessing physician opinion through focus groups can elucidate factors related to safety and error in this setting. METHOD: During phase 1 of the Minimizing Error, Maximizing Outcome (MEMO) Study, 9 focus groups were conducted with 32 family physicians and general internists from 5 areas in the upper Midwest and New York City. RESULTS: The physicians described challenging settings with rapidly changing conditions. Patients are medically and psychosocially complex and often underinsured. Communication is complicated by multiple languages, time pressure, and inadequate information systems. Complex processes of care have missing elements including medication lists and test results. Physicians are pressed to be more productive, and key administrative decisions are made without their input. Targeted areas to improve safety and reduce error included teamwork, aligned leadership values, diversity, collegiality, and respect. CONCLUSIONS: Primary care physicians clearly described positive and negative workplace factors related to safety and error. The themes suggest that systems of care and their dynamic nature warrant attention. Enhancing positive and ameliorating negative cultures and processes of care could bring real benefits to patients, physicians, and ambulatory office settings.

Part-time physicians...prevalent, connected, and satisfied.

OBJECTIVE: The health care workforce is evolving and part-time practice is increasing. The objective of this work is to determine the relationship between part-time status, workplace conditions, and physician outcomes. DESIGN: Minimizing error, maximizing outcome (MEMO) study surveyed generalist physicians and their patients in the upper Midwest and New York City. MEASUREMENTS AND MAIN RESULTS: Physician survey of stress, burnout, job satisfaction, work control, intent to leave, and organizational climate. Patient survey of satisfaction and trust. Responses compared by part-time and full-time physician status; 2-part regression analyses assessed outcomes associated with part-time status. Of 751 physicians contacted, 422 (56%) participated. Eighteen percent reported part-time status (n = 77, 31% of women, 8% of men, p < .001). Part-time physicians reported less burnout (p < .01), higher satisfaction (p < .001), and greater work control (p < .001) than full-time physicians. Intent to leave and assessments of organizational climate were similar between physician groups. A survey of 1,795 patients revealed no significant differences in satisfaction and trust between part-time and full-time physicians. CONCLUSIONS: Part-time is a successful practice style for physicians and their patients. If favorable outcomes influence career choice, an increased demand for part-time practice is likely to occur.

Impact of Work Conditions and Minority Patient Populations on Quality and Errors.

OBJECTIVES: To determine whether workplace conditions affect care quality and errors, especially in primary care clinics serving minority patients. METHODS: We conducted a 3-year assessment of work conditions and patient outcomes in 73 primary care clinics in the upper Midwest and New York City. Study participants included 287 physicians and 1204 patients with hypertension and/or diabetes. Chart audit data were contrasted between clinics with ≥30% minority patients (minority-serving clinics, or MSCs) and those with <30% (nonminority-serving clinics, or NMSCs). Physicians reported on time pressure, work control, clinical resources, and specialty referral access; managers described room availability; and chart audits determined care errors and quality. Two-level hierarchical models tested work conditions as mediators between MSC status and clinical outcomes. RESULTS: Error rates were higher in MSCs than NMSCs (29.6% vs 24.8%, P < .05). Lack of clinical resources explained 41% of the effect of MSC status on errors (P < .05). Diabetes control was poorer in MSCs than in NMSCs (53.8% controlled vs 76.1%, P < .05); lack of clinical resources explained 24% of this difference (P < .05). Room availability increased quality in both MSCs and NMSCs by 5.95% for each additional room per clinician per session. Lack of access to rooms and specialists decreased the likelihood of blood pressure control in MSCs. CONCLUSION: Work conditions such as clinical resources, examination room availability, and access to referrals are significantly associated with errors and quality, especially in MSCs.

Difficult Dialogues: Negotiating Faculty Responses to a Gender Bias Literacy Training Program.

