A Model of Burnout Among Healthcare Professionals.

BACKGROUND: Burnout is common and can lead to worse outcomes for both healthcare workers and patients. Our study purpose was to assess the structural relationship among factors that protect against or worsen burnout. DATA SOURCES AND STUDY SETTING: We surveyed healthcare professionals in 15 different Japanese intensive care units during the 3rd wave of the COVID-19 pandemic (March 2021). Surveys assessed burnout (Mini Z 2.0), resilience (Brief Resilience Scale), depressive (PHQ-9) and anxiety (GAD-7) symptoms, job and work environment characteristics, and personal experience with COVID. We explored survey domains with principal component factor analysis and modeled our results using structural equation modeling. PRINCIPAL FINDINGS: Among 936 ICU professionals, 24.3% met criteria for burnout. Our model suggested that resilience (ß = - 0.26, 95% CI - 0.32 to - 0.20), teamwork (ß = - 0.23, 95% CI - 0.30 to - 0.16), and feeling safe (ß = - 0.11, 95% CI - 0.18 to - 0.04) reduced burnout. Depression (ß = - 0.32, 95% CI - 0.41 to - 0.23) and anxiety (ß = - 0.20, 95% CI - 0.29 to - 0.10) both decreased resilience as did COVID fear (ß = 0.08, 95% CI - 0.14 to - 0.02). In addition to directly reducing resilience, anxiety also indirectly reduced resilience by increasing COVID fear (0.23, 95% CI 0.17 to 0.23), which decreased resilience (ß - 0.08, 95% CI - 0.14 to - 0.02). CONCLUSIONS: Burnout is common among Japanese ICU professionals. Resilience, teamwork, and safety are all correlated with reduced burnout. Those who had depression or anxiety or COVID fear had higher degrees of burnout, an effect that appears to be mediated by reduced resilience. These are potential targets for interventions to reduce burnout.

The "Difficult" Inpatient, a Qualitative Study of Physician Perspectives.

BACKGROUND: Previous studies exploring difficult inpatients have mostly focused on psychiatric inpatients. OBJECTIVE: To explore the characteristics of difficult medicine inpatients. DESIGN: Qualitative study using focus groups and semi-structured interviews. Transcripts were recorded, transcribed, and coded (MAXQDA) using thematic content analysis. PARTICIPANTS: Medicine inpatient providers at a tertiary care facility. KEY RESULTS: Our sample consisted of 28 providers (6 hospitalists, 10 medicine attendings, 6 medicine residents, and 6 interns). Theme 1: Provider experience: Difficult inpatients were time-consuming and evoked emotional responses including frustration and dysphoria. Theme 2: Patient characteristics: Included having personality disorders or mental health issues, being uncooperative, manipulative, angry, demanding, threatening, or distrustful. Difficult patients also had challenging social situations and inadequate support, unrealistic care expectations, were self-destructive, tended to split care-team messages, and had unclear diagnoses. Theme 3: Difficult families: Shared many characteristics of difficult patients including being distrustful, demanding, manipulative, threatening, or angry. Difficult families were barriers to care, disagreed with the treatment plan and each other, did not act in the patient's best interest, suggested inappropriate treatment, or had unrealistic expectations. STRATEGIES: Approaches to dealing with difficult patients or families included building trust, being calm, and having a consistent message. Communication approaches included naming the emotion, empathetic listening, identifying patient priorities and barriers, and partnering. CONCLUSIONS: Difficult patients induced emotional responses, dysphoria, and self-doubt among providers. Underlying personality disorders were often mentioned. Difficult patients and families shared many characteristics. Communication and training were highlighted as key strategies.

Approaches to Assessing and Adjusting for Selective Outcome Reporting in Meta-analysis.

BACKGROUND: Selective or non-reporting of study outcomes results in outcome reporting bias. OBJECTIVE: We sought to develop and assess tools for detecting and adjusting for outcome reporting bias. DESIGN: Using data from a previously published systematic review, we abstracted whether outcomes were reported as collected, whether outcomes were statistically significant, and whether statistically significant outcomes were more likely to be reported. We proposed and tested a model to adjust for unreported outcomes and compared our model to three other methods (Copas, Frosi, trim and fill). Our approach assumes that unreported outcomes had a null intervention effect with variance imputed based on the published outcomes. We further compared our approach to these models using simulation, and by varying levels of missing data and study sizes. RESULTS: There were 286 outcomes reported as collected from 47 included trials: 142 (48%) had the data provided and 144 (52%) did not. Reported outcomes were more likely to be statistically significant than those collected but for which data were unreported and for which non-significance was reported (RR, 2.4; 95% CI, 1.9 to 3.0). Our model and the Copas model provided similar decreases in the pooled effect sizes in both the meta-analytic data and simulation studies. The Frosi and trim and fill methods performed poorly. LIMITATIONS: Single intervention of a single disease with only randomized controlled trials; approach may overestimate outcome reporting bias impact. CONCLUSION: There was evidence of selective outcome reporting. Statistically significant outcomes were more likely to be published than non-significant ones. Our simple approach provided a quick estimate of the impact of unreported outcomes on the estimated effect. This approach could be used as a quick assessment of the potential impact of unreported outcomes.

