Female emergency residents are more likely to experience most forms of workplace mistreatment compared to their male counterparts.
Workplace mistreatment is relatively common among emergency medicine (EM) residents and the mistreatment is associated with suicidal thoughts, a new research article says.
Earlier research has shown that workplace mistreatment—discrimination, abuse, and harassment—is linked to several negative consequences such as feelings of marginalization, decreased job performance, increased stress, job dissatisfaction, and turnover. Workplace discrimination has been associated with health problems, including anxiety, depression, and cardiovascular disease.
The new research article, which was published by JAMA Network Open, is based on survey data collected from more than 7,000 EM residents enrolled in residencies accredited by the Accreditation Council for Graduate Medical Education. The 35-item survey was conducted in February 2020. Male residents (4,768) outnumbered female residents (2,698) in the survey study.
The research article features several key data points.
45.1% of survey respondents reported experiencing workplace mistreatment in the most recent academic year
The most common source of mistreatment was patients and patient family members—among the survey respondents, 1,234 reported gender discrimination, 867 reported racial discrimination, 723 reported sexual harassment, and 282 reported physical abuse by patients or patient family members
Gender discrimination was reported by 2,104 survey respondents, with more women (1,635) reporting this form of mistreatment than men (407)
Racial discrimination was reported by 1,284 survey respondents, including 371 White residents and 907 residents from other racial and ethnic groups
220 survey respondents reported discrimination based on sexual orientation or gender identity
1,047 survey respondents reported sexual harassment, with more women (721) reporting this form of mistreatment than men (294)
Verbal or emotional abuse was reported by 2,069 survey respondents, including 32.2% of female residents and 27.0% of male residents
331 survey respondents reported physical abuse
178 (2.5%) survey respondents reported having suicidal thoughts, with the incidence rate split evenly by gender
The prevalence of suicidal thoughts was relatively high for residents who identified as LGBTQ+ (odds ratio 2.04)
Divorced or widowed residents had a higher probability (odds ratio 3.36) of reporting suicidal thoughts than residents who were married or in a relationship
Experiencing mistreatment at least a few times per month was associated with a relatively high probability of having suicidal thoughts (odds ratio 5.83)
"In this survey study, EM residents reported commonly experiencing workplace mistreatment, and experiences of mistreatment were associated with suicidality. Identifying and promoting best practices to minimize workplace mistreatment during residency may help optimize the professional career experience and improve the personal and professional well-being of physicians throughout their lives," the research article's co-authors wrote.
Interpreting the data
The researchers identified segments of the EM resident population who are most likely to experience workplace mistreatment. "In this comprehensive survey study, mistreatment of EM residents based on gender, race/ethnicity, and sexual orientation was more common among women, residents from racial/ethnic minority populations, and residents identifying as LGBTQ+, respectively. Discrimination based on pregnancy and childcare status was also more common among women than among men," the co-authors wrote.
Female EM residents carry a heavier burden of most workplace mistreatment compared to their male counterparts, the co-authors wrote. "Women reported higher levels of nearly all forms of mistreatment compared with men, with most of the reported gender-based mistreatment originating from patients and their families. The second most likely source of gender-based mistreatment was nurses and staff."
The research provides insight into physician suicide, the co-authors wrote. "In this study, there was a significant association between the reported frequency of mistreatment and suicidal thoughts. After adjusting for mistreatment, women were less likely to report suicidal thoughts. The results suggest that the higher prevalence of mistreatment experienced by women in medicine may be one factor associated with the higher rates of suicide among female physicians."
Mistreatment interventions
Systemic interventions are a primary strategy to address workplace mistreatment, the co-authors wrote. "Leaders, peers, and other hospital colleagues may be bystanders, perhaps inadvertently, to workplace mistreatment. Healthcare systems, hospitals, and department and residency program leaders should consider training interventions to empower bystanders to intervene and to cultivate workplace norms that prohibit workplace mistreatment."
Boosting cultural competency is also likely to reduce workplace mistreatment, the co-authors wrote.
"An additional strategy is to provide cultural competency training to all emergency department staff with the goal of increasing collective knowledge about marginalized groups (women and individuals who are underrepresented in medicine or LGBTQ+) that are at increased risk of experiencing workplace mistreatment. This increase in knowledge and subsequent self-awareness may create a more open, safe, and supportive workplace for EM residents."
The trade association's survey report reflects the negative economic impact of the coronavirus pandemic on medical groups.
Physician compensation increased at a very modest rate in 2020, according to a survey report published by AMGA.
Physician compensation was impacted significantly last year by the coronavirus pandemic. Many physicians who had their compensation linked to productivity took a financial hit from the pandemic, with declines in patient office visits and other disruptions such as suspensions of elective surgery across the country.
The AMGA survey report is based on data collected from 398 medical groups representing about 190,000 clinicians. The survey report has several key data points.
Overall physician compensation increased 0.12% in 2020, down significantly from the 3.79% increase that AMGA reported for 2019.
Overall physician productivity decreased 10.17% in 2020, down dramatically from the 0.56% increase reported for 2019.
In primary care, 2020 median compensation for all specialties increased 0.40% and median productivity fell 10.63%. In 2019, median compensation increased 4.46% and median productivity increased 0.44%.
In medical specialties, 2020 median compensation for all specialties increased 0.39% and median productivity decreased 10.81%. In 2019, median compensation increased 3.52% and median productivity increased 0.9%.
