The overall disparity between male and female physicians decreased from 2017 to 2018, but there was wide regional variation.
From 2017 to 2018, the national divide between male and female physician compensation eased, a report published today says.
In recognition of the ongoing disparity, the American Medical Association last year adopted several policy prescriptions to help close the gender gap in physician compensation, including a call for pay structures that are objective and gender-neutral.
According to today's report from San Francisco-based Doximity, the chasm between male and female physician compensation dropped below the six-figure mark for the first time last year.
"In 2017, the physician gender gap was at 27.7%, when female doctors earned $105,000 less than their male counterparts. In just one year, the gender pay gap in 2018 dropped to 25.2%, or $90,490 less than the average male doctor," the report says.
Doximity has collected compensation data from nearly 90,000 physicians over the past six years.
While there was significant variation in physician compensation by gender in markets across the country, female physician pay could be trending upward compared to their male counterparts, the report says.
"Financial compensation for men stagnated while female compensation grew by 2%. After years of examination, the gender wage gap is now demonstrating a downward trajectory, suggesting that the industry is moving toward equally compensating female physicians."
The report focused on 50 metropolitan areas across the country. Diminishing the gender wage gap has been uneven. "Despite the progress in the overall gender wage gap, most metro areas with larger gaps saw an increase between 2017 to 2018. However, metro areas with smaller gender wage gaps saw the gap improve," the report says.
The headway in moving toward gender parity in physician compensation is heartening—to a point, Mandy Huggins Armitage, MD, director of medical content at Doximity, told HealthLeaders last week. "One of the important findings is the gender gap has decreased. Obviously, there is more work to be done."
Compensation by the numbers
The report generated several other key data points.
The Top 5 metropolitan areas for physician compensation were Milwaukee at $395,363; New Orleans at $384,651; Riverside, California, at $371,296; Minneapolis at $369,889; and Charlotte, North Carolina, at $368,205
The Bottom 5 metropolitan areas were Durham, North Carolina at $266,180; Providence, Rhode Island at $267,013; San Antonio, Texas, at $276,224; Virginia Beach, Virginia, at $294,491; and New Haven, Connecticut, at $295,554
The Top 3 specialties for annual compensation were neurosurgery at $616,823; thoracic surgery at $584,287; and orthopedic surgery at $526,385
The Bottom 3 specialties for annual compensation were pediatric infectious disease at $185,892; pediatric endocrinology at $201,033; and pediatrics at $222,942
"In 2018, medical specialties that require more advanced training continue to have higher salaries and distinct specialties earn significantly higher income than the average annual compensation," the report says.
Compensation growth levels off
Physician pay plateaued last year, the report says. "Nationally, wages were flat with less than 1% decrease in physician compensation between 2017 and 2018."
The slowdown in wage growth was modest, according to the lead author of the report. "It's a relatively minor change—it's not like a 10% decrease. It's more of a leveling off, Christopher Whaley, PhD, an adjunct assistant professor at the University of California's Berkeley School of Public Health told HealthLeaders last week.
The flat wage growth last year is probably a reflection of consolidation in the healthcare sector, he said. "In the past couple of years, there has been a wave of physician practices being bought by health systems. So, if you are working for a larger company like a hospital or health system, you may have less agency over your pay."
The concept of moral injury expresses the systemic nature of the strain on physicians and the need for a comprehensive approach to address the problem.
A pair of doctors believe they have pinpointed the cause of physician burnout symptoms.
Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The root of the problem is "moral injury" resulting from the multiple roles physicians are playing in contradiction to their moral imperative to take care of patients, Simon Talbot, MD, and Wendy Dean, MD, wrote this month in a blog post published by Medical Economics.
"The underlying problem is, we are being pulled in too many directions. We took oaths to put the needs of our patients above all else, but over time that priority has eroded in the face of economic drivers in healthcare and competitive realities. Too often now, physicians must choose between the needs of their patients and the demands imposed by their employers, productivity metrics, insurance companies, mandates to reduce 'leakage,' and satisfaction surveys," they say in the post.
Measures vs. mainspring
The commonly cited Maslach measures of physician burnout do not illuminate the causes of the condition, Talbot and Dean told HealthLeaders recently via email.
