Moral Elevation, Physician Role Models, and Selected Markers of Professional Identity Formation and Well-Being: A Secondary Analysis from Two National Surveys.

OBJECTIVES: Moral elevation is the underlying emotion that arises when witnessing admirable acts, and it is theorized to be the psychological mechanism driving the impact that positive clinical role models have on medical students' professional identity formation (eg, growth in professional virtues, higher sense of meaning, and well-being). This proof-of-concept study explores the development of the Moral Elevation Scale in Medicine by testing the association of moral elevation with various markers of professional identity formation. METHODS: A secondary data analysis of two nationally representative samples of 960 medical students and 2000 physicians was performed. Respondents completed validated measures of moral elevation as well as markers of professional identity formation, including patient-centered virtues (empathic compassion, interpersonal generosity, mindfulness) and measures of well-being (life meaning, life satisfaction, spirituality, burnout). RESULTS: The study obtained adjusted response rates of 56.2% (1047/1863, physician survey) and 48.7% (448/919, student survey). The national estimates for mean moral elevation in medical students and physicians are 4.34/5.00 and 4.22/5.00, respectively. In medical students and physicians, high moral elevation was associated with higher empathic compassion (student odds ratio [OR] 1.30, 95% confidence interval [CI] 1.02-1.67; physician OR 1.22, 95% CI 1.23-1.65) and, similarly, generosity. In addition, higher moral elevation in the physician cohort was associated with greater life meaning (OR 2.03, 95% CI 1.25-3.32) and similarly spirituality. CONCLUSIONS: In medical students and practicing physicians, self-reported experiences of high moral elevation with physician role models were associated with higher self-reported measures of patient-centered virtues, spirituality, and life meaning. Our Moral Elevation Scale in Medicine demonstrates preliminary promise as a measure to assess environmental precursors needed for virtue development in professional identity formation, but further reliability and validity testing of this measure is needed.

Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study.

BACKGROUND: Rapid response systems (RRSs) improve patients' safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS. METHODS: Patients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock. RESULTS: After propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients' overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75). CONCLUSIONS: The presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.

Opioid Prescriptions by Pain Medicine Physicians in the Medicare Part D Program: A Cross-Sectional Study.

BACKGROUND: Pain medicine physicians (PMP) are a group of physicians with background training in various primary specialties with interest and expertise in managing chronic pain disorders. Our objective is to analyze prescription drug (PD) claims from the Medicare Part D program associated with PMP to gain insights into patterns, associated costs, and potential cost savings areas. METHODS: The primary data source for Part D claims data is the Centers for Medicare and Medicaid Services (CMS) Chronic Conditions Data Warehouse, which contains Medicare Part D prescription drug events (PDE) records received through the claims submission cutoff date. Only providers with taxonomies of pain management (PM) and interventional pain management (IPM) were included in the study. The analysis of PDE was restricted to drugs with >250 claims. The distribution of claims and costs were analyzed based on drug class and provider specialty. Subsequently, we explored claims and expenses for opioid drug prescriptions in detail. Prescribing characteristics of the top 5% of providers by costs and claims were examined to gain additional insights. The costs and claims were explored for the top 10 drugs prescribed by PMP in 2017. RESULTS: There were a total of unique 3280 PMP-prescribed drugs with an associated expense of 652 million dollars in the 2017 Medicare Part D program. Prescriptions related to PMP account for a tiny fraction of the program's drug expenditure (0.4%). Opioids, anticonvulsants, and gabapentinoids were associated with the largest number of claims and the largest expenses within this fraction. Among opioid drug prescriptions, brand-named drugs account for a small fraction of claims (8%) compared to generic drugs. However, the expenses associated with brand name drugs were higher than generic drugs. Prescribers in the top 5% by PD costs had a higher number of claims, prescribed a higher proportion of branded medications, and had prescriptions associated with longer day supply compared to an average PMP. There were several opioid medications in the top 10 PD list by cost associated with PMP. CONCLUSIONS: Opioids were the most common medications among Medicare part D claims prescribed by PMP. Only 12% of the total opioid PD claims were by PMP. The top 5% of PMP prescribers had 10 times more claims than the average PMP.

Is It Possible for Registered Nurses and Physicians to Combine Research and Clinical Work to Facilitate Evidence-Based Practice?