In surgical specialties, 2020 median compensation decreased 0.84%.
Primary care nurse practitioner compensation increased 1.29%.
Primary care physician assistant compensation decreased 1.85%.
Orthopedic surgery posted the highest 2020 median specialty compensation at $631,900, followed by gastroenterology at $542,948, and general cardiology at $532,781.
General pediatrics and adolescent medicine posted the lowest 2020 median specialty compensation at $257,432.
For the 170 medical groups that indicated how base salary for physicians is determined, 90% reported that market salary data is the primary determinant.
The survey report reflects the impact of the coronavirus pandemic on physician compensation, according to an AMGA prepared statement. "Though the survey, conducted by AMGA Consulting, found very modest increases in compensation, there were significant decreases in productivity, which can be directly tied to the pandemic. The data reveals the devastating economic impact of COVID-19 on healthcare provider organizations and indicates that they may need to rethink their compensation models in order to remain resilient in the face of future disruptions."
In a prepared statement, AMGA Consulting President Fred Horton, MHA, said the trends in the survey report are associated with flat compensation and a stark decrease in service volume.
"Medical groups paid a steep price to retain their physician talent, even though productivity steeply declined. COVID-19 highlighted the need for medical groups and health systems to reconsider their compensation plans so that they rely less on obligatory annual pay increases and more on incentivizing productivity that rewards valuable outcomes. The shift to more value-based compensation models will help organizations become more resilient against future economic downturns," he said.
Kedar Mate, MD, decided to pursue a career in medicine after working with low-resource people in Haiti and Peru.
This article was published in the July/August edition of HealthLeaders magazine.
As the president and CEO of the Institute for Healthcare Improvement (IHI), Kedar Mate, MD, is the leader of one of the top healthcare reform organizations in the world.
IHI was founded in 1991. The nonprofit organization has been involved in a range of healthcare improvement initiatives, including patient and healthcare workforce safety, elder care, health equity, maternal and infant health, quality, and value-based care. In addition to working with U.S. healthcare organizations, IHI has worked on projects around the world, including Canada, England, Denmark, Sweden, Singapore, Latin America, New Zealand, Ghana, Malawi, South Africa, and the Middle East.
Mate received a degree in American history from Brown University in Providence, Rhode Island, and earned his medical degree at Harvard Medical School in Boston.
After graduating from Brown, Mate worked at Boston-based Partners in Health. He also worked at the World Health Organization and Brigham and Women's Hospital. Prior to being elevated to president and CEO at IHI, he was the organization's chief innovation and education officer. He recently told HealthLeaders that he was inspired to pursue a career in medicine while working for Partners in Health with HIV/AIDS patients in Haiti and drug-resistant tuberculosis patients in Peru.
"I joined Partners in Health and got a chance to work with an interdisciplinary group of doctors, economists, and anthropologists. I observed the work that the physicians did in direct care, and it struck me as very powerful, compelling, and different from the work of those in public health and economics. All of the disciplines were important to the kind of impacts that we were seeing, but it was the clinicians in their direct care and what they could do at the individual level that I found incredibly compelling," he says.
The career choice was in line with his upbringing. "Both of my parents are in the clinical arena. My dad is a pediatrician. My mom is a microbiologist—she works in a hospital laboratory," Mate says.
Following are the highlights of Mate's conversation with HealthLeaders.
"I love the fact that IHI does not view healthcare challenges as inevitable. It treats situations as solvable systems problems. I found that approach relevant whether I was in my practice environment or in sub-Saharan Africa working on a maternal and child health program. Regardless of the care setting, I found problems that were surfacing that were not just the pure clinical problems that were in front of us doing patient care—they were problems of the underlying system that was creating the clinical problems. Most people did not have the vocabulary for solving that systems problem, but IHI did."
"IHI had an approach that felt compelling, and that is what drew me to IHI and made me want to work for the organization, first internationally, then as leading the research and education team."
"The area that has been at the core for me is where health and social justice intersect. Today, that intersection is most evident in issues around health equity. There have been several examples in the work I have done, including the work that I did in Peru and Haiti with Partners in Health, and the work I did with IHI in sub-Saharan Africa."
"Equity was included in the definition of quality that the Institute of Medicine put forward in the late 1990s and early 2000s. But we still have a massive opportunity to bridge the equity chasm much as we have been trying to bridge the quality chasm for years."
"The big defect is to stop admiring the problem. We have had a lot of documentation of inequities and disparities in our systems for a long time. Not too long after we had To Err Is Human, we had Unequal Treatment in 2003. So, we have known these issues for a long time; but even today, we have more descriptive studies and analyses of what drives inequities and fewer intervention studies that talk about how to remediate inequities and close gaps."
"So, for me, the big opportunity that we have in the equity work is to actually tackle inequities."
"There is a big relationship between the inequities that we see and the safety challenges that we see. Some of the biggest opportunities in safety are also opportunities to remediate inequities or to close disparity gaps that we experience. A lot of the vulnerabilities of patients to injuries, infections, and readmissions are concentrated in the most vulnerable and under-resourced people in our communities—often in communities of color."
"We have a framework for change at IHI that has three components—will, ideas, and execution."
"For will, you must have the will and motivation to change. That will needs to exist at the senior leadership level such as the board of directors, but it also has to be driven in part by a sense that the status quo is untenable and that the future might be more attractive if you can chart a path to that future."