Diversity training is challenging and can evoke strong emotional responses from participants including resistance, shame, confusion, powerlessness, defensiveness, and anger. These responses create complex situations for both presenters and other learners. We observed 3 experienced presenters as they implemented 41 gender bias literacy workshops for 376 faculty from 42 STEMM (science, technology, engineering, mathematics, medicine) departments at one Midwestern university. We recorded questions and answers as well as participants' non-verbal activity during each 2.5-hour workshop. Employing content analysis and critical incident technique, we identified content that elicited heightened activity and challenging dialogues among presenters and faculty. Results from analysis of this observational data found three important findings: (1) presenters continually reinforced the idea that implicit bias is ordinary and pervasive, thus avoiding participant alienation by allowing participants to protect their self-worth and integrity; (2) difficult dialogues were managed calmly without verbal sparring or relinquishing control; (3) the presenters created an environment where individuals were more likely to accept threatening information.

Brief physician advice for problem drinking among older adults: an economic analysis of costs and benefits.

OBJECTIVE: Problem alcohol use among elderly persons can have a variety of health-related consequences, complicating management of chronic illnesses and increasing health care utilization and costs. This study evaluates the economic cost and benefits of brief intervention for at-risk drinking older adults. METHOD: A controlled clinical trial with 24-month follow-up tested effectiveness of brief physician advice in reducing alcohol use, health care utilization and other consequences among older (age 65 or older) adult problem drinkers. Of 6,073 patients screened for problem drinking in 24 community-based primary care practices in Wisconsin, 158 patients met inclusion criteria and were randomized into control (n = 71) or intervention (n = 87) groups. Intervention group patients received two 10- to 15-minute physician-delivered counseling sessions including professional advice, education and contracting using scripted workbooks. RESULTS: The intervention group demonstrated significant reductions in alcohol use (p = 0.001) and frequency of excessive drinking (p = 0.03) compared with the control group over 24 months, but no significant differences emerged in economic outcomes, including hospital days, emergency department visits, office visits, medications, lab and x-ray procedures, injuries, legal events or mortality. CONCLUSIONS: Although the clinical benefits of brief alcohol interventions with older adults are clear, the economic results in this age group are less certain. Older adult problem drinkers may require more intensive and costly interventions to achieve economic benefits similar to those seen in younger adult problem drinkers. Methodological issues, such as statistical power, outcome measures, outlier cases and follow-up periods, are identified for future evaluations.

Urban outpatient views on quality and safety in primary care.

OBJECTIVE: The Minimizing Errors Maximizing Outcomes Study is designed to examine the effect of workplace conditions on quality of care and medical errors. In the first phase of the study, patients were asked to "tell their stories" via focus groups. DESIGN: Moderators used a standard question guide. Researchers read the transcripts independently and reached consensus on major themes. Two coders independently assigned transcript statement to themes. SETTING: Three focus groups were conducted in three cities, including 21 patients from three clinics. PATIENTS: Patients with previously scheduled appointments at participating clinics were invited to join the focus groups. MEASUREMENTS AND MAIN RESULTS: Agreement between the two coders was 77.5% (kappa value 0.66). All but 2% of 187 distinct comments could be grouped into four categories: (1) Systems Issues (44% of comments). Long waits for providers and lack of access were the most common frustrations. Understaffing, underfunding and lack of health insurance were perceived as contributing to poor quality of care; (2) Interpersonal Skills (37%). Physician listening skills were valued. Participants felt patient attitudes affected care. (3) Knowledge and Technical Skills (9%). (4) Errors (7%). Medication errors, errors of inattention and technical errors were discussed. CONCLUSIONS: Patients provide important insights into complex systems issues, which can guide planners in improving quality and reducing errors. According to focus group participants, healthcare could be improved and made safer by increasing timely access to patients' own physicians, decreasing the time patients spend in waiting rooms, and adding staff to double-check prescriptions.

Medical Education About the Care of Addicted Incarcerated Persons: A National Survey of Residency Programs.