"As healthcare has become increasingly driven by business requirements, physicians are facing a situation where they are unable to provide the best care possible because of the double and triple binds that get in the way. The crux of these binds is competing allegiances to the patient, the insurer, the hospital, and to themselves," they said.
In their email, Talbot and Dean gave several examples of competing priorities that are resulting in moral injury for physicians.
"Physicians may feel that their ability to provide the highest quality of care is limited by an expectation of seeing too many patients each day, generating an RVU target, completing insurance prior authorizations, and using a cumbersome electronic health record, just to name a few. This has been exacerbated with the corporatization of healthcare, increased profit-drivers, and a move away from the traditional doctor-patient relationship," they said.
Healing moral injury
Fundamental changes are required to limit physician moral injury, Talbot and Dean told HealthLeaders.
"Breaking down the competing allegiances that face physicians requires refocusing the goal of healthcare to ensure the needs of the patient are central to all parties involved. It requires that health system leadership have deep roots in patient encounters, and a vast reservoir of empathy for how systems' decisions impact patients' experience of care, as well as the impact on physician distress."
In the current state of medical practice, business model imperatives are at odds with physician training and tendencies, they said. "When physicians cannot keep their Hippocratic Oath to put patient needs above all else, that is deeply troubling to them; they are forsaking deeply ingrained, over-trained patterns of selfless thoughts and behaviors in service of business motives."
Talbot and Dean gave five prescriptions to treat physician moral injury.
Replace the term burnout, which implies a locus of control within the individual, with the term moral injury, which expresses the systemic nature of the problem and the need for a comprehensive approach.
Develop physician leaders with first-hand experience of the problems and the solutions who have been chosen for their investment in improving clinical care and their abilities to lead.
Focus on physician agency and autonomy as well as maintaining relationships—rather than transactions—that empower physicians to do what is right.
Deploy information technology that adds value to the patient-physician encounter, does not distract from the human connection, does not slow down physicians, and does not shift tasks such as billing to clinicians.
Talbot is a reconstructive plastic surgeon at Brigham and Women's Hospital in Boston and an associate professor of surgery at nearby Harvard Medical School. Dean is a psychiatrist and senior vice president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine in Bethesda, Maryland.
The new care model recognizes that family dynamics impact health and cost of care.
Healthcare providers and payers should adopt integrated family care to boost clinical outcomes and generate return on investment, a United Hospital Fund reportreleased this week says.
Families can have a major impact on an individual's good health, including caregivers easing stress on family members who face serious illness and caregivers supporting the physical and mental health of children. Families can also contribute to an individual's poor health such as dietary habits that lead to obesity.
"Focusing on these dynamics yields an opportunity to invest in supporting families as an effective means for improving population health," the UHF report says.
There also is a strong business case for having a family focus in healthcare delivery and reimbursement. The report cites research published in 2007 by the National Business Group on Health that found four advantages for companies that use insurance benefit design and other tools to foster good maternal-child health: lower healthcare costs, increased worker productivity, employee retention, and a more fit workforce over the long term.
In addition, other research on child-parent psychotherapy estimated the return on investment at $15 for every $1 invested.
Integrated family care has several primary elements, the UHF report says.
Similar to behavioral health integration into primary care, integrated family care ensures all family members' healthcare is effectively coordinated
Healthcare delivery and payment models are crafted to promote family-based approaches to care that decrease care silos between family members
The approach integrates physical and mental health care as well as social services
There are three pillars in the framework for establishing integrated family care, the report says.
1. Insurance is foundational
Health insurance for both children and their parents is crucial for effective integrated family care, the report says.
"Insured children with uninsured parents are more likely to experience insurance coverage gaps, not have a usual source of care, have unmet health care needs, and miss preventive care services. Uninsured parents are also less likely to receive care for their own medical conditions, such as mental health disorders, that when left untreated can adversely affect their child's health."
2. Family-centered care approach
Integrated family care shares principles with the patient centered medical home model of care, the report says.
"The model stresses partnership with families and a continual effort to be responsive to their needs. The primary care team is expected to encourage and support the patient and his or her family in making decisions about treatment and in developing and implementing the plan of care. The PCMH practice also takes on a major responsibility for coordinating care with other providers on behalf of its patients."
