Burnout in Academic Medicine: A Peripandemic Assessment.

The impact of burnout on academic medicine has affected its 3 major missions-education, patient care, and research-in ways both similar to and dissimilar from the community practice of medicine. The authors have assessed major themes in the literature regarding burnout in health care professionals in academic medicine in the peripandemic periods-pre-, intra-, and postpandemic-to gain information on the impact of the pandemic on these perspectives. Additionally, burnout in military physicians, particularly in the military medicine academic community, was assessed to provide comparative perspectives on the factors of military training, personal resiliency, and unit cohesiveness on the development of, or resistance to, professional burnout. Overall, there are data to indicate an aggravation of burnout during the pandemic, but currently no long-term data to indicate a persistence of its effects over time on health care professionals beyond baseline prevalence identified prepandemic. Based on the assessments, recommendations are provided for future research, including clarification and standardization of the concepts of burnout, developing longitudinal studies on health care practitioner burnout status with preventive and/or mitigating interventions, and the special protection of certain professionals, including female physicians, physicians in training, and early-career faculty, including nonclinical researchers.

Medical Ethics in Extreme and Austere Environments.

American society has a history of turning to physicians during times of extreme need, from plagues in the past to recent outbreaks of communicable diseases. This public instinct comes from a deep seated trust in physician duty that has been earned over the centuries through dedicated and selfless care, often in the face of personal risks. As dangers facing our communities include terroristic events physicians must be adequately prepared to respond, both medically and ethically. While the ethical principles that govern physician behavior-beneficence, nonmaleficence, autonomy, and social justice-are unchanging, fundamental doctrines must change with the new risks inherent to terroristic events. Responding to mass casualty disasters caused by terrorists, natural calamities, and combat continue to be challenging frontiers in medicine. Preparing physicians to deal with the consequences of a terroristic disease must include understanding the ethical challenges that can occur.

The changing case-mix of hip fractures in Scotland - evidence from the Scottish Hip Fracture Audit.

Until discontinued in 2008, the Scottish Hip Fracture Audit collected and reported on data relating to the quality of care of hip fracture patients in Scotland. In 2013, the audit was recommenced under the umbrella of the MSK Audit group, which audits high volume orthopaedic pathways across Scotland. Our aim is to report on the changes in the demographics of hip fracture patients in Scotland between 2003 and 2013. There was an increase in the proportion of male patients from 2003 to 2013 (22.4% to 29.5%; p < 0.0001). An increased percentage of hip fracture patients were admitted from their own home (63.9% to 73.1%; p < 0.0001). Both these factors have deleterious effects on the outcome, and use of necessary resources, following hip fracture. There was also an increase in the percentage of patients who were American Society of Anesthesiologists Grade 3 (52.9% to 56.4%). Over the last decade, there has been a shift in the demographics of Scotland's hip fracture patients. If hip fracture incidence increases as predicted, this potentially more-challenging case-mix will likely impact on multiple health resources.

Does delay to theatre for medical reasons affect the peri-operative mortality in patients with a fracture of the hip?

We have investigated how medical postponement, the time to surgery and the correction of medical abnormalities, according to McLaughlin criteria, before operation affected peri-operative mortality after fracture of the hip. From February to December 2007, in addition to core data, the Scottish Hip Fracture Audit collected information relating to surgical delay. Data were available for 4284 patients which allowed 30-day survival analysis to be performed. Multivariable logistic regression models were used to control for differences in case-mix. Patients with major clinical abnormalities were more likely to have a postponement and had a lower unadjusted 30-day survival. The time to operation and postponement were not associated with higher mortality after adjustment for case-mix. Correction of major clinical abnormalities before surgery improved the adjusted survival, but this improvement was not significant (p = 0.10). Postponement without correction of a medical abnormality before surgery was associated with a significantly lower (p = 0.006) 30-day adjusted survival. The possible benefits of postponement need to be weighed against prolonged discomfort for the patient and the possibility of the development of other complications.

Changes in population demographics and the future incidence of hip fracture.