"You also need to have fundamentally better ideas for what the future can be—that is the second dimension. So, you must have will and motivation, but will is not enough without ideas to change your system from what it is today to what it should be tomorrow."
"The third area is execution. You need a disciplined approach to implementing change—whatever the change might be. The execution plan needs to be different based on the nature of the change. So, depending on the nature of the ideas and the will that is present, you might have a pilot program, or you might be ready to scale change widely. It takes different levels of execution depending on the will that is present and the belief you have in your ideas."
"Leadership is increasingly important as we tackle some of the big challenges that we have around equity, racism, and major social problems."
"Some of this work can be uncomfortable, and leaders should lean into that discomfort. There are some big challenges ahead, and they tend to be deeply rooted and systemic. These challenges will be uncomfortable and difficult to fix. You need to recognize that your biggest obstacles are people—the people who are voicing the most opposition to your change initiative are deeply passionate about what you are trying to change and have strong opinions because they are passionate about it, and you want to engage them in the process."
Photo: IHI President and CEO Kedar Mate, Julia Rendleman/Getty Images
Despite coronavirus pandemic disruptions, demand for physicians is high and physician compensation is growing, president of recruiting agency says.
The physician employment market is returning to pre-pandemic levels, a physician recruitment expert says.
Particularly in the spring of 2020, the coronavirus pandemic wreaked havoc on the physician employment market. Some physicians worked without pay and others were placed on furloughs.
"The demand for physicians went dormant in April and May 2020. Healthcare organizations started cutting back on their ability to do physician searches because they were losing money," says Tony Stajduhar, president of Alpharetta, Georgia-based Jackson Physician Search.
Now, demand for physicians is as strong as ever, he says.
"We started to see a change in the last quarter of 2020. There was a turnaround and our volume of hospitals recruiting started growing. Then in the first and second quarter of 2021, we had record months every single month in the history of our organization. Year-over-year in the first quarter of 2021, we were well over a 25% increase in volume. The demand for physicians had been pent up because healthcare organizations fell behind last year—they not only needed to catch up but also had a 2021 medical staff plan."
Stajduhar anticipates strong demand for physicians to continue throughout 2021. "Even with the coronavirus spikes that we are seeing, there were lessons learned in healthcare last year. You have got to keep your foot on the gas—you can't just 100% stop doing anything, including elective surgeries. You have got to figure out different ways to get creative," he says.
Physician compensation trends
Despite the upheavals of 2020, physician compensation has maintained a positive trajectory during the pandemic, Stajduhar says. "There were physicians who went unpaid last year. Physicians were on productivity contracts and having their compensation cut. But overall, physician salaries increased about 1.5%, according to Doximity."
As the pandemic drags on, physician compensation will likely continue to grow, he says.
"I anticipate that physician compensation is going to continue to rise during the pandemic. As physicians leave the field or retire early, the shortage of physicians is going to be even more exaggerated. As physician shortages continue to grow, this could turn into a free agency market because the competition between healthcare organizations needing physicians could lift restrictions and guidelines for hiring physicians. It is a market where the physicians should be able to demand what they want."
Whether or not physicians can negotiate significant salary increases, they should negotiate contracts with the pandemic in mind, Stajduhar says. "They should be negotiating for catastrophe clauses in their contracts. They need some protection financially because there were many physicians who took a major financial hit last year."
Moving away from the cities
Surveys conducted at Jackson Physician Search and other organizations have shown that some physicians are moving out of metropolitan areas for other locations.
"What we have been hearing from physicians is that they are trying to get out of some of the major metropolitan areas that have been hit hard by COVID-19. There is a perception that there are safer places to be located such as rural and suburban areas. Perception is driving a lot of this trend. Some physicians do not want to continue to live in metropolitan areas and put their families at risk," Stajduhar says.
Two other factors may be influencing the move away from metropolitan areas, he says.
"First, many physicians have loved ones who are hundreds of miles away or thousands of miles away, and things could happen to them in a heartbeat. So, physicians are looking to make a move to get closer to family. Second, some physicians may be looking for a slower pace of life. About 20% of the population lives in rural America, but only 10% of physicians work in rural America. So, there are opportunities for physicians to work in rural areas, make a very good living, and have a dramatically lower cost of living."
Recruiting advice for physicians and healthcare organizations
In the physician employment market, time is a crucial factor, Stajduhar says.
"From the physician perspective, they should be thinking ahead at least a year when trying to find the right position. If they think 18 to 24 months out, then they have more time to be selective. But once it gets to a year, the clock starts ticking and it gets louder every day. For healthcare organizations, they absolutely need to start recruiting early. They should start recruiting at least 12 months before they need to fill a position. In some cases, it can be hard to fill specialty positions and it can take two years."
Seeking perfection can be a mistake, he says. "I always tell physicians and healthcare organizations that if they can find 80% of what they are looking for that is probably as good of a match as you are going to find. For physicians, the key is judging the critical 80% of things that you must have for a good opportunity. For healthcare organizations, you must determine the 80% of things that you need in a physician."
Lastly, physicians and healthcare organizations should be open minded during the recruitment process, Stajduhar says.
"For physicians, they should be open about geography. Most people grow up in their town or one or two other places, they vacation in a couple of places, and that is what they think of in terms of locating for a job. They think about what is easy—they know a handful of locations and there is some comfort there. As someone who has recruited physicians across the country, I can say there are amazing places from coast to coast. Physicians just need to give a new location a chance. If the majority of what a physician needs is in a location, they should open their mind and take a look at it."