In June 1998, there were 1.8 million inmates in correctional facilities for adults; 1.2 million in state and federal prisons and 600,000 in municipal/county jails (668 persons per 100,000 U.S. population). Rates of TB, AIDS, mental illness, and substance abuse are 2-13 times higher in persons living in jails and prisons. This study was designed to assess the level of training offered to residents in seven medical specialties in the care of addicted incarcerated persons. The study design involved two stages. The first entailed a mailed survey to 1,831 residency directors in family medicine, internal medicine, osteopathic medicine, pediatrics, obstetrics and gynecology, psychiatry, and emergency medicine. The second stage was a telephone interview, about substance use disorders, of faculty listed by the residency directors as teaching residents. The mailed survey was completed by 1,205 residency directors (66%). The 769 faculty from those identified programs, who participated in the telephone interview, reported that only 14% of their residency programs offered lectures or conferences on the care of incarcerated persons, yet 44% of the programs had residents caring for incarcerated persons with substance abuse problems, in a clinical setting. Only 22% offered clinical experiences for residents in a correctional facility.We recognize that our survey of correctional health and substance abuse training is limited, but as such, a greater number of respondents to our survey do not teach residents addiction medicine topics pertaining to prevention, evaluation, intervention, and management of the addicted criminal offender/patient in a correctional setting or give adequate clinical exposure to this special population. The data suggests a need to develop and implement educational programs on medical care for this high-risk and expanding population.

Electronic medical records and physician stress in primary care: results from the MEMO Study.

BACKGROUND: Little has been written about physician stress that may be associated with electronic medical records (EMR). OBJECTIVE: We assessed relationships between the number of EMR functions, primary care work conditions, and physician satisfaction, stress and burnout. DESIGN AND PARTICIPANTS: 379 primary care physicians and 92 managers at 92 clinics from New York City and the upper Midwest participating in the 2001-5 Minimizing Error, Maximizing Outcome (MEMO) Study. A latent class analysis identified clusters of physicians within clinics with low, medium and high EMR functions. MAIN MEASURES: We assessed physician-reported stress, burnout, satisfaction, and intent to leave the practice, and predictors including time pressure during visits. We used a two-level regression model to estimate the mean response for each physician cluster to each outcome, adjusting for physician age, sex, specialty, work hours and years using the EMR. Effect sizes (ES) of these relationships were considered small (0.14), moderate (0.39), and large (0.61). KEY RESULTS: Compared to the low EMR cluster, physicians in the moderate EMR cluster reported more stress (ES 0.35, p=0.03) and lower satisfaction (ES -0.45, p=0.006). Physicians in the high EMR cluster indicated lower satisfaction than low EMR cluster physicians (ES -0.39, p=0.01). Time pressure was associated with significantly more burnout, dissatisfaction and intent to leave only within the high EMR cluster. CONCLUSIONS: Stress may rise for physicians with a moderate number of EMR functions. Time pressure was associated with poor physician outcomes mainly in the high EMR cluster. Work redesign may address these stressors.

Male Spouses of Women Physicians: Communication, Compromise, and Carving Out Time.

As the numbers of female physicians continue to grow, fewer medical marriages are comprised of the traditional dyad of male physician and stay-at-home wife. The "two-career family" is an increasingly frequent state for both male and female physicians' families, and dual-doctor marriages are on the rise. This qualitative study explored the contemporary medical marriage from the perspective of male spouses of female physicians. In 2010, we conducted semi-structured, in-depth interviews with nine spouses of internal medicine resident and faculty physicians. Interviewers queried work-home balance, career choices, and support networks. We used an interpretive, inductive, iterative approach to thematically analyze interview transcripts and develop broad, consensus-derived themes. A conceptual framework based on three major themes emerged: "A time for us? Really?", "Supporting and protecting her, sometimes at my expense,'" and "Hers is a career, mine is a job." This framework described the inflexibility of physicians' time and its impact on spousal time, career development, and choices. Having a set time for synchronizing schedules, frequent verbal support, and shared decision-making were seen as important by the husbands of female, full-time physicians. This exploratory study examined the contemporary medical marriage from the male spouse's perspective and highlights specific strategies for success.

