Succeeding in Aging Research During the Pandemic: Strategies for Fellows and Junior Faculty.

Fellows and junior faculty conducting aging research have encountered substantial new challenges during the COVID-19 pandemic. They report that they have been uncertain how and whether to modify existing research studies, have faced difficulties with job searches, and have struggled to balance competing pressures including greater clinical obligations and increased responsibilities at home. Many have also wondered if they should shift gears and make COVID-19 the focus of their research. We asked a group of accomplished scientists and mentors to grapple with these concerns and to share their thoughts with readers of this journal.

Embryo transfer training in fellowship: national and institutional data.

OBJECTIVE: To evaluate current national practices in embryo transfer (ET) training in United States reproductive endocrinology and infertility (REI) fellowship programs and live birth rates after ET performed by fellows versus attending physicians. DESIGN: Cross-sectional survey of U.S. fellowship program directors and fellows in 2019 and retrospective cohort study of IVF cycle outcomes after ET performed by fellows versus attending physicians. SETTING: Not applicable. PATIENT(S): Fellowship program directors and fellows completed a survey. Embryo transfers from 2015-2018 were analyzed. INTERVENTION(S): A survey assessed experiences with ET training. Cycle outcomes were analyzed. MAIN OUTCOME MEASURE(S): Proportion of fellows performing ET during training, and live birth rate following fellow and faculty ETs. RESULT(S): Anonymous surveys were sent to 51 REI fellowship program directors and 142 fellows. Twenty-one percent (15/73) reported that no ETs were performed by fellows. Forty-four percent of third-year fellows had performed fewer than ten ETs during fellowship training. Retrospective review of 940 blastocyst ETs revealed no difference in live birth rates between fellows and attending physicians: 51.6% (131/254) versus 49.4% (339/686), respectively. CONCLUSION(S): This study revealed striking differences between fellowship programs regarding the adequacy of ET training; nearly one-half of third-year fellows had performed fewer than ten ETs. With appropriate supervision, there is no difference in live birth rate between ETs performed by fellows and attending physicians. Efforts should be made to address barriers and set minimums for the number of transfers performed during fellowship.

Regional disparities in health care resources in traditional Chinese medicine county hospitals in China.

OBJECTIVE: We aimed to analyze regional disparities of health care resources in traditional Chinese medicine (TCM) county hospitals and their time trends, and to assess the changes of regional disparities before and after 2009 health care reforms. METHODS: We used hospital-based, longitudinal data from all TCM county hospitals in China between 2004 and 2016. To measure the key development features of TCM county hospitals, data were collected on government hospital investment, hospital numbers (the average number of TCM hospitals per county), hospital scale (the number of medical staff and hospital beds) and doctors' workload (the daily visits and inpatient stays per doctor). We used segmented linear regression to test the time trend for outcome variables. We set a breakpoint at 2011, dividing the pre-reform (2004-2011) and post-reform (2012-2016) periods. RESULTS: After the 2009 health reforms, TCM hospitals continued to display large disparities in the number, scale, and doctors' workload across the three regions. In the pre-reform period, yearly government subsidies for TCM hospitals in western area were roughly RMB0.6 million (US$89 thousand) more than those in central and eastern region, which increased under the 2009 reforms to roughly RMB2 million (US$298 thousand) more per yer in post-reform period. These increased subsidies saw an increase in the number of TCM hospitals in the western area, partly addressing regional disparities. But there was no improvement in the regional disparities in terms of scale (number of beds) and the doctors' workload (daily outpatient visits and inpatients per doctor) increased or remained unchanged between the western and other regions. CONCLUSION: Although TCM hospital number, scale, and doctors' workload increased over the past 13 years, substantial regional disparities remained. The 2009 health reforms did not significantly change the regional disparities in health care resources, especially between the eastern and western regions.

Trends in Surgeon Wellness (Take a Sad Song and Make It Better): A Comparison of Surgical Residents, Fellows, and Attendings.