I don't think that means what you think it means: Why precision in lifelong learning terminology matters to medical education.

ISSUE: Medical educators share the belief that fostering the development of lifelong learning skills is a fundamental task for teachers and learners in all stages of a physician's education: undergraduate medical education, graduate medical education, and continuing medical education. A significant challenge to developing and implementing best practices in lifelong learning is the varied interpretation and application of its related terminology, such as 'self-directed learning' in this context. EVIDENCE: This paper discusses the scholarly origins of key terms in lifelong learning ('self-directed learning' and 'self-regulated learning') and explores their commonalities and their common conflation. IMPLICATION: The authors propose a renewed attention to precision in use of lifelong learning terminology in medical education across the spectrum as a way to best design and deploy impactful educational experiences for learners at all levels.

Tool to improve patient-provider interactions in adult primary care: Randomized controlled pilot study.

OBJECTIVE: To assess whether an intervention to help patients prioritize goals for their visit would improve patient-provider communication and clinical outcomes. DESIGN: Randomized controlled pilot study. SETTING: Primary care clinic. PARTICIPANTS: There were 120 adult hypertensive patients enrolled. INTERVENTION: Patients were randomized to receive either usual care or a previsit patient activation card developed through a series of focus groups that prompted patients to articulate their needs and set priorities for their clinic visit. Encounters were audiorecorded, transcribed, and assessed using duplicate ratings of patient activation and decision making. MAIN OUTCOME MEASURES: The primary outcome was change in medication adherence as measured by pill count at 4 and 12 weeks after the initial visit. Secondary outcomes evaluated patient-provider interaction quality (patient satisfaction, patient activation, shared decision making, patient trust, and physicians' perceived difficulty of the encounter), functional status, and blood pressure control. RESULTS: Of the 120 enrolled patients, 106 completed the baseline visit (mean age of 66 years, 53% women, 57% Black, 36% White). Participants had multiple comorbidities (median number of medications = 8). During the visit, there was greater patient activation in the intervention arm than in the control arm (4.4 vs 3.8, P = .047; ratings were based on a scale from 1 to 10). However, after the visit there were no differences in medication adherence (4 weeks: 45.8% vs 49.5%; 12 weeks: 49.4% vs 51.1%), blood pressure control (4 weeks: 133/78 mm Hg vs 131/77 mm Hg; 12 weeks: 129/77 mm Hg vs 129/76 mm Hg), or encounter satisfaction (78.6% vs 73.8% fully satisfied; P = .63). There were also no differences in shared decision making, patients' trust, or perceived difficulty of the encounter. CONCLUSION: A single previsit tool designed to prompt patients to set a prioritized agenda improved patient activation during the visit, but did not affect the quality of the interaction or postvisit patient-centred outcomes.

Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot.

BACKGROUND: Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value. OBJECTIVE: To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients. DESIGN: A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation. PARTICIPANTS: High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites. APPROACH: We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects. KEY RESULTS: Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization. CONCLUSIONS: Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).

Implementation of a patient-collected audio recording audit & feedback quality improvement program to prevent contextual error: stakeholder perspective.