BACKGROUND: Evidence-based patient care requires clinicians to make decisions based on the best available evidence and researchers to provide new scientific knowledge. Clinician-scientists (i.e., registered nurses [RNs] and physicians with a PhD) make important contributions to health care; yet, their roles are not fully understood, supported, or recognized by healthcare leaders. Only a few studies have addressed the factors that enable RNs and physicians to simultaneously pursue both clinical work and research after earning a PhD. AIM: To explore what factors have a bearing on the ability of RNs and physicians to pursue research and clinical work simultaneously after earning a PhD. METHODS: The study used a qualitative design based on open-ended, in-depth interviews. Data were analyzed using conventional content analysis. RESULTS: Analysis of the data yielded a broad range of factors that RNs and physicians perceived to either facilitate or hinder continued research while simultaneously undertaking clinical work. Most of the perceived barriers were due to factors external to the individual. Several factors applied to both professions yet differed in impact. Factors mentioned as fundamental to continued research were financial support and allocated time for research. Maintenance of a good relationship with academia and support from management were also considered to be important. In addition, personal factors, such as motivation to pursue a research career after obtaining a PhD, were influential. LINKING EVIDENCE TO ACTION: A supportive infrastructure is important for enabling clinician-scientists to pursue research after earning a PhD. Creating favorable conditions for RNs and physicians to combine research with clinical work can facilitate evidence-based practice. This information can be used for interventions aimed at improving the conditions for clinician-scientists.

SUDEP classification: Discordances between forensic investigators and epileptologists.

We compared sudden unexpected death in epilepsy (SUDEP) diagnosis rates between North American SUDEP Registry (NASR) epileptologists and original death investigators, to determine degree and causes of discordance. In 220 SUDEP cases with post-mortem examination, we recorded the epileptologist adjudications and medical examiner- and coroner- (ME/C) listed causes of death (CODs). COD diagnosis concordance decreased with NASR's uncertainty in the SUDEP diagnosis: highest for Definite SUDEP (84%, n = 158), lower in Definite Plus (50%, n = 36), and lowest in Possible (0%, n = 18). Rates of psychiatric comorbidity, substance abuse, and toxicology findings for drugs of abuse were all higher in discordant cases than concordant cases. Possible SUDEP cases, an understudied group, were significantly older, and had higher rates of cardiac, drug, or toxicology findings than more certain SUDEP cases. With a potentially contributing or competing COD, ME/Cs favored non-epilepsy-related diagnoses, suggesting a bias toward listing CODs with structural or toxicological findings; SUDEP has no pathognomonic features. A history of epilepsy should always be listed on death certificates and autopsy reports. Even without an alternate COD, ME/Cs infrequently classified COD as "SUDEP." Improved collaboration and communication between epilepsy and ME/C communities improve diagnostic accuracy, as well as bereavement and research opportunities.

AANEM survey of training in electrodiagnostic medicine in U.S. residency programs.

BACKGROUND: Little literature exists describing resident training in peripheral electrodiagnosis (EDX). METHODS: U.S. residency programs in neurology and physical medicine and rehabilitation (PM&R) were surveyed by the AANEM (American Association of Neuromuscular and Electrodiagnostic Medicine) on specific features of EDX training. RESULTS: Ninety-seven programs responded to the survey. Training duration was 4-8 weeks in most neurology programs; training averaged 22 weeks in PM&R programs. EDX experience was required in all PM&R and in 90% of neurology programs. Results varied greatly for the residency years of training, pulling of residents for other responsibilities, participation in continuity clinics, number of teaching physicians, number of needle examinations performed, organization of nerve conduction training, written/oral examinations, muscle/nerve biopsy reviews, and training materials. CONCLUSIONS: This survey demonstrated large variability in training of neurology and PM&R residents in peripheral EDX.

Substance Use Disorder in Physicians after Completion of Training in Anesthesiology in the United States from 1977 to 2013.