"For healthcare organizations, they should keep their minds open, too. They may want someone young who is going to stay for 30 or 40 years, but they can't build their recruiting program on that. If you find someone who is nearing the end of their career, they could still work for you for 10 years and make a huge difference in your practice. These are often physicians who are in your own backyard, and you do not have to work hard to recruit them."
A Boston-based hospital at home program added significant acute-care bed capacity during the city's first COVID-19 patient surge.
Hospital at home programs have the potential to add significant acute-care bed capacity during public health emergencies such as the coronavirus pandemic, a new research article shows.
Health systems and hospitals have been pushed to the brink during coronavirus patient surges across the country. Hospital at home programs can serve as a complementary strategy to open up traditional hospital beds to care for acutely ill patients.
The new research article, which was published by the Journal of General Internal Medicine, highlights the performance of the Brigham Health Home Hospital at Brigham and Women's Hospital program during the early phase of the pandemic. The study covers the period from March 15, 2020, to June 18, 2020, when the Boston area experienced its first COVID-19 patient surge.
The research article features several key data points.
Over the 95-day study period, the Brigham Health home hospital program cared for 65 acutely ill patients, which amounted to 419 bed-days.
During the study period, the home hospital program was staffed daily by one physician, one or two nurses, and one mobile integrated health paramedic.
Most (59%) home hospital patients were treated for infection followed by heart failure exacerbation (22%).
Most (65%) home hospital patients were discharged without services, 12.3% were readmitted within 30 days, and 13.8% presented to the emergency department within 30 days.
Over the 95-day study period, a field hospital established in Boston cared for 394 patients. The field hospital was staffed by 124 clinicians and 331 nurses. The cost of operating the field hospital was $29.8 million, which amounted to more than $75,000 per patient.
Interpreting the data
The lead author of the research article told HealthLeaders that the Brigham Health home hospital program made a significant contribution to acute-care capacity during the COVID-19 patient surge.
"During that first coronavirus surge in Boston, bed capacity was very challenging. Every single bed that we could get for patients who were seriously ill and needed to be in a hospital was a big deal. If you had told me that you could have created a model that could take five patients out of the hospital, I would have said, 'Let's look at that.' So, the fact that we were able to take care of 65 patients was impressive and impactful for the hospital, especially during those surge conditions," said David Levine, MD, MPH, MA, medical director for strategy and innovation at the home hospital program.
The cost of caring for patients in the home hospital program was a small fraction of the cost of caring for patients in the field hospital, he said.
"We did a randomized control trial that was published in Annals of Internal Medicine that showed that home hospital care costs about 38% less than traditional hospital care. Obviously, the cost of home hospital care is going to be way shy of the $75,000 per patient number at the field hospital. Typical hospital care costs about $15,000 per patient and home hospital care is about 38% less of that figure," Levine said.
Brigham Health's home hospital program should be viewed as a supplementary response to Boston's first COVID-19 patient surge, he said. "There was a different patient profile at the field hospital compared to home hospital. It is important to see home hospital as a complementary opportunity for hospital systems when thinking about responding to a pandemic. We should not get rid of field hospitals—but we need to think about complementary strategies for taking care of patients such as home hospital."
Future prospects for hospital at home programs
Levine has an expansive vision for the future of hospital at home programs.
"I am excited about the future of home hospital. If my vision comes true, hospital at home will be the way that we care for many acutely ill patients in the future and being in a traditional hospital bed will the exception as opposed to the rule. We are going to be able to expand home hospital with novel and creative care pathways and new technologies. We should be able to get this new care model to every person in the country irrespective of where they live and be able to get them the care that they need in their home," he said.
Reimbursement has been a major obstacle for hospital at home programs in the United States. That barrier was dramatically eased in November 2020, when the Centers for Medicare & Medicaid Services implemented the Acute Hospital Care At Home waiver. The waiver makes home hospital services eligible for Medicare fee-for-service reimbursement during the coronavirus public health emergency.
"It is exciting to look at the adoption curve since the CMS waiver. We went from about six programs to 145 programs in six months during a pandemic. It is a feat of early adoption," Levine said.
AdventHealth's new division chief clinical officer views seizing opportunities to improve facilities as a top priority.
Altamonte Springs, Florida-based AdventHealth has created a new chief clinical officer position for the health system's Central Florida Division.
Neil Finkler, MD, was recently named to fill the new post. A gynecologic oncologist by training, Finkler has previously served as chief medical officer of the AdventHealth Medical Group and chief medical officer of AdventHealth Orlando, which is the health system's quaternary hospital.
AdventHealth's Central Florida Division spans seven counties, and features more than 20 hospitals, 300 AdventHealth Medical Group physician practices, 35 urgent care centers, and 6,000 physicians and advanced practice providers.
HealthLeaders recently held a conversation with Finkler about the new chief clinical officer role, the challenges of overseeing a far-flung clinical enterprise, patient safety, and physician engagement. The following is a lightly edited transcript of that discussion.
HealthLeaders: Why did AdventHealth create this new chief clinical officer role?
Neil Finkler: This reflected the importance of making sure that we deliver on our service promises. Most notably, this new role is charged with making sure that we deliver the highest quality of safe and effective care throughout our facilities. We believe each of our facilities must function in unison. So, the care that you get at one facility should be identical to the care that you get at another facility, and we expect the outcomes to be similar.