BACKGROUND: Using patient audio recordings of medical visits to provide clinicians with feedback on their attention to patient life context in care planning can improve health care delivery and outcomes, and reduce costs. However, such an initiative can raise concerns across stakeholders about surveillance, intrusiveness and merit. This study examined the perspectives of patients, physicians and other clinical staff, and facility leaders over 3 years at six sites during the implementation of a patient-collected audio quality improvement program designed to improve patient-centered care in a non-threatening manner and with minimal effort required of patients and clinicians. METHODS: Patients were invited during the first and third year to complete exit surveys when they returned their audio recorders following visits, and clinicians to complete surveys annually. Clinicians were invited to participate in focus groups in the first and third years. Facility leaders were interviewed individually during the last 6 months of the study. RESULTS: There were a total of 12 focus groups with 89 participants, and 30 leadership interviews. Two hundred fourteen clinicians and 800 patients completed surveys. In a qualitative analysis of focus group data employing NVivo, clinicians initially expressed concerns that the program could be disruptive and/or burdensome, but these diminished with program exposure and were substantially replaced by an appreciation for the value of low stakes constructive feedback. They were also significantly more confident in the value of the intervention in the final year (p = .008), more likely to agree that leadership supports continuous improvement of patient care and gives feedback on outcomes (p = .02), and at a time that is convenient (p = .04). Patients who volunteered sometimes expressed concerns they were "spying" on their doctors, but most saw it as an opportunity to improve care. Leaders were supportive of the program but not yet prepared to commit to funding it exclusively with facility resources. CONCLUSIONS: A patient-collected audio program can be implemented when it is perceived as safe, not disruptive or burdensome, and as contributing to better health care.

Does Provider Gender Affect the Quality of Primary Care?

BACKGROUND: Women providers have a more patient-centered communication style than men, and some studies have found women primary care providers are more likely to meet quality performance measures. OBJECTIVE: To explore gender differences in the quality of primary care process and outcome measures. DESIGN: Retrospective analysis of primary care performance data from 1 year (2018-2019). PARTICIPANTS: A total of 586 primary care providers (311 women and 275 men) who cared for 241,428 primary care patients at 96 primary care clinics at 8 Veterans Affairs (VA) medical centers. MAIN MEASURES: Our primary outcome was a composite quality measure that averaged all thirty-four primary care performance measures that assessed performance in cancer screening, diabetes care, cardiovascular care, tobacco counseling, risky alcohol screening, immunizations, HIV testing, opiate care, and continuity. Our secondary outcomes were performance on each of the 34 measures. KEY RESULTS: There was no difference in the average performance on our composite measure between men and women (75.8% vs. 76.6%, p = 0.17). Among the 34 primary care quality measures collected, there was no difference between male and female providers' performance. Using a more conservative cut-point, women were more likely to screen at-risk diabetic patients for hypoglycemia and document follow-up on risky alcohol behavior noted during patient check-in. These differences were clinically small and likely due to chance, given the multiple measures evaluated in this study. CONCLUSIONS: We found little evidence of difference in the performance on primary care quality measures between male and female providers.

Sexual Harassment of Female Providers by Patients: a Qualitative Study.

BACKGROUND: Sexual harassment of women is a pervasive problem. Prior studies found that sexual harassment of female providers by patients is common, but guidance on addressing this problem is limited. OBJECTIVE: To understand the experiences of female providers with sexual harassment by patients with a focus on how practicing providers address these events. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Twenty female, internal medicine providers, including resident physicians, staff physicians, and nurse practitioners at a large, urban, academic hospital in the USA. APPROACH: Interviews were analyzed for themes. KEY RESULTS: Two themes were explored: first, the experiences with sexual harassment and, second, the strategies to address sexual harassment. We coded four sub-themes regarding participant experiences: (1) their descriptions of the types of harassment, (2) the context of the event, (3) the impact of the harassment, and (4) their preparation to address the harassment. We coded seven sub-themes on strategies used by participants: (1) indirect strategies, (2) confrontation, (3) modifying the clinical encounter, (4) modifying self, (5) alerting others, (6) debrief, and (7) report. CONCLUSION: Our qualitative study found that sexual harassment of female providers by patients is an ongoing problem, disruptive to the patient-provider relationship, and a possible threat to the well-being of both provider and patient. Formal training on how to address this problem was lacking, but all providers had developed or adapted strategies based on personal experiences or role modeling. Educating providers on strategies is an important next step to addressing this problem.

The Experience of Male Physicians with Sexual and Gender-Based Harassment: a Qualitative Study.