BACKGROUND: During the first three decades of the 21st century the combination of increasing life expectancy and falling birth rates will result in substantial demographic changes within the population of the United Kingdom. A large increase in the elderly population is likely to have significant effects on the number of patients who sustain a hip fracture. AIM: To predict future changes in hip fracture burden in Scotland. MATERIALS AND METHODS: Data was obtained from the Scottish Hip Fracture Audit database for a 12 month period between April 2004 and March 2005. All orthopaedic units in Scotland participated in the audit during this period. This data was used to calculate the incidence of hip fracture by 5 year age/gender cohorts. Outcome data was analysed in a similar manner. Population prediction data obtained from the Registrar General's Office was then used to predict hip fracture numbers for the year 2031. Two separate prediction models were used. The first model assumed that the age/gender specific incidence of hip fracture observed in 2004 would remain constant. Between 1999 and 2004, a 9.6% decrease in the population incidence of hip fracture was observed. Therefore a second prediction model was used which assumed a continuation in the fall in population incidence of hip fracture between 2004 and 2031. RESULTS: The population aged 50 years and above is predicted to increase 28% by 2031, with the most significant increases occurring in the over 1980s. The number of hip fractures is predicted to rise by 45% to 75% (from 6164 to 8829-10756 cases per annum) requiring an additional 287-474 hospital beds. By 2031 approximately 45% of fractures will occur in those aged 85 years and above, compared to 34% in 2004. Predicted changes in population demographics are highly variable by region and so local planning of resource provision will be essential. CONCLUSION: Changes in population demographics will have significant implications for health care provision for the care of hip fracture patients. An increase in the capacity of acute orthopaedic care and a review of care models will be required to ensure adequate resource provision.

Outcome after surgery for the treatment of hip fracture in the extremely elderly.

BACKGROUND: As a consequence of changes in population demographics, the extremely elderly represent one of the fastest growing groups in Western society. Previous studies have associated advanced age with increased mortality after hip fracture; however, this finding has not been consistent. METHODS: The Scottish Hip Fracture Audit is a prospective, national, multicenter study that collects data on patients over the age of fifty years who are admitted to the hospital with a hip fracture. For the present study, we used data collected from twenty-two acute-care orthopaedic units between January 1998 and December 2005. The extremely elderly cohort consisted of 919 individuals with an age of ninety-five years or more. Case-mix variables and outcomes were compared with those for a modal control group of 15,461 individuals who were seventy-five to eighty-nine years of age. Outcome measures included thirty and 120-day mortality rates, the length of the hospital stay, the place of residence, and mobility. A multivariable logistic regression model was used to compare outcomes between groups while controlling for significant case-mix variables. RESULTS: The extremely elderly presented with poorer indicators of health status as demonstrated by higher American Society of Anesthesiologists scores. In addition, this group was less likely to be independently mobile and more likely to be in institutional care at the time of the fracture (p < 0.001). Mortality at thirty and 120 days was higher in the extremely elderly even after adjusting for case-mix variables. The extremely elderly also were less likely to return home or to return to previous levels of mobility. CONCLUSIONS: Although the extremely elderly exhibited a higher prevalence of prefracture indicators of poor outcome, statistical control for these case-mix variables showed further age-related deterioration in survival and outcomes after surgery for the treatment of a hip fracture.

Epidemiology and outcome after hip fracture in the under 65s-evidence from the Scottish Hip Fracture Audit.

AIM: To report the epidemiology and outcomes after hip fractures in the patients under 65 years of age. PATIENTS AND METHODS: We performed a prospective, multi-centre observational study using the Scottish Hip Fracture Audit Database. Case-mix, process and outcome data was collected by dedicated coordinators on site at the time of admission, at 120 days after the injury and on any re-operations within 12 months. The study cohort consisted of 1896 individuals aged 50-64 years. Patient variables and outcomes were compared to a control group of 15,461 individuals aged 75-89 years of age. The control group consisted of three modal 5-year age groups centred about a median age of 83 years, equal to the database value, excluding the effects of the extreme elderly who may act as confounders. Outcomes measures included 30- and 120-day mortality, length of hospital stay, place of residence and ambulatory status. A multivariate logistic regression model was used to compare outcome between groups while controlling for significant case-mix variables. RESULTS: Patients in the study cohort presented with lower ASA scores and were more likely to be independently mobile and live in their own home at the time of fracture (p<0.001). Pathological fractures were more common in younger patients and accounted for more than 1 in 20 fractures. Mortality at 30 and 120 days was significantly lower (p<0.0001) in the study cohort, however it was increased compared to age and gender adjusted mortality rates for the general population (p<0.001) Younger patients were more likely to recover independent mobility and living. CONCLUSION: Patients aged 50-64 years have significantly better outcome measures after surgery for hip fracture in terms of survival and function. Such differences exist even after controlling for differences in patient case-mix variables.

Making difficult ethical decisions in patient care during natural disasters and other mass casualty events.