BACKGROUND: Substance use disorder among physicians can expose both physicians and their patients to significant risk. Data regarding the epidemiology and outcomes of physician substance use disorder are scarce but could guide policy formulation and individual treatment decisions. This article describes the incidence and outcomes of substance use disorder that resulted in either a report to a certifying body or death in physicians after the completion of anesthesiology training. METHODS: Physicians who completed training in U.S. anesthesiology residency programs from 1977 to 2013 and maintained at least one active medical license were included in this retrospective cohort study (n = 44,736). Substance use disorder cases were ascertained through records of the American Board of Anesthesiology and the National Death Index. RESULTS: Six hundred and one physicians had evidence of substance use disorder after completion of training, with an overall incidence of 0.75 per 1,000 physician-years (95% CI, 0.71 to 0.80; 0.84 [0.78 to 0.90] in men, 0.43 [0.35 to 0.52] in women). The highest incidence rate occurred in 1992 (1.79 per 1,000 physician-years [95% CI, 1.12 to 2.59]). The cumulative percentage expected to develop substance use disorder within 30 yr estimated by Kaplan-Meier analysis equaled 1.6% (95% CI, 1.4 to 1.7%). The most common substances used by 353 individuals for whom information was available were opioids (193 [55%]), alcohol (141 [40%]), and anesthetics/hypnotics (69 [20%]). Based on a median of 11.1 (interquartile range, 4.4 to 19.8) yr of follow-up, the cumulative proportion of survivors estimated to experience at least one relapse within 30 yr was 38% (95% CI, 31 to 43%). Of the 601 physicians with substance use disorder, 114 (19%) were dead from a substance use disorder-related cause at last follow-up. CONCLUSIONS: A substantial proportion of anesthesiologists who develop substance use disorder after the completion of training die of this condition, and the risk of relapse is high in those who survive.

Medicare Reimbursement to Physicians Decreased for Common Emergency Medicine Services From 2000 to 2020.

STUDY OBJECTIVE: The change in reimbursement rates for emergency physician services has yet to be quantified. We attempted to fill this knowledge gap by evaluating the monetary trends in Medicare reimbursement rates over the last 20 years for the most common emergency medicine services. METHODS: We obtained commonly used Current Procedural Terminology (CPT) codes in emergency medicine from the American College of Emergency Physicians website. We queried the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services for each of the included CPT codes, and we extracted reimbursement data. We adjusted all monetary data for inflation to 2020 US dollars by using changes to the United States consumer price index. Both the average annual and the total percentage change in reimbursement were calculated on the basis of these adjusted trends for all included services. RESULTS: Reimbursement by Medicare for the services decreased by an average of 29.13% from 2000 to 2020 after adjusting for inflation. There was a stable decline in adjusted reimbursement rates throughout the study period, with an average decrease of 1.61% each year. The largest decrease was seen for laceration repairs up to 7.5 cm, with reimbursement rates for all 4 relevant CPT codes decreasing by more than 60%. CONCLUSION: When adjusted for inflation, Medicare reimbursement declined by an average of 29% over the last 20 years for the 20 most common emergency medicine services. Knowledge of these trends is essential to address current controversies in emergency medicine billing adequately and advocate for sustainable payment system reform.

Quality evaluation of the Japanese Adverse Drug Event Report database (JADER).

INTRODUCTION: The spontaneous adverse drug reaction (ADR) reporting system plays an important role in pharmacovigilance by providing information from clinical settings in the postmarketing environment. The Japanese Adverse Drug Event Report (JADER) database contains a portion of Japanese ADR reports, and no previous study has described the quality or characteristics of ADR reports in the JADER. OBJECTIVE: The aim of this study was to identify the characteristics of the JADER database and to evaluate the quality of ADR reports contained in the JADER using the documentation-grading scheme developed by the World Health Organization. METHODS: Of 478 508 ADR reports in the JADER, the analysis set consisted of 395 091 reports meeting inclusion criteria. An analysis was carried out to evaluate the quality of the reports according to the type of report, the type of sender, and the qualification of the reporter. Annual changes in the number of reports from medical institutions submitted by pharmacists were compared with changes in the number submitted by physicians. RESULTS: The distribution of documentation grade differed according to the type of report, the type of sender, and the qualification of the reporter. Regarding "medical institution reports", the quality of reports was similar among qualification types, while the quality of reports submitted by physicians was higher for "company reports" and "study reports" (P < .0001, respectively). CONCLUSION: Our study showed that the quality of the ADR reports in the JADER differed among the type of report, the sender of the report, and the qualification of the reporter.

Variation in physician-directed immunohistochemistry screening among women with endometrial cancer.

