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.

Which Outreach Modes Improve Response Rates to Physician Surveys? Lessons from an Experiment at the American Board of Internal Medicine.

Physicians are a notoriously difficult group to survey due to a low propensity to respond. We investigate the relative effectiveness of reminder phone calls, pre-notification postcards, mailed paper surveys, and $1 upfront incentives for boosting survey response rate by embedding a randomized experiment into a mixed-mode operational survey at the American Board of Internal Medicine in 2019. Expected response rates and average marginal effects for each follow-up method were computed from a logistic regression model. The control group which only received email reminders achieved a response rate of 18.2%, 95% CI: (15.0%, 21.9%). The intervention group which included reminder emails, pre-notification postcards, and mailed paper surveys with $1 incentives achieved a response rate of 43.1%, 95% CI: (38.8%, 47.5%). Mailed paper surveys yielded the largest percentage point increase in response rate of 11.2%, 95% CI: (7.3%, 15.2%), while $1 upfront monetary incentives and phone call reminders increased survey response rate by 5.9%, 95% CI: (1.6%, 10.2%) and 5.5%, 95% CI: (2.6%, 8.3%) respectively. Pre-notification postcards are associated with a 2.0%, 95% CI: (-1.7%, 5.6%) increase in survey response rate. Cost-effectiveness for each method is discussed. This research supports optimal decision making for researchers when planning a physician survey study.

Remind Me Again: Physician Response to Web Surveys: The Effect of Email Reminders Across 11 Opinion Survey Efforts at the American Board of Internal Medicine from 2017 to 2019.

For survey researchers, physicians in the United States are a difficult-to-reach subgroup. The purpose of this study is to quantify the effect of email reminders on web-based survey response rates targeting physicians. We conducted a retrospective analysis of 11 American Board of Internal Medicine surveys from 2017 to 2019. We compute aggregate response rates for the periods between weekly email contacts across the 11 surveys, while controlling for survey time to complete, physician age, gender, region, board certification status, and initial exam performance. The overall predicted response rate after six weekly email contacts was 23.7%, 95% CI: (17.1%, 33.0%). Across the 11 surveys, we found response rate for the first period to be 8.9%, 95% CI: (6.5%, 12.2%). We observed a 50% decrease in response from the first to the second period, which had a 4.4%, 95% CI: (3.2%, 6.2%), response rate. The third and fourth response periods yielded similar response rates of 3.0%, 95% CI: (2.3%, 3.9%) and 3.3%, 95%CI: (2.4%, 4.6%), respectively. The fifth and sixth response periods yielded similar response rates of 2.2%, 95%CI: (1.5%, 3.3%) and 1.9%, 95% CI: (1.3%, 2.7%), respectively. The results were further stratified into different levels of participant survey interest, and are helpful for cost and sample size considerations when designing a physician survey.

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.

Measurement in Veterans Affairs Health Services Research: veterans as a special population.

OBJECTIVE: To introduce this supplemental issue on measurement within health services research by using the population of U.S. veterans as an illustrative example of population and system influences on measurement quality. PRINCIPAL FINDINGS: Measurement quality may be affected by differences in demographic characteristics, illness burden, psychological health, cultural identity, or health care setting. The U.S. veteran population and the VA health system represent a microcosm in which a broad range of measurement issues can be assessed. CONCLUSIONS: Measurement is the foundation on which health decisions are made. Poor measurement quality can affect both the quality of health care decisions and decisions about health care policy. The accompanying articles in this issue highlight a subset of measurement issues that have applicability to the broad community of health services research. It is our hope that they stimulate a broad discussion of the measurement challenges posed by conducting "state-of-the-art" health services research.

Professionalism and maintenance of certification: using vignettes describing interpersonal dilemmas to stimulate reflection and learning.

INTRODUCTION: Physicians do not always agree on "rules" governing behavior in professionally challenging situations. Little is known about contextual factors that influence physician approaches in these situations. We explored the individual-, social-, and societal-level factors that physicians consider when responding to 2 common professional dilemmas. We were particularly interested in knowing the extent to which physicians engage in self-reflection as a result of responding to the vignettes. METHODS: A cross-sectional Web-based survey was sent to a random sample of 396 physicians, prompting them to respond to scripted professional dilemmas. RESULTS: A total of 120 physicians responded, yielding a response rate of 32.6%. Physicians responded to these dilemmas in highly variable ways, negotiating a complex array of contextual factors in their decisions. Interacting factors involving individual-level physician (eg, worry, guilt), patient (eg, nature of medical condition or relationship with patient), and social/societal (eg, policy, what peers or colleagues do) were important drivers in physician responses. Qualitative analysis revealed that several interacting themes guide physician approaches to professional dilemmas: patient welfare; types of patients; political, ethical, or legal issues; guiding principles; values; rules; and habits. DISCUSSION: Physicians negotiate a complex set of individual-, social-, and societal-level factors in response to professional dilemmas. This finding has important implications for the promotion and assessment of professional behavior in practicing physicians. Reflecting on scenarios may be an opportunity for physicians to learn about how and why they make decisions in difficult situations.

The ABIM's clinical supervision practice improvement module and its effect on faculty's supervisory skills.