OBJECTIVE: Recent experiences in the United States with unprecedented terrorist attacks (9/11) and a devastating natural disaster (Hurricane Katrina) have demonstrated that the medical care of mass casualties during such disasters poses ethical problems not normally experienced in civilian health care. It is important to 1) identify the unique ethical challenges facing physicians who feel an obligation to care for victims of such disasters and 2) develop a national consensus on ethical guidelines as a resource for ethical decision making in medical disaster relief. STUDY DESIGN: A survey of pertinent literature was performed to assess experience and opinions on the condition of medical care in terrorist attacks and natural disasters, the ethical challenges of disaster medical care, and the professional responsibilities and responsiveness in disasters. CONCLUSIONS: It is necessary to develop a national consensus on the ethical guidelines for physicians who care for patients, victims, and casualties of disasters, and to formulate a virtue-based, yet practical, ethical approach to medical care under such extreme conditions. An educational curriculum for medical students, residents, and practicing physicians is required to best prepare all physicians who might be called upon, in the future, to triage patients, allocate resources, and make difficult decisions about treatment priorities and comfort care. It is not appropriate to address these questions at the time of the disaster, but rather in advance, as part of the ethics education of the medical profession. Important issues for resolution include inpatient and casualty triage and prioritization, medical liability, altered standards of care, justice and equity, informed consent and patient autonomy, expanding scope of practice in disaster medicine, and the moral and ethical responsibilities of physicians to care for disaster victims.

Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit.

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered.

An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues.

BACKGROUND: Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach. METHOD: A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID. RESULTS: There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

The socioeconomic status of older adults: how should we measure it in studies of health inequalities?

STUDY OBJECTIVE: To identify which of seven indicators of socioeconomic status used singly or combined with one other would be most useful in studies of health inequalities in the older population. DESIGN: Secondary analysis of socioeconomic and health data in a two wave survey. SETTING: Great Britain. Participants were interviewed at home by a trained interviewer. PARTICIPANTS: Nationally representative sample of 3543 adults aged 55-69 interviewed in 1988/9, 2243 of whom were interviewed again in 1994. METHODS: Desirable features of socioeconomic measurement systems for identifying health inequalities in older populations were identified with reference to the literature. Logistic regression was used to examine variations in self reported health by seven indicators of socioeconomic status. The pair of indicators with the greatest explanatory power was identified. MAIN RESULTS: All indicators were significantly associated with differences in self reported health. The best pair of variables, according to criteria used, was educational qualification or social class paired with a deprivation indicator. DISCUSSION: For a range of reasons the measurement of socioeconomic status is particularly challenging in older age groups. Extending our knowledge of which indicators work well in analyses and are relatively easy to collect should help both further study of health inequalities in the older population and appropriate planning.

BIOMED-MEROPE project: service provision for adults with intellectual disability: a European comparison.

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self-advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.

Adult life experiences and health in early old age in Great Britain.

In Britain and other developed countries older people comprise a large majority of all those reporting long term illness or disability. However, most studies of socio-demographic variations in health have focussed on those in younger age groups. Moreover approaches to the study of health variations are often fragmented. In this study we have adopted a life course approach to analyse differentials in health in early old age. The data comes from the Retirement and Retirement Plans Survey and follow-up, a two-wave study of persons aged 55-69 in 1988/9. As well as information on current circumstances, the data set includes occupational, marital, and fertility history information. At baseline a nationally representative sample of the population of Great Britain were interviewed at home by trained interviewers (n = 3543). The sample was followed up and in 1994, 2247 survivors were re-interviewed, a response rate of 70% (of survivors). The data were weighted to adjust for non-response bias. Two outcome measures were used: self rated health and presence or absence of disability assessed from a scale derived from detailed questions on thirteen domains of disability. The severity score used was that developed for the 1985/6 ONS Surveys of Disability. The findings indicate that health and disability status at baseline and at follow up were associated with socioeconomic and geographic variables, such as proportion of adult life spent unemployed and residence outside the Southeast of England; demographic factors, such as early age at marriage and high parity; and experience of adverse events, such as the death of a child and being dismissed from work. The results show that socio-economic, demographic, and geographical and life events' factors are all associated with health status in early old age and that integrated, rather than bifurcated, approaches to the study of health differentials are needed.

Paying surgeons less can cost more.

Fees for physicians' services represent only a small component of total health care costs. Complementary costs (particularly hospital charges for surgical treatment) are a far more substantial portion of total costs, and may be 10 times larger than surgical fees. Because surgeons have considerable influence over the demand for surgery, and because the complementary costs do not cost the surgeon at all, marginally lowering surgeons' fees can, paradoxically, increase total health care costs, even if net payments to surgeons go down. This is because surgeons may respond to a decrease in their per-case reimbursements by performing more surgery to maintain their status-quo income. This phenomenon is known as physician income homeostasis. A health care payer may benefit by paying surgeons more to perform tasks that do not have high associated costs, such as outpatient nonoperative care, research, or teaching. In this fashion, faced with declining surgical fees, the surgeon will maintain his or her income not by performing more expensive surgery, but rather by doing more nonoperative work.