OBJECTIVE: Immunohistochemistry screening is a reliable method for identifying women with endometrial cancer who are at risk for Lynch syndrome, but clinical workflows used to implement immunohistochemistry screening protocols can vary by institution. The goal of this study was to investigate variation in performance of immunohistochemistry screening when a physician order is required. METHODS: Retrospective study from an integrated healthcare system with a risk-based immunohistochemistry screening policy for Lynch syndrome from January 2015 to December 2016. Immunohistochemistry screening was indicated for all women with endometrial cancer aged <60 years and women with endometrial cancer aged ≥60 years who had a personal/family history suggestive of Lynch syndrome. However, a physician order was needed to have immunohistochemistry screening performed on the tumor specimen as our health system did not have reflex screening in the clinical workflow. Demographics and tumor characteristics were reviewed, and patients were stratified by immunohistochemistry screening status. Multivariable regression was performed to identify factors associated with immunohistochemistry performance and reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: There were 1399 eligible patients in the study. With a required physician order, immunohistochemistry screening rates (20% overall, 34% aged <60 years) were significantly lower than previous reports (36% overall, 90% aged <60 years, p≤0.0001 for both comparisons). Significant factors associated with immunohistochemistry screening performance identified by multivariable analysis included age, race, body mass index, personal/family cancer history, diabetes, endometrioid histology, and tumor grade. Asian women were most likely to have immunohistochemistry screening (OR 1.58, 95% CI 1.07 to 2.34) whereas black women were least likely (OR 0.43, 95% CI 0.22 to 0.91). CONCLUSIONS: Immunohistochemistry screening rates in women with endometrial cancer were lower in our health system compared with prior reports in the literature, and there were variations in screening performance according to patient age, race, and body mass index. Requiring a physician order for immunohistochemistry screening likely creates a barrier in screening uptake, therefore automated immunohistochemistry screening is recommended.

I Tweet, Therefore I Learn: An Analysis of Twitter Use Across Anesthesiology Conferences.

BACKGROUND: Twitter in anesthesiology conferences promotes rapid science dissemination, global audience participation, and real-time updates of simultaneous sessions. We designed this study to determine if an association exists between conference attendance/registration and 4 defined Twitter metrics. METHODS: Using publicly available data through the Symplur Healthcare Hashtags Project and the Symplur Signals, we collected data on total tweets, impressions, retweets, and replies as 4 primary outcome metrics for all registered anesthesiology conferences occurring from May 1, 2016 to April 30, 2017. The number of Twitter participants, defined as users who contributed a tweet, retweet, or reply 3 days before through 3 days after the conference, was collected. We also collected influencer data as determined by mentions (number of times a user is referenced). Two authors independently verified the categories for influencers assigned by Symplur. Conference demographic data were obtained by e-mail inquiries. Associations between meeting attendees/registrants and Twitter metrics, between Twitter participants and the metrics, and between physician influencers and Twitter participants were tested using Spearman rho. RESULTS: Fourteen conferences with 63,180 tweets were included. With the American Society of Anesthesiologists annual meeting included, the correlations between meeting attendance/registration and total tweets (rs = 0.588; P = .074), impressions (rs = 0.527; P = .117), and retweets (rs = 0.539; P = .108) were not statistically significant; for replies, it was moderately positive (rs = 0.648; P = .043). Without the American Society of Anesthesiologists annual meeting, total tweets (rs = 0.433; P = .244), impressions (rs = 0.350; P = .356), retweets (rs = 0.367; P = .332), and replies (rs = 0.517; P = .154) were not statistically significant. Secondary outcomes include a highly positive correlation between Twitter participation and total tweets (rs = 0.855; P < .001), very highly positive correlations between Twitter participation and impressions (rs = 0.938; P < .001), retweets (rs = 0.925; P < .001), and a moderately positive correlation between Twitter participation and replies (rs = 0.652; P = .044). Doctors were top influencers in 8 of 14 conferences, and the number of physician influencers in the top 10 influencers list at each conference had a moderately positive correlation with Twitter participation (rs = 0.602; P = .023). CONCLUSIONS: We observed that the number of Twitter participants for a conference is positively associated with Twitter activity metrics. No relationship between conference size and Twitter metrics was observed. Physician influencers may be an important driver of participants.

Alcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers.