Does a higher frequency of difficult patient encounters lead to lower quality care?

BACKGROUND: Difficult patient encounters in the primary care office are frequent and are associated with physician burnout. However, their relationship to patient care outcomes is not known. OBJECTIVE: To determine the effect of difficult encounters on patient health outcomes and the role of physician dissatisfaction and burnout as mediators of this effect. DESIGN: A total of 422 physicians were sorted into 3 clusters based on perceived frequency of difficult patient encounters in their practices. Patient charts were audited to assess the quality of hypertension and diabetes management and preventive care based on national guidelines. Summary measures of quality and errors were compared among the 3 physician clusters. RESULTS: Of the 1384 patients, 359 were cared for by high-cluster physicians (those who had a high frequency of difficult encounters), 871 by medium-cluster physicians, and 154 by low-cluster physicians. Dissatisfaction and burnout were higher among physicians reporting higher frequencies of difficult encounters. However, quality of patient care and management errors were similar across all 3 groups. CONCLUSIONS: Physician perception of frequent difficult encounters was not associated with worse patient care quality or more medical errors. Future studies should investigate whether other patient outcomes, including acute care and patient satisfaction, are affected by difficult encounters.

Promoting Institutional Change Through Bias Literacy.

The National Science Foundation and others conclude that institutional transformation is required to ensure equal opportunities for the participation and advancement of men and women in academic science, technology, engineering, mathematics, and medicine (STEMM). Such transformation requires changing the habitual attitudes and behaviors of faculty. Approaching implicit bias as a remediable habit, we present the theoretical basis and conceptual model underpinning an educational intervention to promote bias literacy among university faculty as a step toward institutional transformation regarding gender equity. We describe the development and implementation of a Bias Literacy Workshop in detail so others can replicate or adapt it to their setting. Of the 220 (167 faculty and 53 nonfaculty) attendees from the initial 17 departments/divisions offered this workshop, all 180 who completed a written evaluation found the workshop at least "somewhat useful" and 74% found it "very useful." Over 68% indicated increased knowledge of the workshop material. Of the 186 participants who wrote a commitment to engage in new activities to promote gender equity, 87% incorporated specific workshop content. Twenty-four participants were interviewed 4-6 months after attending the workshop; 75% of these not only demonstrated increased bias awareness, but described plans to change-or had actually changed-behaviors because of the workshop. Based on our sample of faculty from a Midwestern university, we conclude that at least one third of STEMM faculty who are invited will attend a 2.5-hr Bias Literacy Workshop, that nearly all will find it useful, and that most will complete a written commitment to promoting gender equity. These findings suggest that this educational intervention may effectively promote institutional change regarding gender equity.

Separate and unequal: clinics where minority and nonminority patients receive primary care.

BACKGROUND: Few studies have examined the influence of physician workplace conditions on health care disparities. We compared 96 primary care clinics in New York, New York, and in the upper Midwest serving various proportions of minority patients to determine differences in workplace organizational characteristics. METHODS: Cross-sectional data are from surveys of 96 clinic managers, 388 primary care physicians, and 1701 of their adult patients with hypertension, diabetes mellitus, or congestive heart failure participating in the Minimizing Error, Maximizing Outcome (MEMO) study. Data from 27 clinics with at least 30% minority patients were contrasted with data from 69 clinics with less than 30% minority patients. RESULTS: Compared with clinics serving less than 30% minority patients, clinics serving at least 30% minority patients have less access to medical supplies (2.7 vs 3.4, P < .001), referral specialists (3.0 vs 3.5, P < .005) on a scale of 1 (none) to 4 (great), and examination rooms per physician (2.2 vs 2.7, P =.002) . Their patients are more frequently depressed (22.8% vs 12.1%), are more often covered by Medicaid (30.2% vs 11.4%), and report lower health literacy (3.7 vs 4.4) on a scale of 1 (low) to 5 (high) (P < .001 for all). Physicians from clinics serving higher proportions of minority populations perceive their patients as frequently speaking little or no English (27.1% vs 3.4%, P =.004), having more chronic pain (24.1% vs 12.9%, P < .001) and substance abuse problems (15.1% vs 10.1%, P =.005), and being more medically complex (53.1% vs 39.9%) and psychosocially complex (44.9% vs 28.2%) (P < .001 for both). In regression analyses, clinics with at least 30% minority patients are more likely to have chaotic work environments (odds ratio, 4.0; P =.003) and to have fewer physicians reporting high work control (0.2; P =.003) or high job satisfaction (0.4; P =.01). CONCLUSION: Clinics serving higher proportions of minority patients have more challenging workplace and organizational characteristics.

