Changes in Stress and Workplace Shortages Reported by U.S. Critical Care Physicians Treating Coronavirus Disease 2019 Patients.

OBJECTIVES: Eleven months into the coronavirus disease 2019 pandemic, the country faces accelerating rates of infections, hospitalizations, and deaths. Little is known about the experiences of critical care physicians caring for the sickest coronavirus disease 2019 patients. Our goal is to understand how high stress levels and shortages faced by these physicians during Spring 2020 have evolved. DESIGN: We surveyed (October 23, 2020 to November 16, 2020) U.S. critical care physicians treating coronavirus disease 2019 patients who participated in a National survey earlier in the pandemic (April 23, 2020 to May 3, 2020) regarding their stress and shortages they faced. SETTING: ICU. PATIENTS: Coronavirus disease 2019 patients. INTERVENTION: Irrelevant. MEASUREMENT: Physician emotional distress/physical exhaustion: low (not at all/not much), moderate, or high (a lot/extreme). Shortage indicators: insufficient ICU-trained staff and shortages in medication, equipment, or personal protective equipment requiring protocol changes. MAIN RESULTS: Of 2,375 U.S. critical care attending physicians who responded to the initial survey, we received responses from 1,356 (57.1% response rate), 97% of whom (1,278) recently treated coronavirus disease 2019 patients. Two thirds of physicians (67.6% [864]) reported moderate or high levels of emotional distress in the Spring versus 50.7% (763) in the Fall. Reports of staffing shortages persisted with 46.5% of Fall respondents (594) reporting a staff shortage versus 48.3% (617) in the Spring. Meaningful shortages of medication and equipment reported in the Spring were largely alleviated. Although personal protective equipment shortages declined by half, they remained substantial. CONCLUSIONS: Stress, staffing, and, to a lesser degree, personal protective equipment shortages faced by U.S. critical care physicians remain high. Stress levels were higher among women. Considering the persistence of these findings, rising levels of infection nationally raise concerns about the capacity of the U.S. critical care system to meet ongoing and future demands.

The Role of Gender in the Experience and Impact of Recertification Exam Preparation: A Qualitative Study of Primary Care Physicians.

Background: Little is known about how physicians experience preparing for board recertification examinations. As women make up a growing proportion of the primary care physician workforce, we aimed to explore how primary care physicians experience the personal and professional impacts of recertification examination preparation activities, and whether these impacts differ by gender. Materials and Methods: We conducted exploratory qualitative semistructured interviews with 80 primary care physicians, who had recently taken either the American Board of Family Medicine or American Board of Internal Medicine recertification examination and who practice outpatient care. We used an iterative recruitment approach to obtain a representative sample. We applied a team-based constant comparative analytic approach to identify and categorize themes related to how preparing for the recertification examination impacted their personal or professional lives, and then compared these themes by physician gender. Results: We interviewed 41 male and 39 female participants. Physicians most frequently described taking time from personal rather than professional activities to study, but often said this was "no big deal." Physicians described impacts on personal life such as missing out on family or leisure time, conflicts with parenting responsibilities, and an increased reliance on their spouse for domestic and childcare duties. Female physicians more frequently described parenting and leisure time impacts than males did. Conclusions: Recertification examination preparation impacts physicians' personal lives in a variety of ways and are sometimes experienced differently along gendered lines. These findings suggest opportunities for employers, payers, and specialty boards to help physicians ease potential burdens related to maintaining board certification.

How Physicians Prepare for Maintenance of Certification Exams: A Qualitative Study.

PURPOSE: Little is known about how board-certified physicians prepare for their periodic maintenance of certification (MOC) examinations. This qualitative study explores how physicians experience MOC exam preparation: how they prepare for the exams and decide what to study and how exam preparation compares with what they normally do to keep their medical knowledge current. METHOD: Between September 2016 and March 2017, the authors interviewed 80 primary care physicians who had recently taken either the American Board of Family Medicine or American Board of Internal Medicine MOC exam. They analyzed transcripts and notes from these interviews looking for patterns and emergent themes, using the constant comparative method and a social practice theory perspective. RESULTS: Most interviewees studied for their MOC exams by varying from their routines for staying current with medical knowledge, both by engaging with a different scope of information and by adopting different study methods. Physicians described exam preparation as returning to a student/testing mindset, which some welcomed and others experienced negatively or with ambivalence. CONCLUSIONS: What physicians choose to study bounds what they can learn from the MOC exam process and, therefore, also bounds potential improvements to their patient care. Knowing how physicians actually prepare, and how these activities compare with what they do when not preparing for an exam, can inform debates over the value of requiring such exams, as well as conversations about how certification boards and other key stakeholders in physicians' continuing professional development could improve the MOC process.

Assessment and evaluation in interprofessional education: exploring the field.