We aim to investigate the prevalence of posttraumatic stress disorder (PTSD), physician burnout (PBO), and work-life balance (WLB) among surgical residents, fellows, and attendings to illustrate the trends in surgeon wellness. A cross-sectional national survey of surgical residents, fellows, and attendings was conducted screening for PTSD, PBO, and WLB. The prevalence of screening positive for PTSD was more than two times that of the general population at all levels of experience, and more than half have an unhealthy WLB. The prevalence of PTSD, PBO, and unhealthy WLB declined with increasing level of experience (P < 0.001). One deviation in this trend was a lower prevalence of PBO among surgical fellows compared with residents and attendings (P < 0.001). Surgeon wellness improved with increasing level of experience. The incorporation of wellness programs into surgical residencies is essential to the professional development of young surgeons to cultivate healthy lasting habits for a well-balanced career and life.

The Growing Executive-Physician Wage Gap in Major US Nonprofit Hospitals and Burden of Nonclinical Workers on the US Healthcare System.

BACKGROUND: In an era of increasing healthcare costs, the number and value of nonclinical workers, especially hospital management, has come under increased study. Compensation of hospital executives, especially at major nonprofit medical centers, and the "wage gap" with physicians and clinical staff has been highlighted in the national news. To our knowledge, a systematic analysis of this wage gap and its importance has not been investigated. QUESTIONS/PURPOSES: (1) How do wage trends compare between physicians and executives at major nonprofit medical centers? (2) What are the national trends in the wages and the number of nonclinical workers in the healthcare industry? (3) What do nonclinical workers contribute to the growth in national cost of healthcare wages? (4) How much do wages contribute to the growth of national healthcare costs? (5) What are the trends in healthcare utilization? METHODS: We identified chief executive officer (CEO) compensation and chief financial officer (CFO) compensation at 22 major US nonprofit medical centers, which were selected from the US News & World Report 2016-2017 Hospital Honor Roll list and four health systems with notable orthopaedic departments, using publicly available Internal Revenue Service 990 forms for the years 2005, 2010, and 2015. Trends in executive compensation over time were assessed using Pearson product-moment correlation tests. As institution-specific compensation data is not available, national mean compensation of orthopaedic surgeons, pediatricians, and registered nurses was used as a surrogate. We chose orthopaedic surgeons and pediatricians for analysis because they represent the two ends of the physician-compensation spectrum. US healthcare industry worker numbers and wages from 2005 to 2015 were obtained from the Bureau of Labor Statistics and used to calculate the national cost of healthcare wages. Healthcare utilization trends were assessed using data from the Agency for Healthcare Quality and Research, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey. All data were adjusted for inflation based on 2015 Consumer Price Index. RESULTS: From 2005 to 2015, the mean major nonprofit medical center CEO compensation increased from USD 1.6 ± 0.9 million to USD 3.1 ± 1.7 million, or a 93% increase (R = 0.112; p = 0.009). The wage gap increased from 3:1 to 5:1 with orthopaedic surgeons, from 7:1 to 12:1 with pediatricians, and from 23:1 to 44:1 with registered nurses. We saw a similar wage-gap trend in CFO compensation. From 2005 to 2015, mean healthcare worker wages increased 8%. Management worker wages increased 14%, nonclinical worker wages increased 7%, and physician salaries increased 10%. The number of healthcare workers rose 20%, from 13 million to 15 million. Management workers accounted for 3% of this growth, nonclinical workers accounted for 27%, and physicians accounted for 5% of the growth. From 2005 to 2015, the national cost-burden of healthcare worker wages grew from USD 663 billion to USD 865 billion (a 30% increase). Nonclinical workers accounted for 27% of this growth, management workers accounted for 7%, and physicians accounted for 18%. In 2015, there were 10 nonclinical workers for every one physician. The cost of healthcare worker wages accounted for 27% of the growth in national healthcare expenditures. From 2005 to 2015, the number of inpatient stays decreased from 38 million to 36 million (a 5% decrease), the number of physician office visits increased from 964 million to 991 million (a 3% increase), and the number of emergency department visits increased from 115 million to 137 million (a 19% increase). CONCLUSIONS: There is a fast-rising wage gap between the top executives of major nonprofit centers and physicians that reflects the substantial, and growing, cost of nonclinical worker wages to the US healthcare system. However, there does not appear to be a proportionate increase in healthcare utilization. These findings suggest a growing, substantial burden of nonclinical tasks in healthcare. Methods to reduce nonclinical work in healthcare may result in important cost-savings. LEVEL OF EVIDENCE LEVEL: IV, economic and decision analysis.