3. Building bridges
Practitioners of integrated family care identify health conditions of family members that affect a patient's health and they strengthen family bonds, the report says.
"The best-known example of 'bridging efforts' may be the implementation of maternal depression screening during well-child visits and the billing for such services under the child’s insurance plan. Other clinical interventions akin to this include detection of parental substance use disorder or significant parental stress."
Integrated family care openings
There are several opportunities to pursue the integrated family care model, the report says.
Providers and payers can increase awareness of evidence-based family interventions such as the Blueprints for Healthy Youth Development database and seek "braided funding" such as block grants from the federal Substance Abuse and Mental Health Services Administration.
Providers and payers should promote maternal depression screening in children's primary care.
Collecting and examining state data on complex families can identify risk factors facing children.
Payers should offer planning grants to providers that want to develop integrated family care through new partnerships such as behavioral health providers in New York that received grants to increase readiness for value-based payment.
Payers and providers can use the Center for Medicare & Medicaid Innovation's Integrated Care for Kids and Maternal Opioid Misuse demonstration projects to test integrated family care models.
Health plans can work with providers to test new payment models that encourage collaboration between providers that care for different members of the same family.
Many hospitalized patients are reluctant to raise concerns about their care, which reduces opportunities for improvement.
Encouraging patients to speak up about problems that occur during hospitalizations can improve patient experience and safety, recent research indicates.
Patients are uniquely qualified to raise concerns about care because they are present for the entire episode of care. Earlier research has shown most patients do not raise concerns or file formal complaints, with hesitancy to speak up linked to several factors such as an expectation that complaining will not make a difference.
The lead author of research published this month in BMJ Quality & Safety told HealthLeaders that health systems and hospitals have nothing to lose in asking patients about their concerns.
"From an institutional perspective, I don't think there is a downside to encouraging patients to speak up. However, institutions that do this should be prepared to take the next step and respond to patients who bring up concerns," said Kimberly Fisher, MD, an associate professor in the Department of Medicine at the University of Massachusetts Medical School in Worcester, Massachusetts.
Fisher's research team, which examined data from more than 10,000 patients, published several key findings.
48.6% of patients reported experiencing a problem during their hospitalization
30.5% of patients did not always feel comfortable raising concerns
Patients who had the highest likelihood of not speaking up were older, had worse overall and mental health, were admitted from the emergency department, and did not speak English at home
Mental health was a strong predictor of unlikelihood to speak up, with patients who had poor mental health nearly four times as likely to not feel comfortable raising concerns compared to patients who had excellent mental health
Patients who were not always comfortable raising concerns gave lower ratings for nurse communication, physician communication, and the hospital overall
"The most common type of problem that patients report is inadequate communication—they didn't get the information that they wanted, they didn't get their questions answered, or things were not explained to them in a way that they could understand," Fisher said.
Taking an active approach
To maximize the number of patients who raise concerns, health systems and hospitals should take an active approach, she said.
"Directly asking patients whether they have any concerns and conveying a sincere desire to hear from patients is essential in encouraging patients to speak up. We learn about many more—by an order of magnitude—concerns and problems in care with an 'active outreach' approach in which someone inquires of patients as to whether they've had any problems, as compared to just setting up and publicizing mechanisms—websites, phone numbers, or email addresses."
Care team members are well-positioned to ask patients whether they have concerns, Fisher said. "If it comes from someone on the care team, you are not fragmenting care by introducing yet another cook into the kitchen."
Health systems and hospitals need to be prepared for patient feedback, Fisher said. "When you ask a patient if there is a problem and a concern is raised, the response cannot be saying nothing. You can't ask people to raise their hands and speak up about something and not be ready to respond."
Rising to mental health challenge
Encouraging patients with poor mental health to speak up is daunting and will require further research, she said.
"In conditions that require patient activation and engagement, it's clear that poor mental health can be a barrier to doing what they need to do to take care of themselves. It's a cross-cutting problem. It's not just about speaking up—it affects managing diabetes, heart failure, and other conditions. Mental health can impact many health management behaviors."
Enlisting friends and family members could be an effective technique to help patients with poor mental health speak up, Fisher said.