AIMS: A recently completed Cochrane review assessed the effectiveness and cost-benefits of Alcoholics Anonymous (AA) and clinically delivered 12-Step Facilitation (TSF) interventions for alcohol use disorder (AUD). This paper summarizes key findings and discusses implications for practice and policy. METHODS: Cochrane review methods were followed. Searches were conducted across all major databases (e.g. Cochrane Drugs and Alcohol Group Specialized Register, PubMed, Embase, PsycINFO and ClinicalTrials.gov) from inception to 2 August 2019 and included non-English language studies. Randomized controlled trials (RCTs) and quasi-experiments that compared AA/TSF with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants or no treatment, were included. Healthcare cost offset studies were also included. Studies were categorized by design (RCT/quasi-experimental; nonrandomized; economic), degree of manualization (all interventions manualized versus some/none) and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). Random-effects meta-analyses were used to pool effects where possible using standard mean differences (SMD) for continuous outcomes (e.g. percent days abstinent (PDA)) and the relative risk ratios (RRs) for dichotomous. RESULTS: A total of 27 studies (21 RCTs/quasi-experiments, 5 nonrandomized and 1 purely economic study) containing 10,565 participants were included. AA/TSF interventions performed at least as well as established active comparison treatments (e.g. CBT) on all outcomes except for abstinence where it often outperformed other treatments. AA/TSF also demonstrated higher health care cost savings than other AUD treatments. CONCLUSIONS: AA/TSF interventions produce similar benefits to other treatments on all drinking-related outcomes except for continuous abstinence and remission, where AA/TSF is superior. AA/TSF also reduces healthcare costs. Clinically implementing one of these proven manualized AA/TSF interventions is likely to enhance outcomes for individuals with AUD while producing health economic benefits.

Telehealth in the time of Corona: 'doctor in the house'.

The COVID-19 pandemic has led to many physicians working from home whenever possible. Although the concept of 'remote' patient care has been around for decades, present circumstances have provided a grand impetus in that direction with a view to protecting both patient and caregiver. In this article, we discuss some of the various challenges to moving forward with telemedicine, drawing in part on our own experiences in dealing with the COVID-19 pandemic. Clinical, technical, financial and cultural barriers to telemedicine are identified, along with a discussion concerning anticipated benefits. We conclude that the COVID-19 pandemic will likely forever change how healthcare is conducted as telemedicine figures increasingly prominently in the clinical landscape.

Trends in nonroutine physician visits and hospitalizations: findings among five cohorts from the Spinal Cord Injury Longitudinal Aging Study.

STUDY DESIGN: Longitudinal cohort study OBJECTIVE: To evaluate lifetime variation in healthcare utilization among individuals with a chronic spinal cord injury (SCI). SETTING: Medical university in the Southeastern United States (US). METHODS: Participants were identified from two Midwestern University hospitals and a specialty hospital in the Southeastern US and were enrolled in 1973-1974, 1984-1985, 1993-1994, and 2003-2004. Generalized linear mixed models were used to explore changes in nonroutine physician visits, hospitalizations, and days hospitalized within the 24 months prior to the study. RESULTS: Significant temporal linear spline change was found for nonroutine physician visits. The proportion of participants reporting ≥10 nonroutine physician visits in the 24 months prior to assessment kept relatively constant over the 30 years post injury (p value of trend: p = 0.605) and sharply increased afterwards (pknot = 30 years since injury = 0.016). The trajectory for hospitalization and days hospitalized followed a quadratic pattern (pyears post injury2 < 0.001) for all participants. The proportion of individuals who had at least one hospitalization and were hospitalized for more than 1 week significantly declined from the onset of SCI to 25-30 years post injury, then significantly increased thereafter. CONCLUSIONS: The natural course of changes in three indices of healthcare utilization was curve-linearly, rather than linearly related to years post injury. People with SCI tended to have significant changes in healthcare utilization after about 30 years injury.

Physician Distribution by Specialty and Practice Setting: Findings in Japan in 2000, 2010 and 2016.

