Comparison of Hospital Mortality and Readmission Rates by Physician and Patient Sex.

BACKGROUND: Little is known as to whether the effects of physician sex on patients' clinical outcomes vary by patient sex. OBJECTIVE: To examine whether the association between physician sex and hospital outcomes varied between female and male patients hospitalized with medical conditions. DESIGN: Retrospective observational study. SETTING: Medicare claims data. PATIENTS: 20% random sample of Medicare fee-for-service beneficiaries hospitalized with medical conditions during 2016 to 2019 and treated by hospitalists. MEASUREMENTS: The primary outcomes were patients' 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital-level averages of exposures (effectively comparing physicians within the same hospital). RESULTS: Of 458 108 female and 318 819 male patients, 142 465 (31.1%) and 97 500 (30.6%) were treated by female physicians, respectively. Both female and male patients had a lower patient mortality when treated by female physicians; however, the benefit of receiving care from female physicians was larger for female patients than for male patients (difference-in-differences, -0.16 percentage points [pp] [95% CI, -0.42 to 0.10 pp]). For female patients, the difference between female and male physicians was large and clinically meaningful (adjusted mortality rates, 8.15% vs. 8.38%; average marginal effect [AME], -0.24 pp [CI, -0.41 to -0.07 pp]). For male patients, an important difference between female and male physicians could be ruled out (10.15% vs. 10.23%; AME, -0.08 pp [CI, -0.29 to 0.14 pp]). The pattern was similar for patients' readmission rates. LIMITATION: The findings may not be generalizable to younger populations. CONCLUSION: The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients. PRIMARY FUNDING SOURCE: Gregory Annenberg Weingarten, GRoW @ Annenberg.

Trends in Scientific Collaboration Between Men and Women Following the #MeToo Movement.

BACKGROUND: The #MeToo movement raised global awareness about harassment in the workplace. Concerns were raised, however, that the movement may have unintendedly harmed women in academia by decreasing collaboration invitations from men in senior positions, who might be more reluctant to collaborate. OBJECTIVE: To analyze whether collaborations between first author women and last author men decreased after the #MeToo movement. DESIGN: Retrospective observational study. PARTICIPANTS: Names of first and last authors of 122,450 US review articles from the PubMed database published between 2014 and 2020. MAIN MEASURES: Change in the proportion of review articles with a first author woman and a last author man following the peak of the #MeToo movement in October 2017. Additionally, among review articles with a last author man, trends of women first authorship in the USA and Europe (control group) were compared. KEY RESULTS: We analyzed 122,450 review articles with first and last authors from US institutions. Of 85,015 articles by a man last author, 37.5% (31,902) had a woman first author. In contrast, when the last author was a woman, the first author was also a woman in 53.6% of articles (20,078) (p<0.001 for difference). Among review articles with a last author man, there was no change in the proportion of articles with a woman first author before versus after the peak of the #MeToo movement (e.g., p=0.13 for difference between the 12 months following October 2017 compared to the pre-#Me-too period). Among European institutions, of 72,036 articles by a man last author, 43.4% (31,294) had a woman first author, higher than the proportion observed in the USA. Trends in collaboration between first author women and last author men were similar in the USA and Europe after the peak of the #MeToo movement (p=0.65). CONCLUSIONS: The #MeToo movement was not associated with a reduction in the rate of scientific review article authorship collaborations between first author women and last author men in the life sciences. These findings, if generalizable, suggest it is possible to promote accountability for harassment in the workplace without limiting decreases in collaboration.

Quantifying EHR and Policy Factors Associated with the Gender Productivity Gap in Ambulatory, General Internal Medicine.

BACKGROUND: The gender gap in physician compensation has persisted for decades. Little is known about how differences in use of the electronic health record (EHR) may contribute. OBJECTIVE: To characterize how time on clinical activities, time on the EHR, and clinical productivity vary by physician gender and to identify factors associated with physician productivity. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal study included general internal medicine physicians employed by a large ambulatory practice network in the Northeastern United States from August 2018 to June 2021. MAIN MEASURES: Monthly data on physician work relative value units (wRVUs), physician and practice characteristics, metrics of EHR use and note content, and temporal trend variables. KEY RESULTS: The analysis included 3227 physician-months of data for 108 physicians (44% women). Compared with men physicians, women physicians generated 23.8% fewer wRVUs per month, completed 22.1% fewer visits per month, spent 4.0 more minutes/visit and 8.72 more minutes on the EHR per hour worked (all p < 0.001), and typed or dictated 36.4% more note characters per note (p = 0.006). With multivariable adjustment for physician age, practice characteristics, EHR use, and temporal trends, physician gender was no longer associated with productivity (men 4.20 vs. women 3.88 wRVUs/hour, p = 0.31). Typing/dictating fewer characters per note, relying on greater teamwork to manage orders, and spending less time on documentation were associated with higher wRVUs/hour. The 2021 E/M code change was associated with higher wRVUs/hour for all physicians: 10% higher for men physicians and 18% higher for women physicians (p < 0.001 and p = 0.009, respectively). CONCLUSIONS: Increased team support, briefer documentation, and the 2021 E/M code change were associated with higher physician productivity. The E/M code change may have preferentially benefited women physicians by incentivizing time-intensive activities such as medical decision-making, preventive care discussion, and patient counseling that women physicians have historically spent more time performing.

Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study.

BACKGROUND: The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation. OBJECTIVE: To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types. DESIGN: Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours. PARTICIPANTS: A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021. MAIN MEASURES: Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit. KEY RESULTS: Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit). CONCLUSIONS: Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.

The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19.

BACKGROUND: Burnout has risen across healthcare workers during the pandemic, contributing to workforce turnover. While prior literature has largely focused on physicians and nurses, there is a need to better characterize and identify actionable predictors of burnout and work intentions across healthcare role types. OBJECTIVE: To characterize the association of work overload with rates of burnout and intent to leave (ITL) the job in a large national sample of healthcare workers. DESIGN: Cross-sectional survey study conducted between April and December 2020. SETTING: A total of 206 large healthcare organizations. PARTICIPANTS: Physicians, nurses, other clinical staff, and non-clinical staff. MEASURES: Work overload, burnout, and ITL. RESULTS: The sample of 43,026 respondents (mean response rate 44%) was comprised of 35.2% physicians, 25.7% nurses, 13.3% other clinical staff, and 25.8% non-clinical staff. The overall burnout rate was 49.9% (56.0% in nursing, 54.1% in other clinical staff, 47.3% in physicians, and 45.6% in non-clinical staff; p < 0.001 for difference). ITL was reported by 28.7% of healthcare workers, with nurses most likely to report ITL (41.0%), followed by non-clinical staff (32.6%), other clinical staff (32.1%), and physicians (24.3%) (p < 0.001 for difference). The prevalence of perceived work overload ranged from 37.1% among physicians to 47.4% in other clinical staff. In propensity-weighted models, work overload was significantly associated with burnout (adjusted risk ratio (ARR) 2.21 to 2.90) and intent to leave (ARR 1.73 to 2.10) across role types. LIMITATIONS: Organizations' participation in the survey was voluntary. CONCLUSIONS: There are high rates of burnout and intent to leave the job across healthcare roles. Proactively addressing work overload across multiple role types may help with concerning trends across the healthcare workforce. This will require a more granular understanding of sources of work overload across different role types, and a commitment to matching work demands to capacity for all healthcare workers.

Variation in Family Physicians' Experiences Across Different Electronic Health Record Platforms: a Descriptive Study.

BACKGROUND: Electronic health records (EHRs) have been connected to excessive workload and physician burnout. Little is known about variation in physician experience with different EHRs, however. OBJECTIVE: To analyze variation in reported usability and satisfaction across EHRs. DESIGN: Internet-based survey available between December 2021 and October 2022 integrated into American Board of Family Medicine (ABFM) certification process. PARTICIPANTS: ABFM-certified family physicians who use an EHR with at least 50 total responding physicians. MEASUREMENTS: Self-reported experience of EHR usability and satisfaction. KEY RESULTS: We analyzed the responses of 3358 physicians who used one of nine EHRs. Epic, athenahealth, and Practice Fusion were rated significantly higher across six measures of usability. Overall, between 10 and 30% reported being very satisfied with their EHR, and another 32 to 40% report being somewhat satisfied. Physicians who use athenahealth or Epic were most likely to be very satisfied, while physicians using Allscripts, Cerner, or Greenway were the least likely to be very satisfied. EHR-specific factors were the greatest overall influence on variation in satisfaction: they explained 48% of variation in the probability of being very satisfied with Epic, 46% with eClinical Works, 14% with athenahealth, and 49% with Cerner. CONCLUSIONS: Meaningful differences exist in physician-reported usability and overall satisfaction with EHRs, largely explained by EHR-specific factors. User-centric design and implementation, and robust ongoing evaluation are needed to reduce physician burden and ensure excellent experience with EHRs.

Development of a Primary Care Transitions Clinic in an Academic Medical Center.

INTRODUCTION: Transitions of care experiences leave patients vulnerable to adverse outcomes, including readmissions, worsening symptoms, and reductions in functional status. AIM: To describe and evaluate a primary care transitions clinic that serves patients with medical and/or social needs that must be addressed prior to establishment of primary care. SETTING: Brigham Health, an academic medical center in Boston, MA. PROGRAM DESCRIPTION: The transitions clinic opened within an existing primary care practice in January 2019. It employs one full-time nurse care coordinator and one full-time medical assistant, and is staffed by one primary care physician (PCP) or nurse practitioner each weekday afternoon. Both medical and social diagnoses that require follow-up post-discharge are addressed. Patients with any insurance are seen as many times as necessary until PCP care is established. PROGRAM EVALUATION: In the year after its establishment (January 20, 2019, to January 19, 2020), the transitions clinic received 498 referrals (73.2% from the emergency department (ED), 23.3% from inpatient), with 207 patients ultimately seen. Patients were seen 5 (median; IQR 4-6) work days post-discharge, with 2 (median; IQR 1-3) visits per patient. Patients seen in the transitions clinic had significantly fewer ED visits than a comparator cohort referred to Brigham Health Primary Care after ED or hospital discharge in the year prior (January 20, 2018, to January 20, 2019). Patients seen in the transitions clinic additionally had significantly fewer ED visits and hospitalizations in the three months post-referral than in the three months pre-referral. The most common social determinants addressed by the clinic's nurse coordinator were insurance, transportation, and housing. DISCUSSION: A primary care transitions clinic can provide accessible, attentive care post-discharge with positive effects on healthcare utilization. Availability of a multidisciplinary team that can see patients for repeated visits until establishment of PCP care was a key success factor for the transitions clinic.