BACKGROUND: Sexual harassment and gender-based harassment are common in medicine; however, there is little in the literature regarding men's experience with gender-based and sexual harassment. OBJECTIVE: The objective of this study was to better understand the experience men have with sexual and gender-based harassment in medicine. DESIGN: We developed and piloted an interview guide based on a review of the literature and conducted semi-structured interviews of male physicians, from trainees to attendings, at a tertiary care facility. Participants were recruited via email between April and August of 2019. These interviews were transcribed verbatim and, using an iterative coding approach based in grounded theory, were coded and analyzed for themes. MAIN RESULTS: We conducted a total of 16 interviews. Five major themes were identified: (1) personal experiences of harassment, (2) witnessed harassment, (3) characterization of harassment, (4) impact of harassment, and (5) strategies for responding to harassment. The men reported experiences with sexual and gender-based harassment but were hesitant to define these encounters as such. They had minimal emotional distress from these encounters but worried about their professional reputation and lacked training for how to respond to these encounters. Many had also witnessed their female colleagues being harassed by both male patients and colleagues but did not respond to or stop the harassment when it originated from a colleague. CONCLUSION: We found that men experience sexual harassment differently from women. Most notably, men report less emotional distress from these encounters and often do not define these events as harassment. However, similar to women, men feel unprepared to respond to episodes of harassment against themselves or others. Whether to deter sexual harassment against themselves, or, more commonly, against a female colleague, men can gain the tools to speak up and be part of the solution to sexual harassment in medicine.

Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis.

BACKGROUND: Clinical practice guidelines recommend performing a cuff leak test in mechanically ventilated adults who meet extubation criteria to screen those at high risk for post-extubation stridor. Previous systematic reviews demonstrated excellent specificity of the cuff leak test but disagreed with respect to sensitivity. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the cuff leak test for predicting post-extubation airway complications in intubated adult patients in critical care settings. METHODS: We searched Medline, EMBASE, Scopus, ISI Web of Science, the Cochrane Library for eligible studies from inception to March 16, 2020, without language restrictions. We included studies that examined the diagnostic accuracy of cuff leak test if post-extubation airway obstruction after extubation or reintubation was explicitly reported as the reference standard. Two authors in duplicate and independently assessed the risk of bias using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We pooled sensitivities and specificities using generalized linear mixed model approach to bivariate random-effects meta-analysis. Our primary outcomes were post-extubation airway obstruction and reintubation. RESULTS: We included 28 studies involving 4493 extubations. Three studies were at low risk for all QUADAS-2 risk of bias domains. The pooled sensitivity and specificity of cuff leak test for post-extubation airway obstruction were 0.62 (95% CI 0.49-0.73; I2 = 81.6%) and 0.87 (95% CI 0.82-0.90; I2 = 97.8%), respectively. The pooled sensitivity and specificity of the cuff leak test for reintubation were 0.66 (95% CI 0.46-0.81; I2 = 48.9%) and 0.88 (95% CI 0.83-0.92; I2 = 87.4%), respectively. Subgroup analyses suggested that the type of cuff leak test and length of intubation might be the cause of statistical heterogeneity of sensitivity and specificity, respectively, for post-extubation airway obstruction. CONCLUSIONS: The cuff leak test has excellent specificity but moderate sensitivity for post-extubation airway obstruction. The high specificity suggests that clinicians should consider intervening in patients with a positive test, but the low sensitivity suggests that patients still need to be closely monitored post-extubation.

Opioid Dose and Benzodiazepine Use Among Commercially Insured Individuals on Chronic Opioid Therapy.

OBJECTIVE: To examine morphine milligram equivalent (MME) trends, use of concurrent opioids and benzodiazepines, and opioid-related emergency department (ED) visits or hospitalizations in a national cohort of patients on chronic opioid therapy. DESIGN: Retrospective cohort analysis of prospectively collected data from the Truven Health MarketScan Commercial Claims and Encounters database from 2009 to 2015. This includes individuals in both the Commercial Claims and Medicare Supplemental databases of MarketScan. METHODS: MME comparisons of 1) patients on chronic opioids with and without opioid-related ED visits or hospitalizations, 2) patients on concurrent opioids and benzodiazepines with and without opioid-related ED visits or hospitalizations, and 3) patients on chronic opioids compared with those on concurrent opioid and benzodiazepine using the Student t test. RESULTS: MME decreased from 194 mg in 2009 to 119 mg in 2015 among patients on chronic opioids. Patients on opioids and benzodiazepines had higher doses than those on opioids alone for all years (P < 0.001). Those with an opioid-related ED visit or hospitalization had a higher average MME than those without, for all years except 2009 (P < 0.05). Patients on chronic opioids or on concurrent benzodiazepine with an MME >50 had a twofold increased risk of having an opioid-related ED visit or hospitalization compared with those with an MME <50, for all years. CONCLUSIONS: Although the average MME decreased over time, patients on combination opioid and benzodiazepine and those with opioid-related ED visits and hospitalizations had significantly higher doses.