As the medical demand is projected to increase along with the population aging in Japan, the geographical distribution of physicians is a significant concern for society and policymakers. To implement effective measures on geographical physician distribution, this study aimed to describe and compare the distribution of physicians by specialty in 2000, 2010 and 2016 in Japan, and examine whether practice setting was associated with distribution. To quantify the geographical physician distribution by specialty, we calculated the Gini coefficients of physicians working at clinics or hospitals in 2000, 2010, and 2016. We used the basic geographic unit for medical care planning in Japan, a secondary medical area, as the study unit. To show the association between the geographical distribution of physicians in each specialty and their practice setting, we categorized specialties into two groups by the proportion of physicians in that specialty working in hospitals, and showed aggregated Lorenz curves for each category. The overall geographical distribution of physicians appeared to improve during the study period, but varied by specialty. Those in specialties, where at least 90% of physicians work in hospitals such as anesthesiologists and radiologists, were more clustered, as shown by the Lorenz curves and the Gini coefficients. Similar distributional differences were also found even when we excluded physicians working in clinics, meaning that the distributional variation could be explained by other factors than the distribution of hospitals. These results suggest that the nature of practice in each specialty strongly affects the geographical distribution of specialists.

[Work and Training of Young Doctors in Germany - a Comprehensive Analysis of Survey Results from Six Disciplines]. / Die Arbeits- und Weiterbildungssituation junger Ärztinnen und Ärzte in Deutschland ­ eine zusammenfassende Analyse von Befragungsergebnissen aus sechs Fachrichtungen.

OBJECTIVE: The working and training conditions of young physicians in Germany have changed over the last few years, as a result of far-reaching changes in the healthcare system. Therefore, Germany-wide surveys among young physicians of several disciplines were evaluated in a pooled analysis, in order to obtain a current interdisciplinary impression of conflicts in their daily work. MATERIAL AND METHODS: Data from web-based surveys from residents training in six disciplines were analyzed together retrospectively. One focus was a gratification crises model for the assessment of psychosocial workload. RESULTS: Data on 4041 participants were evaluated. In day-to-day work, young physicians were burdened with a high proportion of tasks that were not directly medical. Instruments of good subspecialty training, such as training contracts, curricula and regular feedback were associated with a lower psychosocial workload, which was generally significant among the participants. An economic influence on medical-professional decisions was subjectively clearly present among the participants. CONCLUSION: Many young doctors find the current work and training conditions in the medical work environment unsatisfactory. This might have consequences not only for the doctors themselves, but also for the patients they care for. A healthy work environment with health professionals in good health is therefore crucial and should be in everyone's interest.

[Effects of Changes in Healthcare on Doctors and Patients using the Example of Ukraine]. / Wandel im Gesundheitswesen: Analyse der Auswirkungen auf Ärzte und Patienten am Beispiel der Ukraine.

BACKGROUND: The health care sector is experiencing a drastic transition all over the world. This has an impact not only on the way hospitals, clinics, special-care homes etc. are organized, but also on patients, personnel and other stakeholders involved. The consequences of changes for both physicians and patients are investigated using a comprehensive health care reform in Ukraine as an example. METHODS: The analysis is based on empirical data collected from general physicians in 2 Ukrainian cities. Based on the Job Demands-Resources Model, we developed a set of hypotheses and tested them using the structural equation modelling technique. A total of 178 general physicians (81% of the approached population) participated in the study. RESULTS: Our investigation reveals a clear relationship between the organizational job demands (additional tasks, structural changes, new processes) and their psychological effects (e. g., burnout). The latter have a negative impact on cooperation of physicians in hospitals leading to lower patient satisfaction. DISCUSSION AND CONCLUSIONS: Change in health care is inevitable. The example of Ukraine shows that openness of hospitals towards change reduces the probability of physicians' burnout and, eventually, increases patient satisfaction. We strongly suggest applying the process management approach in order to increase openness to change, especially in turbulent times.

"An indelible mark" the response to participation in euthanasia and physician-assisted suicide among doctors: A review of research findings.