Primary Care Practice Transformation in the Era of COVID-19 and Beyond: Key Principles for General Internal Medicine Practitioners.

As members of the Clinical Practice Committee (CPC) of the Society for General Internal Medicine (SGIM), we support practice innovation and transformation to achieve a more just system by which all people can achieve and maintain optimal health. The COVID-19 pandemic has tested the US healthcare delivery system and sharpened our national awareness of long-standing and ingrained system shortcomings. In the face of crisis, SGIM members innovated and energetically mobilized to focus on the immediate needs of our patients and communities. Reflecting on these experiences, we are called to consider what was learned from the pandemic that applies to the future of healthcare delivery. CPC members include leaders in primary care delivery, practice finance, quality of care, patient safety, hospital practice, and health policy. CPC members provide expertise in clinical practice, serving as primary care doctors, hospitalists, and patient advocates who understand the intensity of care needed for those with severe COVID-19 infections, the disproportionate impact of the pandemic on Black and Brown communities, the struggles created for those with poor access to care, and the physical and emotional impact it has placed on patients, families, and clinicians. In this consensus statement, we summarize lessons learned from the 2020-2021 pandemic and their broader implications for reform in healthcare delivery. We provide a platform for future work by identifying many interactive elements of healthcare delivery that must be simultaneously addressed in order to ensure that care is accessible, equitably provided, patient-centered, and cost-effective.

The Electronic Inbox-Benefits, Questions, and Solutions for the Road Ahead.

This Viewpoint looks at digital communication between patients and physicians, including approaches to provide adequate support for these efforts that balance patient needs with appropriate time investments from clinicians.

Prevalence of Burnout Among Physicians: A Systematic Review.

Importance: Burnout is a self-reported job-related syndrome increasingly recognized as a critical factor affecting physicians and their patients. An accurate estimate of burnout prevalence among physicians would have important health policy implications, but the overall prevalence is unknown. Objective: To characterize the methods used to assess burnout and provide an estimate of the prevalence of physician burnout. Data Sources and Study Selection: Systematic search of EMBASE, ERIC, MEDLINE/PubMed, psycARTICLES, and psycINFO for studies on the prevalence of burnout in practicing physicians (ie, excluding physicians in training) published before June 1, 2018. Data Extraction and Synthesis: Burnout prevalence and study characteristics were extracted independently by 3 investigators. Although meta-analytic pooling was planned, variation in study designs and burnout ascertainment methods, as well as statistical heterogeneity, made quantitative pooling inappropriate. Therefore, studies were summarized descriptively and assessed qualitatively. Main Outcomes and Measures: Point or period prevalence of burnout assessed by questionnaire. Results: Burnout prevalence data were extracted from 182 studies involving 109 628 individuals in 45 countries published between 1991 and 2018. In all, 85.7% (156/182) of studies used a version of the Maslach Burnout Inventory (MBI) to assess burnout. Studies variably reported prevalence estimates of overall burnout or burnout subcomponents: 67.0% (122/182) on overall burnout, 72.0% (131/182) on emotional exhaustion, 68.1% (124/182) on depersonalization, and 63.2% (115/182) on low personal accomplishment. Studies used at least 142 unique definitions for meeting overall burnout or burnout subscale criteria, indicating substantial disagreement in the literature on what constituted burnout. Studies variably defined burnout based on predefined cutoff scores or sample quantiles and used markedly different cutoff definitions. Among studies using instruments based on the MBI, there were at least 47 distinct definitions of overall burnout prevalence and 29, 26, and 26 definitions of emotional exhaustion, depersonalization, and low personal accomplishment prevalence, respectively. Overall burnout prevalence ranged from 0% to 80.5%. Emotional exhaustion, depersonalization, and low personal accomplishment prevalence ranged from 0% to 86.2%, 0% to 89.9%, and 0% to 87.1%, respectively. Because of inconsistencies in definitions of and assessment methods for burnout across studies, associations between burnout and sex, age, geography, time, specialty, and depressive symptoms could not be reliably determined. Conclusions and Relevance: In this systematic review, there was substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods, and study quality. These findings preclude definitive conclusions about the prevalence of burnout and highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools to assess the effects of chronic occupational stress on physicians.