We obviously understand that there are certain things that only the quaternary facility can do such as ECMO or transplants. But if you come in and you are treated for pneumonia, that treatment should look identical across our entire clinical spectrum.
In addition, we started to recognize that there was more than just the acute care side, which is where I have spent most of my career. We have a whole other aspect of our health system where most patients receive their care outside the walls of our hospitals. We have called that care "integrated health services." I also have oversight for the integrated health services world as well as the acute care world.
Healthleaders: What constitutes integrated health services at AdventHealth?
Finkler: The easiest way to think about integrated health services is everything that is outside the walls of the hospital. It includes physician offices, free-standing radiology and laboratory services, skilled nursing facilities, long-term acute care facilities, transition clinics, and infusion clinics.
HealthLeaders: What are the primary elements of this new chief clinical officer role?
Finkler: The most important thing for me to understand is the opportunities within each of our facilities. I particularly look at this from the standpoint of clinical excellence. Our division has several parameters that we use to assess clinical excellence. The three major ones are the Centers for Medicare & Medicaid Services five-star rating, the Leapfrog rating, as well as ranking in the top quartile of national mortality rates using the Premier Healthcare Database.
In addition, there are other parameters that we look at. We know that healthcare is constantly evolving, which means that the parameters and the metrics that we use are also changing. It is our job to make sure that we are on the spectrum of continuous improvement.
Regarding the CMS stars rating, AdventHealth Orlando, which includes the seven hospitals operating under the Orlando license in Orange, Osceola, and Seminole counties as well as AdventHealth Daytona Beach were recently awarded five stars. This is a great accomplishment, and it represents the skilled physicians and the collective effort it takes to bring excellence to the table. Only 13.5% of all hospitals are five-star ranked. These ratings are ranked with factors such as readmissions, mortality, safety of care, and patient satisfaction—all things that we believe that the communities that we serve should find important.
Within the Leapfrog reports, which give letter grades A through D, all AdventHealth hospitals in Seminole, Orange, Osceola, Valusia, and Lake counties have received an A grade for safety.
The world is changing, and every hospital and facility is also on this journey. So, the bar that you were able to meet this year for CMS star ratings or Leapfrog grades gets raised next year. Everybody needs to raise their game and these rankings give me the opportunity to look across my facilities and to see where we have opportunities to improve.
HealthLeaders: How are you focused on the issue of patient safety?
Finkler: We want to develop safe and reliable facilities across all avenues that our patients touch. We will know when we have reached success when we are all in a proactive system. We need to be able to identify future problems and be able to intervene now to prevent those future problems.
Improving safety involves empowering our entire workforce to speak up. I was trained in an era when the physician was the team. When I was trained, no one questioned what the physician had to say. That is not a safe environment.
We need to empower all members of the team to be able to speak up if they see something that does not look or sound right. Anybody on a team should be able to "stop the line." Even if you are the person who cleans the room, if you see something in that room that does not look right, you should be able to speak up. Everybody needs to understand the concerns of every member of the team. That is the way to achieve the safest possible environment.
HealthLeaders: What is your vision for leadership of AdventHealth's Central Florida Division?
Finkler: One of the advantages that I have is that our health system understands the importance of having chief medical officers at each one of the local facilities. These chief medical officers understand better than I do the issues in their local facility, and we communicate frequently. If there are any leadership issues, I can turn to my chief medical officers locally and we act as a dyad.
At the highest levels of this organization, the executive team realizes what the chief medical officers bring to the table. The chief medical officers understand that first and foremost we are a clinical organization that needs to deliver the highest quality care to the communities that we serve.
Given the fact that there is buy-in from every level of the organization, that is a great source of help for me. There has never been a time when the leadership has challenged or questioned what needs to get done to deliver high quality care. As a group, our physicians recognize that we are serious about what we are trying to do and that we are on a journey to become a top decile company because we want to be a leader in healthcare throughout the entire country. That is a journey that is going to take every one of us to make.
HealthLeaders: What are the key factors in physician engagement?
Finkler: The key factors are getting physicians to the table and having them be part of decisions. In general, physicians do not mind hearing "no." But when physicians hear a "no," they want to hear the why behind it.
I certainly believe in being completely transparent and putting physician leaders at the decision-making table. Several years ago, we started a group called the Catalyst. This is a group of physician leaders across our entire division, and there are now about 250 of them across our facilities. We have open discussions; we talk about the clinical goals that we want to attack in the next year. These physician leaders are part of the planning, development, and implementation of our strategies.
There is no better way to get physician buy-in than to have them be part of the plan. Part of including them in the plan is you must be completely transparent with your data.
You also need to celebrate wins. You start with easy wins because the easy wins will lead to more difficult wins. After a while, I will not need to lead the conversation. Physicians will come to me, they will recognize opportunities, and they will help us seize on opportunities.
The Ohio State University Wexner Medical Center sees opportunities to provide home-based medical care services along the entire continuum of care.
The Ohio State University Wexner Medical Center (OSUWMC) is embracing home-based medical care.
Health systems, hospitals, and physician practices have been offering home-based medical care services for years as part of a strategy to improve access to care and to meet patients where they are instead of traditional medical settings. The coronavirus pandemic has accelerated utilization of home-based medical care services, including expansion of hospital at home programs.