Provision of stroke thrombolysis services in New Zealand: changes between 2011 and 2016.

AIMS: To obtain an overall picture of the organisation of stroke thrombolysis provision in New Zealand hospitals and compare changes between 2011 and 2016. METHODS: Surveys were distributed to all New Zealand district health boards (DHBs) in 2011 and 2016, and included questions about the infrastructure, staffing, training, guidelines and audit provided for stroke thrombolysis. RESULTS: Responses were received from all DHBs, with 86% offering stroke thrombolysis in 2011 and 100% in 2016. In 2016, thrombolysis rosters of large DHBs (those with a population >250,000 people) had a mean (range) of 14 (5-34) clinicians, approximately double that of medium-sized DHBs (population 125-250,000) who had eight (3-15) and small DHBs (population <125,000) with seven, (2-13) clinicians. While a similar distribution of senior medical officer clinical specialty was seen across medium and small DHBs in both years, large DHBs in 2016 had a higher number of neurologists (5, 1-12) and an increasing number of general physicians (8, 0-30) rostered to provide thrombolysis compared to 2011. Thrombolysis services at medium and small DHBs are chiefly managed by general physicians and geriatricians, while telestroke support was only available in three medium-sized DHBs. In 2016, all hospitals had developed thrombolysis guidelines and audited thrombolysed patients in the National Stroke Thrombolysis Register, which is an improvement compared with 2011 when only seven (39%) DHBs reported regular audit. Challenges in staffing and training remain greatest in smaller and geographically isolated DHBs. CONCLUSION: While there have been improvements in the provision of stroke thrombolysis throughout New Zealand, regional variations in service quality remains. The needs for better solutions to geographical barriers and formal training must be addressed as priorities.

Analysis of Compensation Disparities between Junior Academic and Private Practice Vascular Surgeons.

BACKGROUND: Compensation may be a significant factor for academic vascular surgeons seeking or changing employment. We compared compensation for academic and private practice vascular surgeons practicing for approximately similar duration. METHODS: Compensation data for academic and private practice vascular surgeons were obtained from the Association of American Medical Colleges (AAMC) and Medical Group Management Association (MGMA), respectively. Comparisons of nominal annual compensation data were made between Group 1 (assistant professor vascular surgeons versus private practice vascular surgeons in practice for 1-7 years), Group 2 (associate professor vascular surgeons versus private practice vascular surgeons in practice for 8-17 years), and Group 3 (professor vascular surgeons versus private practice vascular surgeons in practice for ≥18 years) from 2003 to 2012. RESULTS: In Group 1, there was a $54,500 difference in 2003 (P = 0.043) which increased to $110,500 by 2012 (P = 0.001). In Group 2, there was a $44,200 difference in 2007 (P = 0.016) which increased to $53,400 by 2010 (P = 0.034). In Group 3, there was no statistically significant difference in compensation (P ≥ 0.999). CONCLUSIONS: There is a significant and increasing disparity in compensation in favor of private practice vascular surgeons compared with assistant professor vascular surgeon faculty. Differences equalized with increasing seniority and experience. Compensation plans should be market based and in line with nonacademic benchmarks as well.

Understanding specialist sharing: A mixed-method exploration in an increasingly price-competitive hospital market.