The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.

BACKGROUND: A report by the Institute of Medicine suggests that changing the culture of health care organizations may improve patient safety. Research in this area, however, is modest and inconclusive. Because culture powerfully affects providers, and providers are a key determinant of care quality, the MEMO study (Minimizing Error, Maximizing Outcome) introduces a new model explaining how physician work attitudes may mediate the relationship between culture and patient safety. RESEARCH QUESTIONS: (1) Which cultural conditions affect physician stress, dissatisfaction, and burnout? and (2) Do stressed, dissatisfied, and burned out physicians deliver poorer quality care? METHODS: A conceptual model incorporating the research questions was analyzed via structural equation modeling using a sample of 426 primary care physicians participating in MEMO. FINDINGS: Culture, overall, played a lesser role than hypothesized. However, a cultural emphasis on quality played a key role in both quality outcomes. Further, we found that stressed, burned out, and dissatisfied physicians do report a greater likelihood of making errors and more frequent instance of suboptimal patient care. PRACTICE IMPLICATIONS: Creating and sustaining a cultural emphasis on quality is not an easy task, but is worthwhile for patients, physicians, and health care organizations. Further, having clinicians who are satisfied and not burned out or stressed contributes substantially to the delivery of quality care.

An interdisciplinary faculty development model for the prevention and treatment of alcohol use disorders.

BACKGROUND: The skills of faculty working in health fields are inadequate to meet the needs of those adversely affected by alcohol. This project was designed to increase the teaching, clinical, and research activities of faculty from multiple disciplines at the university level. METHODS: The faculty development model included two 2-day skills-based courses held 6 months apart, precourse and postcourse evaluations, active mentoring, and development of a specific work plan for each participant. The educational model utilized skills-based courses previously developed for full-time clinical/teaching medical faculty with limited time and resources. RESULTS: A total of 153 participants at 6 locations completed the courses; 131 completed the 6-month follow-up interview. Sixty-four designed teaching, clinical, or research projects during the 6-month period between the first and second courses. Precourse versus postcourse clinical scores from standardized patient encounters showed highly significant improvements in screening, brief intervention, and motivational interviewing skills (p<0.001). At the 6-month follow-up interview, 61% of the participants reported teaching on alcohol, tobacco, or drug problems; 49% reported clinical activities in this area; 36% reported conducting research; 10% had submitted manuscripts for publication; 12% had submitted grant applications; and 32% percent had sought additional AODA training. Participants gave high scores to all components of the faculty development model; 81% would repeat the training and 98% would recommend the program to colleagues. CONCLUSIONS: This cost-effective faculty development program can serve as a model to increase educational programs on substance abuse at public universities, increase faculty research activities in the alcohol area, and increase clinical programs in university hospitals.

Prevalence of tobacco and alcohol use disorders in Polish primary care settings.