Columbus, Ohio-based OSUWMC is committed to expanding the academic medical center's home-based medical care services, says Rachit Thariani, MBA, chief administrative officer of OSUWMC's Post-Acute and Home-Based Care Division.
"The pandemic has been horrible for society, but it has also shown us what is possible for healthcare in the home. Home-based medical care will be an essential part of what healthcare organizations will offer their patients and customers. It will no longer be a nice-to-have capability. We will have to figure out how to do home-based medical care in-person and how to do it digitally. Ohio State recognizes the home-based medical care trend. What we want to do is be at the frontend of this journey. Then we want to design breakthrough solutions that can transform the lives of the people we serve and the communities we serve," he says.
Drivers of home-based medical care
Four primary factors are driving adoption of home-based medical care at healthcare organizations, Thariani says.
1. Demand: Patients are demanding house calls and home health services, he says. "Demand is high, whether it is experiences patients have had receiving care in the home over the past 18 months, or whether it is because of the aging population and the ability to care more effectively for the aging population in the home. There are numerous surveys and studies that show that consumers want house calls and home health services."
2. High-value care: Home-based medical care generates value for patients and their healthcare providers, he says. "There is more evidence that when done right care in the home works, whether it is on the cost side or whether it is on the quality side."
3. Technology: Advancements in technology such as remote patient monitoring are enabling home-based medical care, he says. "There have been advances in technology that make things possible that were not possible even a couple years ago. There are digital and mobile healthcare applications that make home-based medical services possible."
4. Finance: Payment models are evolving to support home-based medical care, he says. "Specifically, value-based care is creating financial reasons for healthcare providers to offer home-based medical care."
House call resurgence
As part of the trend toward more home-based medical care utilization, house calls are making a comeback, Thariani says.
"House calls are a good solution for patients who are elderly or patients who are at high risk because of their health status. If patients have multiple complex conditions, they are a good fit for house calls. House calls are also a good solution for patients who have issues with mobility—they have difficulty leaving the home. House calls also work for patients who have been discharged from an acute hospital setting or post-acute care setting back to home. House calls are also good for patients who do not have access to transportation," he says.
House calls can involve multiple medical services, Thariani says. "When you think about house calls, you think about the patients who can benefit, then you think about the kinds of services you can offer, which is a broad range. It could be primary medical care, urgent care services, management of chronic conditions, and pharmacy needs such as home delivery of medications. Typically, many of these services would be accompanied by ancillary services such as lab work and portable X-ray."
At OSUWMC, house calls are just the tip of the home-based medical care iceberg, he says.
"If you think about the notion of personalized and comprehensive care, it is obvious that we need to create an ecosystem of care that is driving care into homes and communities. This is a kind of care that meets people where they are and helps them to remain healthy. So, when we think about what care can be provided in the home-based setting along the continuum of care, we are thinking about everything ranging from prevention and wellness to end-of-life care and everything in between, whether it is primary care, acute care, or post-acute care."
Making home-based medical care financially sustainable
There are four primary considerations to make sure home-based medical care services are financially sustainable, Thariani says.
1. Variety of payment models: "It is important to realize that the economics are very different for different home-care services. For example, the payment model for home healthcare is different than the payment model for home medical equipment, or home infusions, or house calls. Depending on the service you are providing, there is an underlying payment model that varies by service. You need to optimize the payment models for each of the unique areas of service," he says.
2. Value-based contracting: "If you go outside of the specific financial models, you need to explore value-based arrangements both with payers to establish payment models for home-based care and with potential industry partners such as technology companies or companies that facilitate unique models of care," he says.
3. Return on investment: "We need to have a more holistic view on return on investment. The traditional return on investment model is you invest then generate a direct financial return. In home-based medical care, we need to be thinking about not only the direct financial impact but also the impact on indirect elements such as clinical benefits, efficiency measures, length of stay, utilization rates, and readmission rates," he says.
4. Program size: "We also need to be mindful of the size and scale at which we launch new home-based medical care offerings. Rather than trying to launch services at scale, it can be more prudent to start small. You can prove the concept, get people engaged, show the outcomes, then scale up. Particularly once you show the outcomes, the propensity to invest might be greater."
Physicians report reduced income, increased burnout, and heightened mental health concerns over past year of the pandemic.
The coronavirus pandemic is taking a heavy toll on the wellbeing of physicians, a new survey report says.
The coronavirus pandemic is one of the most significant public health crises in more than a century. Physicians have been on the frontline of the struggle, working long hours and enduring the emotional toll of losing hundreds of thousands of patients to the virus.
The new survey report, which was published this week by The Physicians Foundation, is based on data collected from 2,500 physicians. The survey was conducted from May 26 to June 9, 2021.
The survey report features eight key findings.
About 80% of physicians have been significantly impacted by the pandemic, with 49% reporting reduced income, 32% reporting reduced staff, and 18% switching to a primary telemedicine practice.
In consideration of the long-term effects of the pandemic, most physicians anticipate continuing telehealth in their practices, seeing an increase in serious health conditions, and experiencing a significant decrease in independent physician practices.
There has been a significant increase in physician burnout during the pandemic, with 61% of physicians reporting having feelings of burnout often, which is a 20% increase compared to the physician burnout level that The Physicians Foundation reported in 2018.
The pandemic has had a negative impact on physician mental health, with 57% of survey respondents reporting inappropriate feelings of anger, sadness, or anxiety because of COVID-19. Nearly half of physicians (46%) report withdrawing or isolating themselves from others, and 34% report feeling hopeless or without a purpose. Despite the high level of mental health concerns, only 14% of physicians reported seeking medical attention.