INTRODUCTION: Medical specialists seem to increasingly work in- and be affiliated to- multiple organizations. We define this phenomenon as specialist sharing. This form of inter-organizational cooperation has received scant scholarly attention. We investigate the extent of- and motives behind- specialist sharing, in the price-competitive hospital market of the Netherlands. METHODS: A mixed-method was adopted. Social network analysis was used to quantitatively examine the extent of the phenomenon. The affiliations of more than 15,000 medical specialists to any Dutch hospital were transformed into 27 inter-hospital networks, one for each medical specialty, in 2013 and in 2015. Between February 2014 and February 2016, 24 semi-structured interviews with 20 specialists from 13 medical specialties and four hospital executives were conducted to provide in-depth qualitative insights regarding the personal and organizational motives behind the phenomenon. RESULTS: Roughly, 20% of all medical specialists are affiliated to multiple hospitals. The phenomenon occurs in all medical specialties and all Dutch hospitals share medical specialists. Rates of specialist sharing have increased significantly between 2013 and 2015 in 14 of the 27 specialties. Personal motives predominantly include learning, efficiency, and financial benefits. Increased workload and discontinuity of care are perceived as potential drawbacks. Hospitals possess the final authority to decide whether and which specialists are shared. Adhering to volume norms and strategic considerations are seen as their main drivers to share specialists. DISCUSSION: We conclude that specialist sharing should be interpreted as a form of inter-organizational cooperation between healthcare organizations, facilitating knowledge flow between them. Although quality improvement is an important perceived factor underpinning specialist sharing, evidence of enhanced quality of care is anecdotal. Additionally, the widespread occurrence of the phenomenon and the underlying strategic considerations could pose an antitrust infringement.

Making doctors manage but how? Recent developments in the Italian NHS.

BACKGROUND: Involving doctors in management has been intended as one of the strategies to spread organizational principles in healthcare settings. However, professionals often resist taking on relevant managerial responsibility, and the question concerning by which means to engage doctors in management in a manner that best fit the challenges encountered by different health systems remains open to debate. METHODS: This paper analyzes the different forms of medical management experienced over time in the Italian NHS, a relevant "lab" to study the evolution of the involvement of doctors in management, and provides a framework for disentangling different dimensions of medical management. RESULTS: We show how new means to engage frontline professionals in management spread, without deliberate planning, as a consequence of the innovations in service provision that are introduced to respond to the changes in the healthcare sector. CONCLUSIONS: This trend is promising because such means of performing medical management appear to be more easily compatible with professional logics; therefore, this could facilitate the engagement of a large proportion of professionals rather than the currently limited number of doctors who are "forced" or willing to take formal management roles.

Changes in the workload composition in a plastic surgery unit over a 12 year period.

BACKGROUND: Guidelines issued by the British Association of Plastic Reconstructive and Aesthetic Surgeons suggest that the ratio of elective to emergency cases in plastic surgery units should be 2:1. AIM: To investigate how the workload composition of a regional plastic surgery unit compared with these guidelines. METHODS: The changes in the workload composition of a regional plastic surgery unit were examined by retrospectively analysing all plastic and reconstructive surgery cases performed over 12 years (1998-2009). RESULTS: This time period saw a change from a 1:2 ratio of elective to trauma procedures, to the recommended ratio, at a time when the overall caseload increased by almost 40 % (3,281 procedures in 1998 to 4,529 procedures in 2009). CONCLUSION: Expansion of staff numbers at consultant and non-consultant grades, and increased resources (allocated theatre sessions and outpatient clinics) were pivotal to this change.

Avoid costly mistakes of the past.

Physician employment is here to stay. The challenge for healthcare finance professionals is to make physician relationships work without the financial losses experienced by hospitals that tried physician employment in the past. Capturing market share should be a key strategy in any physician employment effort. Physicians who are engaged and actively involved in the process make great business partners because they understand the productivity, efficiencies, and cost controls needed to succeed.

Rising hospital employment of physicians: better quality, higher costs?

In a quest to gain market share, hospital employment of physicians has accelerated in recent years to shore up referral bases and capture admissions, according to the Center for Studying Health System Change's (HSC) 2010 site visits to 12 nationally representative metropolitan communities. Stagnant reimbursement rates, coupled with the rising costs of private practice, and a desire for a better work-life balance have contributed to physician interest in hospital employment. While greater physician alignment with hospitals may improve quality through better clinical integration and care coordination, hospital employment of physicians does not guarantee clinical integration. The trend of hospital-employed physicians also may increase costs through higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care. To date, hospitals' primary motivation for employing physicians has been to gain market share, typically through lucrative service-line strategies encouraged by a fee-for-service payment system that rewards volume. More recently, hospitals view physician employment as a way to prepare for payment reforms that shift from fee for service to methods that make providers more accountable for the cost and quality of patient care.