"One approach that we have found helpful in getting patients' concerns heard that could be useful for patients who have a mental health barrier to speaking up is having friends or family members involved and available to speak up on their behalf."
In earlier research that she conducted, Fisher found patients were much more likely to express concerns if a friend or family member was in the room than if the patient was alone.
"We often think of people who are unable to advocate on their behalf as impaired, but there are a lot of people who are not particularly impaired but still find speaking up a hard thing to do."
Survey data collected from children's hospital leaders targets primary patient-safety challenges. Find out what other focus areas topped the list.
The journal Pediatrics recently published a list of 24 children's hospital patient-safety challenges ripe for research. The list was developed from survey data collected from more than 100 children's hospital leaders and parents.
James Hoffman, PharmD, MS, chief patient safety officer at St. Jude Children's Research Hospital in Memphis, Tennessee, and Stephen Muething, MD, chief quality officer at Cincinnati Children's Hospital Medical Center, spoke with HealthLeaders recently about the top five patient-safety research priorities identified in the list.
"The intent was for researchers to take this list and know where to focus their efforts," says Hoffman, who helped craft the list of 24 research priorities and served as lead author of the Pediatrics article that details the patient-safety challenges list.
In 1999, the Institute of Medicine publishedTo Err Is Human: Building a Safer Health System, which included the alarming statistic that as many as 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country's third-leading cause of death.
In a February 2019 policy statement, the American Academy of Pediatrics noted that medical errors "affect as many as one-third of all hospitalized children," citing articles in JAMA and Pediatrics.
Following are the top five pediatric patient-safety focus areas in prioritized order.
1. Achieving high reliability
"The discussions about the necessity of building a high-reliability culture have been relentless among our children's hospitals over at least the past five years at all levels—from the boards to the CEOs to the clinicians," Muething says.
Hoffman says achieving high reliability is consistent with the goals of the Solutions for Patient Safety network, a group featuring 130 children's hospitals that supported the effort to identify the top 24 research priorities. "Embracing high-reliability principles is a huge focus for SPS—it's a common thread across the organization."
The experience of striving for high reliability at St. Jude Children's Research Hospital demonstrates the need for examining how to implement high-reliability initiatives, Hoffman says.
"We have a relatively new quality and patient care strategic plan, where we worked to adopt high-reliability principles, and we have wrestled with putting principles into place and finding out what the principles really mean."
2. Maintaining a safety culture
Improving safety requires more than effort to prevent common harms such as central line infections, adverse drug events, and falls, Muething says.
"You are not going to get anywhere near your [patient-safety] goal unless you build a culture where people are talking about safety and are focused on safety everywhere they go. It's not as simple as creating processes or getting the right equipment—everybody in the organization needs to be thinking about safety every day."
Establishing a safety culture requires commitment, Hoffman says. "It's easy to do your safety culture survey once every year, or once every other year. It's a whole other matter to go deeply into your results, look at every unit, and actually do something. That's what we try to do at St. Jude."
3. Improving the speed and accuracy of predicting patient deterioration
Most children's hospitals have made a commitment to share information on patient safety, and predicting patient deterioration has become a top priority, Muething says. "The leading hospitals with the research groups are putting a lot of energy into these areas. We have researchers, IT, and clinicians working on this."
"There is also a parent component to this—patient deterioration was the highest rated challenge by the parents," Hoffman says
4. Encouraging open communication between families and care teams
Engaging with patients and families is essential at children's hospitals, Muething says. "In pediatrics, patient and family engagement is second nature to us. I'm a pediatrician, and you learn early on that you are not getting anywhere in taking care of a child unless you learn how to work effectively with the rest of the family."
For pediatric care teams it is not innate to know how to engage families effectively, he says.
"You have to learn how to gauge—as quickly as you can—how much information and detail a particular family wants and how active they want to be in making decisions. You can't treat every family the same. Some families want to be active and want to know every detail. Other families can be stressed out—they don't want that much detail."
Pediatric care teams need more evidence-based approaches to engaging patients and their families, Hoffman says. "Everywhere you look in patient safety, there is a communication opportunity. We need to have more standardized methods and approaches for communication. There are various approaches out there. One is I-PASS for care handoffs."