BACKGROUND: Primary care settings are an ideal system in which to identify and treat tobacco and alcohol use disorders. This project surveyed patients from the offices of 20 Polish primary care clinicians to ascertain the prevalence of tobacco and alcohol use by gender and age. METHODS: A total of 4373 adults aged 18-80 years seeking routine care completed a nurse-administered Health Screening Survey as part of a clinical trial designed to assess the efficacy of brief physician advice on heavy alcohol use. RESULTS: Of the 4373 subjects screened, 44.4% reported cigarette use within the past three months. Most perceived smoking as a problem and had considered reducing their tobacco use. A stepwise model to examine factors that predict smoking status found that alcohol consumption was the best predictor of current cigarette use. Alcohol consumption was common, with 64% of the subjects reporting some use within the previous three months. Of these, 55% were classified as low risk drinkers, 14% as at-risk drinkers, 12% as problem drinkers, and 19% as dependent drinkers. CONCLUSION: This is the first report on the combined prevalence of tobacco and alcohol use disorders in a sample of persons attending community-based primary care clinics in Poland. This report confirms the high prevalence of these problems and suggests that patients will accurately complete a screening test such as the Health Screening Survey. The methods employed for this study provide the Polish health care system with a procedure to effectively screen patients for tobacco and alcohol use disorders.

Correlates of depression among heavy drinkers in Polish primary care clinics.

OBJECTIVE: Depression and co-morbid substance abuse disorders are a major public health problem. Information is limited for patients attending Polish primary care clinics. This article addresses 30-day and lifetime prevalence of major depression in a heavy drinking population from 12 Polish primary care clinics. METHOD: 277 heavy drinkers were interviewed by a researcher in each clinic. Heavy drinking was defined as more than 20 drinks per week for males, or more than 13 drinks per week for females, or consumption of more than four drinks five or more times in the previous 30 days, or two or more positive replies to the CAGE questions. Criteria from the Diagnostic and Statistical Manual were used to assess lifetime and past 30-day depression. RESULTS: 35% of women and men met criteria for depression in the 30 days prior to the interview. Lifetime rates were 45% for women and 52% for men. Men and women with a CAGE score of 4 were at higher risk for both 30-day (67%, OR = 3.85 [1.47, 10.08]) and lifetime (78%, OR = 3.28 [1.12, 9.66]) depression. Recreational drug users and patients reporting symptoms of anti-social personality disorders were at increased risk for lifetime depression. Subjects reporting symptoms of a childhood conduct disorder were at higher risk for 30-day depression. CONCLUSIONS: Depression among patients with substance abuse problems is a common problem. The rates are higher than for other countries and highlight the need for Polish primary care clinicians to routinely screen for depression in patients with substance use disorders.

Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis.

BACKGROUND: This report describes the 48-month efficacy and benefit-cost analysis of Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled trial of brief physician advice for the treatment of problem drinking. METHODS: Four hundred eighty-two men and 292 women, ages 18-65, were randomly assigned to a control (n = 382) or intervention (n = 392) group. The intervention consisted of two physician visits and two nurse follow-up phone calls. Intervention components included a review of normative drinking, patient-specific alcohol effects, a worksheet on drinking cues, drinking diary cards, and a drinking agreement in the form of a prescription. RESULTS: Subjects in the treatment group exhibited significant reductions (p < 0.01) in 7-day alcohol use, number of binge drinking episodes, and frequency of excessive drinking as compared with the control group. The effect occurred within 6 months of the intervention and was maintained over the 48-month follow-up period. The treatment sample also experienced fewer days of hospitalization (p = 0.05) and fewer emergency department visits (p = 0.08). Seven deaths occurred in the control group and three in the treatment group. The benefit-cost analysis suggests a 43,000 dollars reduction in future health care costs for every 10,000 dollars invested in early intervention. The benefit-cost ratio increases when including the societal benefits of fewer motor vehicle events and crimes. CONCLUSIONS: The long-term follow-up of Project TrEAT provides the first direct evidence that brief physician advice is associated with sustained reductions in alcohol use, health care utilization, motor vehicle events, and associated costs. The report suggests that a patient's personal physician can successfully treat alcohol problems and endorses the implementation of alcohol screening and brief intervention in the US health care system.