INTRODUCTION: The debate regarding euthanasia and physician-assisted suicide (E/PAS) raises key issues about the role of the doctor, and the professional, ethical, and clinical dimensions of the doctor-patient relationship. This review aimed to examine the published evidence regarding the response of doctors who have participated in E/PAS. METHODS: Original research papers were identified reporting either qualitative or qualitative data published in peer-reviewed literature between 1980 and March 2018, with a specific focus on the impact on, or response from, physicians to their participation in E/PAS. PRISMA and CASP guidelines were followed. RESULTS: Nine relevant papers met selection criteria. Given the limited published data, a descriptive synthesis of quantitative and qualitative findings was performed. Quantitative surveys were limited in scope but identified a mixed set of responses. Where studies measured psychological impact, 30-50% of doctors described emotional burden or discomfort about participation, while findings also identified a comfort or satisfaction in believing the request of the patient was met. Significant, ongoing adverse personal impact was reported between 15% to 20%. A minority of doctors sought personal support, generally from family or friends, rather than colleagues. The themes identified from the qualitative studies were summarized as: 1) coping with a request; 2) understanding the patient; 3) the doctor's role and agency in the death of a patient; 4) the personal impact on the doctor; and 5) professional guidance and support. SIGNIFICANCE OF RESULTS: Participation in E/PAS can have a significant emotional impact on participating clinicians. For some doctors, participation can contrast with perception of professional roles, responsibilities, and personal expectations. Despite the importance of this issue to medical practice, this is a largely neglected area of empirical research. The limited studies to date highlight the need to address the responses and impact on clinicians, and the support for clinicians as they navigate this challenging area.

A global real-world assessment of the impact on health-related quality of life and work productivity of migraine in patients with insufficient versus good response to triptan medication.

BACKGROUND: Migraine is a chronic, disabling neurological disease characterized by moderate-to-severe headache pain with other symptoms, including nausea, vomiting, and photophobia. Triptans, while generally effective, are insufficiently efficacious in 30-40% of patients and poorly tolerated by or contraindicated in others. We assessed the impact of insufficient response to triptans on health-related quality of life (HRQoL) and work productivity in patients currently receiving any prescribed triptan formulation as their only acute migraine medication. METHODS: Data were from the 2017 Adelphi Migraine Disease Specific Programme, a cross-sectional survey of primary care physicians, neurologists, and headache specialists and their consulting patients with migraine in the USA, France, Germany, Italy, Spain, and UK. Triptan insufficient responders (TIRs) achieved freedom from headache pain within 2 h of acute treatment in ≤3/5 migraine attacks; triptan responders (TRs) achieved pain freedom within 2 h in ≥4/5 attacks. Multivariable general linear model examined differences between TIRs and TRs in HRQoL and work productivity. Logistic regression identified factors associated with insufficient response to triptans. RESULTS: The study included 1413 triptan-treated patients (TIRs: n = 483, 34.2%; TRs: n = 930, 65.8%). TIRs were more likely to be female (76% vs. 70% for TIRs vs TRs, respectively; p = 0.011), older (mean age 42.6 vs. 40.5 years; p = 0.003), and had more headache days/month (7.0 vs. 4.4; p < 0.001). TIRs had significantly more disability, with higher Migraine Disability Scores (MIDAS; 13.2 vs. 7.7; p < 0.001), lower Migraine-specific Quality of Life scores, indicating greater impact (Role Function Restrictive: 62.4 vs. 74.5; Role Function Preventive: 70.0 vs. 82.2; Emotional Function: 67.7 vs. 82.1; all p < 0.001), and lower EQ5D utility scores (0.84 vs. 0.91; p = 0.001). Work productivity and activity were impaired (absenteeism, 8.6% vs. 5.1% for TIRs vs. TRs; presenteeism, 34.3% vs. 21.0%; work impairment, 37.1% vs. 23.3%; overall activity impairment, 39.8% vs. 25.3%; all p < 0.05). CONCLUSION: HRQoL and work productivity were significantly impacted in TIRs versus TRs in this real-world analysis of patients with migraine acutely treated with triptans, highlighting the need for more effective treatments for patients with an insufficient triptan response. Further research is needed to establish causal relationships between insufficient response and these outcomes.

Genomic education for the next generation of health-care providers.

Historically, medical geneticists and genetic counselors have provided the majority of genetic services. Advances in technology, reduction in testing costs, and increased public awareness have led to a growing demand for genetic services in both clinical and direct-to-consumer spaces. Recent and anticipated changes in the workforce of genetic counselors and medical geneticists require a reexamination of the way we educate health-care providers and the means by which we provide access to genetic services. The time is ripe for rapid growth of genetic and genomic services, but to capitalize on these opportunities, we need to consider a variety of educational mechanisms to reach providers both within and beyond the traditional genetic counseling and medical genetics sectors, including nurses, physician assistants, and nongenetics physicians. This article summarizes the educational efforts underway in each of these professions.