5. Detecting sepsis in pediatric patients
To advance patient safety, detection of sepsis is equally as important as speedily recognizing patient deterioration, Muething says. "Because children's hospitals have been sharing information with each other, we know that recognizing clinical deterioration and sepsis are the most common causes of preventable serious harm at children's hospitals."
Improving sepsis detection capabilities is a paramount concern at children's hospitals, Hoffman says. "It's very top of mind in pediatrics."
Learning about patient safety from children's hospitals
While there is still work for hospital leaders to do to increase pediatric patient-safety, Hoffman says adult acute-care hospitals can benefit from adopting approaches to patient safety occurring at children's hospitals.
The high level of cohesion in the children's hospital community promotes the sharing of patient-safety information and data.
Children's hospitals routinely include patients and family members on teams dedicated to preventing harm.
There is widespread establishment of patient and family advisory councils at children's hospitals. These advisory councils have been established at 40% of hospitals nationwide, according to research published in 2014.
To achieve fundamental change, healthcare leaders and their teams face multiple challenges such as establishing an enterprise-wide strategy.
Health systems, hospitals, and physician practices are under pressure to improve care and grow market share.
The drivers of transformational change include the imperative to deliver safer care, the shift from volume-based to value-based business models, and efforts to boost quality of care.
A Press Ganey report published Tuesday features three steps to achieve transformational change at healthcare organizations.
"We describe the key considerations for creating a transformational road map and present the steps needed to build an organizational culture that supports patient-centered care and a purpose-driven workforce that can deliver it," the report says.
1. Establish an enterprise-wide strategy
To achieve transformative change, direction has to come from the top of the organization and all teams must understand their role, the report says. "Healthcare CEOs and senior leaders must be aligned on the strategic vision and the path needed to reach it, and they have to consistently and transparently communicate both to the entire organization."
There are four elements to crafting an enterprise-wide strategy:
An assessment process determines the organization's performance level and the divide between baseline performance and ideal performance. The assessment effort should have several components, including leadership surveys and stakeholder interviews.
Healthcare organizations should determine the interdependencies across safety, quality, patient experience, and workforce engagement. Organizations with many silos in their operating model will face a greater need for redesigning processes than organizations that have reduced silos.
Transformational plans require benchmarks and metrics to set goals, measure performance, and guide strategy adjustments.
An integrated dashboard should give the CEO and other top leaders a comprehensive view of the organization's performance.
"Rolling out an integrated balanced score card is the first step to ensuring leaders begin to understand the interdependencies of various performance verticals. Starting with the Board to every level of the organization, all leaders need to have visibility to the data," James Merlino, MD, chief transformation officer at South Bend, Indiana-based Press Ganey, told HealthLeaders.
2. Build a change-receptive culture
Healthcare organizations that are committed to transformational change should gauge their readiness for innovation, the report says. "During periods of large-scale disruption, an organization's ability to pivot quickly and nimbly is predicated on the degree to which its culture—organizational values, beliefs, and work practices—is aligned with the strategic vision."
There are five components to evaluating readiness for change:
Assessing the engagement and resilience of physicians, nurses, and other staff members
Determining whether the workforce understands why change is desirable
Finding out whether employees are aligned with the organization's transformational vision
Ensuring the workforce is ready to move away from the status quo
Establishing confidence in the leadership's ability to guide change and the organization's commitment to devoting necessary resources
3. Develop an integrated data and management strategy
Harnessing data is essential to transformational change at healthcare organizations, the Press Ganey report says. "As with all enterprise-wide, business-critical initiatives, the data strategy should have executive sponsorship and a governance structure to ensure ongoing alignment with organizational objectives."
There are six ingredients for an effective integrated data and management strategy:
Data should be scientifically rigorous with large sample sizes.
The data platform should have multiple layers that allow the organization to examine both broad measures of performance and narrow performance variables.
Establishing key performance indicators is crucial to measure, evaluate, and track initiatives.
Engineering cross-functional capabilities helps leaders work as strategic partners and enables engagement.
A premium should be placed on communication such as sharing updates at regular intervals during the transformation process.
Leaders should hold themselves and their teams accountable, even when insights gained from data indicate that adjustments are needed in strategy or implementation of change.