PURPOSE: Inadequate supervision of medical trainees hampers education and patient care. The authors examine the use of the American Board of Internal Medicine's Clinical Supervision Practice Improvement Module (CS-PIM) to determine whether it facilitated and enhanced faculty's skills in direct observation, providing feedback, identifying errors, and auditing medical records. METHOD: In this descriptive cohort study, module satisfaction was assessed using a five-point Likert scale. Changes in supervisory skills were measured using a retrospective pre-/postmodule self-assessment; deltas were compared by the Wilcoxon signed rank test. RESULTS: Between March 2009 and October 2010, 644 faculty completed 647 CS-PIMs. Asked how effective the module was for improving their observation and evaluation skills, 91% rated it excellent, very good, or good. Similarly high percentages of the faculty gave those same ratings to the module for facilitating documenting trainee evaluations, documenting feedback to trainees, reflecting on the summary report, developing an improvement plan, and documenting their self-assessment of supervisory skills. Faculty self-reported improved skills in observation, giving feedback, identifying errors, and auditing medical records. CONCLUSION: The CS-PIM facilitated and improved faculty skills in the supervision of trainees and led to self-reported changes in supervisory practices. Future research should evaluate trainees' perceptions and the actual impact on quality of care in the teaching setting.

Prevalence and functionality of electronic health records in internal medicine continuity clinics.

PURPOSE: Health information technology (HIT), particularly electronic health records (EHRs), will become universal in ambulatory practices, but the current roles and functions that HIT and EHRs play in the ambulatory clinic settings of internal medicine (IM) residents are unknown. METHOD: The authors conducted a Web-based survey from July 2007 to January 2008 to ascertain HIT prevalence and functionality. Respondents were directors of one or more ambulatory clinics where IM residents completed any required outpatient training, as identified by directors of accredited U.S. IM residencies. RESULTS: The authors identified 356 clinic directors from 264 accredited U.S. programs (70%); 221 directors (62%) completed the survey, representing 185 accredited programs (49%). According to responding directors, residents in 121 of 216 clinics (56%) had access to EHRs, residents in 147 of 219 clinics (67%) used some type of electronic data system (EDS) to manage patient information, and residents in 62 clinics (28% of 219 responding) used an EDS to generate lists of patients needing follow-up care. Compared with smaller IM training programs, programs with > or =50 trainees were more likely to have an EDS (67% versus 53%, P = .037), electronic prescription writer (57% versus 42%, P = .026), or EHR (63% versus 45%, P = .007). CONCLUSIONS: Resident ambulatory clinics seem to have greater adoption of HIT and EHRs than practicing physicians' ambulatory offices. Ample room for improvement exists, however, as electronic systems with suboptimal patient data, limited functionality, and reliance on multiple (paper and electronic) systems all hinder residents' ability to perform important care coordination activities.

Teaching and evaluating point of care learning with an Internet-based clinical-question portfolio.

INTRODUCTION: Diplomates in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program satisfy the self-evaluation of medical knowledge requirement by completing open-book multiple-choice exams. However, this method remains unlikely to affect practice change and often covers content areas not relevant to diplomates' practices. We developed and evaluated an Internet-based point of care (POC) learning portfolio to serve as an alternative. METHODS: Participants enter information about their clinical questions, including characteristics, information pursuit, application, and practice change. After documenting 20 questions, they reflect upon a summary report and write commitment-to-change statements about their learning strategies. They can link to help screens and medical information resources. We report on the beta test evaluation of the module, completed by 23 internists and 4 internal medicine residents. RESULTS: Participants found the instructions clear and navigated the module without difficulty. The majority preferred the POC portfolio to multiple-choice examinations, citing greater relevance to their practice, guidance in expanding their palette of information resources, opportunity to reflect on their learning needs, and "credit" for self-directed learning related to their patients. Participants entered a total of 543 clinical questions, of which 250 (46%) resulted in a planned practice change. After completing the module, 14 of 27 (52%) participants committed to at least 1 change in their POC learning strategies. DISCUSSION: Internists found the portfolio valuable, preferred it to multiple-choice examinations, often changed their practice after pursuing clinical questions, and productively reflected on their learning strategies. The ABIM will offer this portfolio as an elective option in MOC.

The role of physician engagement on the impact of the hospital-based practice improvement module (PIM).

BACKGROUND: Physicians play an important role in hospital quality improvement (QI) activities. The Hospital-Based Practice Improvement Module (Hospital PIM) is a web-based assessment tool designed by the American Board of Internal Medicine (ABIM) to facilitate physician involvement in QI as a part of maintaining certification. OBJECTIVE: The primary objective of this study is to explore the impact of the Hospital PIM on physicians participating in hospital-based QI. DESIGN: Qualitative design consisting of semistructured telephone interviews. PARTICIPANTS: A purposeful sample of 21 early-completers of the Hospital PIM. MEASUREMENTS: Grounded-theory analysis was used to analyze transcripts of the semistructured telephone interviews. RESULTS: Physician completers of the Hospital PIM describe the impact in a variety of ways, including new learning about QI principles and activities, added value to their practice, and enhanced QI experience. An emerging theme was the mediating role of physician engagement in relation to the overall impact of the Hospital PIM. Four case studies illustrate these findings. Facilitators and barriers that influence the overall experience of the PIM are described. CONCLUSIONS: The impact of completing the Hospital PIM is mediated by the degree of physician engagement with the QI process. Physicians who become engaged with the Hospital PIM and QI process may be more likely to report successful experiences in implementing QI activities in hospital settings than those who do not become engaged.