BACKGROUND: The practice of interprofessional education (IPE) is expanding rapidly in the United States and globally. The publication of competencies from the Interprofessional Education Collaborative (IPEC) was a significant step forward to recognize the importance of health professions collaboration and to guide institutions for educational program development. However, there remains substantial difficulty in implementation, as well as considerable variability in assessment of learners' interprofessional collaborative knowledge and skills and evaluation of IPE programs. METHODS: We conducted a multi-methods project which included 20 key informant interviews, a literature review, and a meeting of an expert panel. Our goals were 1) explore the current field of IPE, 2) identify and disseminate best practices to institutions wishing to implement/augment IPE assessment and evaluation processes, 3) uncover gaps in current IPE assessment and evaluation practices, and 4) recommend next steps for the field. RESULTS: A small and growing literature indicates evidence of the effectiveness of IPE. A diverse collection of methods and tools are used to assess and evaluate IPE learners and programs; these are often used without an explicit program-evaluation framework. CONCLUSIONS: For the field to advance and to align with the demands of changing clinical care systems, robust assessment and evaluation methods, standardized use of common tools, and longitudinal assessment from diverse data streams are needed for IPE.

Assessing interprofessional teamwork: pilot test of a new assessment module for practicing physicians.

INTRODUCTION: Teamwork is a basic component of all health care, and substantial research links the quality of teamwork to safety and quality of care. The TEAM (Teamwork Effectiveness Assessment Module) is a new Web-based teamwork assessment module for practicing hospital physicians. The module combines self-assessment, multisource feedback from members of other professions and specialties with whom the physician exercises teamwork, and a structured review of those data with a peer to develop an improvement plan. METHODS: We conducted a pilot test of this module with hospitalist physicians to evaluate the feasibility and usefulness of the module in practice, focusing on these specific questions: Would physicians in hospitals of different types and sizes be able to use the module; would the providers identified as raters respond to the request for feedback; would the physicians be able to identify one or more "trusted peers" to help analyze the feedback; and how would physicians experience the module process overall? RESULTS: 20 of 25 physicians who initially volunteered for the pilot completed all steps of the TEAM, including identifying interprofessional teammates, soliciting feedback from their team, and identifying a peer to help review data. Module users described the feedback they received as helpful and actionable, and indicated this was information they would not have otherwise received. CONCLUSIONS: The results suggest that a module combining self-assessment, multisource feedback, and a guided process for interpreting these data can provide help practicing hospital physicians to understand and potentially improve their interprofessional teamwork skills and behaviors.

A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.

Teamwork is a vital skill for health care professionals, but the fragmented systems within which they work frequently do not recognize or support good teamwork. The American Board of Internal Medicine has developed and is testing the Teamwork Effectiveness Assessment Module (TEAM), a tool for physicians to evaluate how they perform as part of an interprofessional patient care team. The assessment provides hospitalist physicians with feedback data drawn from their own work of caring for patients, in a way that is intended to support immediate, concrete change efforts to improve the quality of patient care. Our approach demonstrates the value of looking at teamwork in the real world of health care-that is, as it occurs in the actual contexts in which providers work together to care for patients. The assessment of individual physicians' teamwork competencies may play a role in the larger effort to bring disparate health professions together in a system that supports and rewards a team approach in hope of improving patient care.

The roles of practice systems and individual effort in quality performance.

INTRODUCTION: Individual effort and practice systems contribute to quality performance, but the nature of their contributions remains unclear. METHODS: This study assessed the roles of individual attributes and behaviours versus practice attributes in quality performance by assessing general internists' perceptions of factors that drive their engagement in quality improvement (QI). The authors interviewed 20 physicians in two distinct categories from diverse practice settings who had the greatest discordance between their ranked scores on standardised measures of individual quality performance and practice 'systems' performance. RESULTS: Findings suggest that there are subtle but important differences between high-scoring physicians practising in low-scoring practice systems, and low-scoring physicians practising in high-scoring practice systems with regards to quality performance and improvement. Physicians with high individual and low systems scores contributed a greater individual effort in quality improvement (QI), exhibited greater internal drivers to change, and reported a greater number and broader list of QI activities than physicians with low individual scores and high systems scores. Physicians with high individual scores also tended to be more reflective. There was a lack of consensus between categories on the relative usefulness of different systems resources, including electronic information systems. Our findings also suggest that physicians practice in isolation and autonomously, and highly independent of each other, and perceive a tension between pursuing technical quality and patient satisfaction at the same time. Both categories were skeptical of performance measurement more generally. CONCLUSION: QI efforts may be more effective if they foster both specific individual attitudes and capabilities, as well as improve practice-level systems.

How teams work--or don't--in primary care: a field study on internal medicine practices.

We conducted a field study in three primary care practices representing different practice types: a solo practice; a certified patient-centered medical home; and a multiphysician, multispecialty practice connected to a local university. All three practices shared a common culture in the way that practice members related to each other. In each instance, the practice team operated in separate social "silos," isolating physicians from each other and from the rest of the practice staff. We concluded that current practice structures are primarily focused on supporting physicians' hectic routines and have trouble accommodating the diversity of patients' needs. For practices to succeed in managing diverse patients and in helping them understand and manage their own health, it will be critical to break down the silos and organize teams with shared roles and responsibilities.