"Healthcare organizations can improve accountability of leaders by setting clear expectations and goals, establishing key performance indicators, and creating an accountability loop to monitor performance and course correct when necessary. These are some of the basic tenants of an operating model that every healthcare organization should have to help improve and sustain performance," Merlino said.
At national level, the annual cost of index admissions for sepsis are estimated at more than $23.3 billion.
The annual estimated cost of sepsis readmissions is about half the annual cost of all four of the conditions in Medicare's Hospital Readmissions Reduction Program, recent research shows.
"In our study, the estimated annual cost of sepsis readmissions amounted to more than $3.5 billion within the United States. When compared to $7.0 billion for the four conditions (AMI, CHF, COPD and pneumonia) targeted by the Hospital Readmissions Reduction Program (HRRP), this accounts for a significant under-recognized burden on the U.S. healthcare system," the researchers wrote in the journal CHEST.
Sepsis is the body's extreme reaction to an infection, which can result in life-threatening symptoms such as multiple organ failure. Annually, more than 1.5 million people get sepsis in the United States, with about 250,000 fatalities.
The economic impact of sepsis on a national scale is significant, the CHEST researchers found in their study, which featured more than 1 million index admissions.
The annual cost of index admissions for sepsis was estimated at more than $23.3 billion
The mean cost per sepsis readmission within 30 days of discharge was $16,852
30-day readmissions after an index admission for sepsis accounted for 13% of all sepsis-related hospitalization costs
The lead author of the CHEST research, Shruti Gadre, MD, told HealthLeaders that sepsis readmissions are likely expensive because of intensive care unit treatment, antibiotics administration, and invasive procedures.
Sepsis readmissions are expensive relative to the HRRP conditions most likely because of the acuity of sepsis patients, said Gadre, a member of the Department of Pulmonary, Allergy and Critical Care Medicine at Cleveland Clinic's Respiratory Institute.
"The hypothesis is that sepsis patients are sicker when they get readmitted to the hospital. They require ICU-level care and may have multi-organ involvement compared with patients with AMI, heart failure, COPD, and pneumonia, which may lead to higher costs."
Anticipating readmissions
For patients who had an index sepsis admission, 17.5% were readmitted within 30 days. Gadre and her research team identified predictors of sepsis readmissions.
Infection was the most common cause for 30-day readmissions, accounting for 42.16% readmitted patients. Sepsis accounted for 22.86% of readmissions.
The other most common causes for sepsis readmissions were gastrointestinal (9.60%), cardiovascular (8.73%), pulmonary (7.82%), and renal (4.99%) conditions.
"Our findings serve to create awareness among clinicians, administrators and policy makers alike regarding patient populations that are vulnerable to sepsis readmission and thus increased utilization of resources. Although it may be necessary to readmit some patients, the striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this adverse outcome," the research team wrote.
Strategies adopted to address burnout include sponsoring social events to enhance connections between physicians.
From 2014 to 2017, physician burnout increased five percentage points at Massachusetts General Hospital Physicians Organization in Boston, according to research published today.
Other research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The research published today in Journal of the American Medical Association found exhaustion and cynicism were the primary drivers of increased burnout at Mass General's physician organization. The research was based on survey data collected from more than 1,700 physicians.
The survey data showed exhaustion increased from 52.9% in 2014 to 57.7% in 2017, and cynicism increased from 44.8% in 2014 to 51.1% in 2017.
The exhaustion finding was particularly troubling, the JAMA researchers wrote. "We found physicians were more vulnerable to emotional exhaustion than any of the other subscales of burnout. Physicians reporting high levels of exhaustion were more likely to reduce their clinical schedules, reduce the number of patients in their practice, leave the practice, or retire."
The researchers noted that physician turnover has several costs including patient and clinician distress as well as the expense of replacing physicians, which can be as high as three times a doctor's annual salary.
Primary care physicians reported higher levels of exhaustion compared to medical specialists. "These findings may be associated with the amount of time primary care physicians spend documenting on the EHR and serving as the clinicians responsible for the management of patients' multiple complex medical and social problems," the researchers wrote.
Burnout data points
The JAMA article has several other key data points.
Early-career physicians who had less than a decade of practice experience since their training were more susceptible to burnout than veteran physicians.