Physicians reported that family (89%), friends (82%), and colleagues (71%) have been most helpful in addressing their mental health and wellbeing during the pandemic.
Most physicians (70%) reported that a multifaceted approach is necessary to address their mental health conditions, burnout, and suicide prevention. Suggested approaches included confidential therapy, counseling, or support lines as well as evidence-based professional training.
Over the past year, about 20% of physicians reported knowing a physician who had either considered, attempted, or died by suicide. Throughout their career, 55% of physicians reported knowing a physician who had either considered, attempted, or died by suicide.
A positive element of the pandemic has been widespread adoption of telehealth. Among physicians who are 45 or younger, 75% reported they anticipate continuing to use telehealth in the practices. Among female physicians, 74% reported they anticipate continuing to use telehealth in the practices.
Interpreting the data
Physicians need help to address the negative impacts of the pandemic, the report says. "Given the high levels of stress, burnout, and physical and mental harm caused to physicians by COVID-19, it is clear that more must be done to foster and promote physician wellbeing, for the good of the public and for physicians."
More must be done to encourage physicians with mental health conditions to seek help, the report says. "The Physicians Foundation’s 2021 Survey of America's Physicians indicates that the COVID-19 pandemic not only continues to exert a heavy toll on physician wellbeing and professional fulfillment, but also has shined a bright light on the stigma still associated with medical professionals seeking mental health care."
The survey report highlights two public health concerns that have impacted physicians for decades.
1. Linkage between physician wellbeing and healthcare outcomes: "A decline in physician wellbeing and an increase in physician burnout levels have consistently been linked to poor healthcare outcomes. It is in the public's interest to help maintain physician wellbeing and lower levels of physician burnout because healthy, engaged physicians generally provide better care than unhealthy, disengaged physicians," the report says.
2. Physician suicide: The finding that about 20% of physicians reported knowing a physician who had either considered, attempted, or died by suicide during the pandemic indicates physician suicide remains a top concern for the profession. "Left untreated, burnout can cause more cases of depression, anxiety, PTSD, substance use and suicidal thoughts for physicians. It is estimated that approximately 1 million Americans lose their physician to suicide each year," the report says.
The survey report shows that physicians want systematic change to improve how their field addresses burnout and mental health conditions, Gary Price, MD, president of The Physicians Foundation, said in a prepared statement.
"We know evidence-based solutions exist; they now need to be scaled. For example, through the Foundation's collaboration with the American Medical Association in the Practice Transformation Initiative, Washington Permanente Medical Group in Washington state implemented pre-visit laboratory testing, which gave their physicians the opportunity to discuss results directly with patients at their appointment. This streamlined administrative tasks and contributed to a reduction in the number of hours spent on indirect patient care by three hours," he said.
Cesarean section births can have dangerous complications such as hemorrhaging.
The years-long effort to reduce unnecessary Cesarean section births in the United States is coming to fruition, an obstetrics expert says.
Complications from C-sections such as hemorrhaging are widely considered to be a contributing factor to the country's high maternal mortality rate. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
"We are finally at the point where most hospitals are sharing their data and having conversations on an individual basis about C-section rates. We are having conversations about quality at labor and delivery units as well as about the quality of individual providers. It has taken more than a decade to get to this point," says Amy VanBlaricom, MD, vice president of clinical operations for western states at Greenville, South Carolina-based Ob Hospitalist Group.
VanBlaricom says she is optimistic about the ongoing effort to limit unnecessary C-sections. "I would not say that we are at the finish line, but we are definitely in the home stretch. Reducing C-sections is on everyone's radar screen. Everyone who is in the practice of obstetrics knows that this is a problem, and they understand that there are medical complications that are happening to women that are avoidable because many C-sections have been done historically for less than medically sound reasons."
Roots of the problem
Both clinicians and patients are responsible for unnecessary C-section births, VanBlaricom says.
"From the physician side, there is fear of medical-legal risk. There is an old adage that obstetricians say, 'You never regret the C-section that you do, but you regret the C-section that you did not do.' There are many obstetricians who are fearful of being sued if they delay too long in performing a C-section, so they may call for a C-section sooner than is medically necessary. There are also inconveniences in scheduling—obstetricians need to coordinate their day if they have other issues going on. An obstetrician can become impatient with how long it takes a labor to progress," she says
"On the patient side, there is a segment of the patient population that asks for a C-section when it is not necessarily medically indicated. Some mothers want a C-section because they want to schedule the day of their birth. Some mothers want a C-section because they are fearful of the process of vaginal delivery—they want to preserve the integrity of their pelvic musculature. They read articles in lay journals about how it is going to impact their body to have a vaginal birth, and they decide they want to try to avoid that impact," VanBlaricom says.
Financial incentives can also drive unnecessary C-sections, she says. "There is a concern that insurance companies pay more for a C-section than for a vaginal delivery. The worry is that there is the convenience factor and the medical-legal climate that makes obstetricians fearful, then the payers incentivize financially toward the surgical delivery. That creates an environment that leans many providers toward the surgical mode of delivery."
Avoiding unnecessary C-sections
Peer pressure can be an effective way to encourage clinicians to avoid unnecessary C-sections, VanBlaricom says.