The higher burnout rate in 2017 may be linked to implementation of a new electronic health record system because average time devoted to administrative tasks increased from 23.7% in 2014 to 27.9% in 2017, and increased time spent on administrative tasks was linked to higher burnout.
Several favorable working conditions were associated with lower odds of burnout: workflow satisfaction, positive relationships with colleagues, time and resources for continuing medical education, opportunities to impact decision making, and having a trusted adviser.
Addressing physician burnout
The lead author of the research, Mass General physician organization CMO Marcela del Carmen, MD, MPH, told HealthLeaders that the physician group has implemented several efforts to reduce burnout.
"We have allocated funding to each of our 16 clinical departments to develop and institute initiatives to mitigate burnout in their departments. We have central efforts including sponsoring social events to enhance connectivity amongst the faculty, efforts to improve our use of the electronic health record through personal- and practice-level training, and funding to support peer-to-peer coaching programs, yoga, and meditation sessions."
Del Carmen's research team also suggested that burnout prevention efforts could be tailored for early-career physicians, who reported relatively high dissatisfaction with department leadership, relationships with colleagues, quality of care delivery, control over work environment, and career fit.
"These findings point to potential opportunities in this vulnerable group to mitigate burnout, such as initiatives that promote community building and networking and harnessing effective leadership," the researchers wrote.
Exporting best practices from high-performing hospitals and establishing regional referral centers can level variation in hospital networks' clinical outcomes.
There are two primary strategies for health systems to limit variation in their hospital networks, researchers say in an article published this week in JAMA Surgery.
The number of hospitals joining networks has doubled over the past decade. The motivations for network formation include strategic allocation of resources, improved administrative efficiency, and opportunities to create centers of excellence.
The JAMA Surgery researchers investigated whether networks of hospitals affiliated with U.S. News & World Report honor roll hospitals delivered a consistent level of care in three service lines.
"It remains unclear whether these multihospital networks are able to deliver a uniform standard of care. While some networks may provide consistent outcomes, others may offer disparate levels of quality across affiliated hospitals despite sharing the same mission or brand," the researchers wrote.
The researchers analyzed data for colectomy, coronary artery bypass graft, and hip replacement at 87 hospitals in 16 networks. Surgical outcomes at affiliated hospitals varied widely. For example, mortality rates varied from 1.1-fold to 4.1-fold.
The research team highlighted two strategies to limit clinical outcome variation in hospital networks.
1. Exporting quality
To limit variation, hospital networks can export delivery models that achieve high quality at top-performing hospitals to all affiliates. Sharing best practices across the entire network can potentially generate better clinical outcomes at all network hospitals.
2. Referral centers
Networks can try to achieve better collective outcomes by centralizing care at referral centers that treat rare conditions, high-risk patients, and volume-sensitive procedures.
"In this scenario, higher or more variable adverse event rates would manifest in networks that fail to restrict complex services to hospitals with limited experience managing complications or to those that lack specific resources, such as 24-hour intensivist staffing," the researchers wrote.
Executing corrective strategies
Gauging the performance of hospitals in a network is essential to limiting variation in clinical outcomes, the researchers wrote. "Networks should monitor variations in outcomes to characterize and improve the extent to which a uniform standard of care is being delivered."
Focusing on service lines is imperative. "Networks that fail to critically evaluate their service lines to align expertise and resources appropriately will demonstrate more variability in quality across their affiliates," the researchers wrote.
Engaging clinicians is another key element in limiting variation, they wrote. "Beyond service-line reorganization, it will be increasingly important for networks to determine how to integrate clinicians into these multihospital quality improvement efforts. Clinician input is critical to all aspects of delivery system redesign but may be particularly relevant to quality improvement."
Focal points in neonatology include better communication with families and sepsis screening.
Maternal mortality and sepsis detection are two of the most vexing challenges in obstetrics and neonatology.
Neonatologist Meg Prado, MD, who was recently appointed as president of Women's and Children's Services at Nashville-based Envision Physician Services, recently discussed these challenges with HealthLeaders.
Prado joined Envision in 2001, practicing as a neonatologist at Miami Children's Hospital. She most recently served as vice president of Women's and Children's Services for Envision. Prado began her new role in February.