"That means benchmarking C-section rates for all of the hospital providers and making it transparent. You need to champion those who are doing a good job at keeping their C-section rates low. You also want to allow the providers who have higher C-section rates to learn. They should find out the ways that a colleague, who is seeing patients from the same community and has a lower C-section rate, is doing their practice in ways that achieve a lower C-section rate," she says.
Benchmarking should focus on first-time C-sections because once a C-section has been performed on a mother, she is more likely to have a surgical birth in the future, VanBlaricom says.
"Most hospitals look at the rate of first-time C-sections. There are a couple of different ways to look at that. One is the NTSV C-section rate, which stands for Nulliparous, Term, Singleton, Vertex. This measure eliminates twin gestations, breach babies, and those kinds of situations where it can be a no brainer to conduct a C-section. This is all about avoiding the avoidable, first-time C-section and looking at that rate. A good number is somewhere around 23% of births—that is usually where the data has shown that an appropriate number of avoidable C-sections are avoided," she says.
Standardization of care is another approach to limit unnecessary C-sections, VanBlaricom says.
"A good standardization tool is a labor dystocia checklist. Many clinicians think that the most avoidable form of C-section is the one that is done for a slow labor process—what is called labor dystocia. It is a labor that is taking longer than you think it should take. This can be very subjective. It can be based on the clinician's patience level, it can be based on what the clinician is usually willing to tolerate over time, or it can be based on what the mother is willing to accept," she says.
Labor dystocia checklists are based on evidence and a stepwise approach to labor, VanBlaricom says. "The checklists account for the number of steps you have taken, the amount of time that you have let the mother labor in each section of the labor process, and how long it is safe to let the mother labor. For example, the checklists account for how long the amniotic sack has been broken and how long the mother has been on labor augmentation medications without having the appropriate amount of cervical change."
Including mothers in their care teams is another way to limit C-sections, she says.
"When the mother is included in the care team, she will be more informed about the process and ask appropriate questions. We as clinicians will be less likely to call for a C-section out of convenience or call for a C-section based on a nonstandard indication. At hospitals that involve mothers in the process of labor, what we see is each member of the care team is held accountable to each phase of the process. The physicians are less likely to recommend a procedure that is not medically indicated because the patient requires a level of information and being informed. The patient is more likely to feel empowered to say 'no' if there is not a medical reason to perform a C-section," VanBlaricom says.
C-sections by the numbers
Statistics indicate that unnecessary C-sections are becoming less common.
Ob Hospitalist Group's NTSV C-section rate for the deliveries their clinicians perform is 20.4% of all births.
The rate of low-risk C-sections spiked to 28.1% of all births in 2009 but the rate fell to 25.9% in 2018.
Healthy People 2030 set a national target for low-risk, first-birth C-section deliveries at 23.6% of all births and many states are making headway. For example, California reached a statewide average of 24.5% for low-risk, first-time C-section births in 2017.
Researchers found that some patients became sick after exposure to other patients with influenza-like illness in primary care offices.
There is a significant risk of spreading infection of influenza-like illness in primary care offices, a new research article shows.
The potential for the spread of respiratory illness in healthcare settings has been a primary concern during the coronavirus pandemic. To address this concern, many outpatient clinics closed their doors in the early phase of the pandemic and telehealth expanded tremendously to keep patients and their clinicians safely connected for care.
The new research article, which was published by Health Affairs, is based on information collected from a national electronic health records database for patient visits at more than 6,000 office-based primary care practices from 2016 to 2017.
The researchers focused on patient visits for influenza-like illness. Patients were considered potentially exposed to infection if another patient with influenza-like illness was seen in the same clinic as long as 90 minutes before an office visit. Patients who had office visits before another patient with influenza-like illness was seen in the same clinic were considered unexposed. The researchers sought to see whether exposed patients returned to the clinic within two weeks of exposure with influenza-like illness.
The research article features three key data points:
The researchers found 2.7 patients per 1,000 returned within two weeks with influenza-like illness, with exposed patients more likely to return with influenza-like illness (an adjusted difference of 0.7 per 1,000 patients)
Compared with the baseline rate of a return visit with influenza-like illness for unexposed patients, this change represented a 31.8% increase
With more than 7.3 million patients exposed in the study, about 5,140 excess influenza-like illness visits were potentially attributable to appointment timing
"In this study of a large, national EHR dataset, we found that in primary care offices, those seen after a patient with influenza-like illness were more likely to return with a similar illness in the next two weeks compared with nonexposed patients seen earlier in the day," the research article's co-authors wrote.
Policy implications
There are two primary healthcare provider policy implications from the study, the research article says.
"First, given that the presence of a symptomatic patient with influenza-like illness is associated with increased rates of likely infection among patients present in the clinic at the same time, healthcare facilities should consider explicit guidelines for the triage to telemedicine of patients with low-risk respiratory viral symptoms such as cough, runny nose, muscle aches, sore throat, or low-grade fever," the research article's co-authors wrote.
The second policy implication is that clinics should use strict infection control techniques if patients with influenza-like illness must be seen in person.
"Many infection control practices are standard expectations of care in outpatient settings, as outlined by recommendations from the Centers for Disease Control and Prevention, but compliance with even basic infection control practices such as hand hygiene is notoriously poor. Enhanced infection control practices could include strict requirements for patient mask wearing, which might not be a universal expectation among patients, and immediate cohorting of patients with influenza-like illness into reserved exam rooms that are not shared with other patients before decontamination," the research article's co-authors wrote.