She received her medical degree from the University of Miami and completed both her residency and fellowship at Jackson Memorial Hospital in Florida.
The following is a lightly edited transcript of Prado's conversation with HealthLeaders.
HL: Why did you pick neonatology as your specialty?
Prado: When I was in medical school going through all the rotations, I tended to have an affinity for the higher energy and intensive care situations. Once I did my rotation in the neonatal ICU, the deal was pretty much sealed because I already knew I wanted to go into pediatrics, and I wanted to improve healthcare for infants.
HL: Has practicing as a neonatologist lived up to your expectations?
Prado: It has been so much more than what I expected because of the life lessons learned from the parents and their babies.
For example, I was taking care of a baby that was born prematurely, and at a couple months old he was just not progressing the way I wanted him to. By this time, I would have expected this little baby to be off his respiratory support, taking a bottle, or nursing from his mother. He just didn't have the ability to do that because of his lung disease.
I remember taking the parents into the room and telling them how sorry I was that the baby was not as healthy as I wanted him to be. They said, "Dr. Prado, it's not your fault. You're doing everything you can for the baby, and when it's time for him to get better, he will get better."
HL: What are the main trends in neonatology?
Prado: The primary trends are in the softer areas, which include improving communication with parents and families, and not just when a baby is in a NICU. We need to have access to a woman when she gets admitted to a labor ward if she has broken her water early and is at high risk of infection or delivering prematurely. We need to talk with families ahead of time to let them know national and center-based data, so parents can know what to expect for the long-term outcome of their infant.
Including parents on rounds can help them know that their opinions matter. While I am not going to necessarily let a father or mother make an important decision that I need to make as the attending physician, involving them on rounds and making them feel they are part of the decision-making process is vital.
Good medicine is not just good diagnosing and treating, but also making sure we are open and transparent, which is vital to trust and reducing litigation. Even if you have an adverse outcome for a patient, if you have communicated fully the chances of a claim being filed are less likely.
Another trend is introducing skin-to-skin contact early—when you allow a parent to hold a small premature infant even when the baby is on a ventilator or has central lines in place. We need to buy into this idea because we know babies' vital signs stabilize when they are being held by their caregiver. It can potentially improve neurodevelopmental outcomes.
Another major focus is improving nutrition. Neonatologists need to do everything they can to optimize the use of breast milk, especially in low birthweight infants. At Envision, we believe this is best practice, so we work with our hospital partners to make sure that breastfeeding is encouraged. When breastfeeding cannot occur for any reason, we promote the use of donor milk.
HL: You have overseen the development of an innovative neonatal sepsis screening tool. How can we rise to the challenge of screening babies for sepsis?
Prado: The primary challenge of sepsis screening is deciding which infants need antibiotics at birth. At the birth of neonatology, the philosophy was if a baby was sick enough to be in a NICU the baby was sick enough to be on antibiotics. The idea was that any baby who was in a NICU was predisposed to an infection and warranted antibiotics.
In recent years, the increasing instances of antibiotic-resistant organisms in the community as well as in hospitals has prompted calls to decrease use of antibiotics. My concern is the pendulum could be swinging against antibiotics too far. We could be dismissing signs of infection and not administering antibiotics in symptomatic infants.
After an adverse outcome, one of our doctors in Phoenix developed a sepsis screening tool for babies over 34 weeks—babies under 34 weeks are very small and physicians have to exercise their best judgment on whether to start antibiotics. We use a sepsis calculator developed by Kaiser Permanente in conjunction with the baby's symptoms.
HL: Gauge the country's effort to reduce maternal mortality.
Prado: As physicians, we are making sure that the issue is being brought to the forefront and that we are aggressively addressing the issue with proper policies and protocols. However, we are addressing the problem after it has already occurred. It would be better to address poor health challenges before they happen.
As a society, we should be making every effort possible to be healthier because the downstream effects are contributing to increased maternal mortality.
One of the things that has been happening on the OB-GYN front is reducing C-section rates, especially for first-time pregnant women who are at relatively low risk—they only have one baby and the baby's head is presenting down. There's a big effort across the country to reduce the C-section rate, which hopefully will affect maternal hemorrhage.