Practice Management

While plenty of anecdotal and other evidence exists to connect the use of electronic health records to physician burnout, new research puts a more standard, quantifiable measure to it in an effort to help measure progress in improving the usability of EHRs.

Leah-Anne Thompson/Thinkstock

Researchers used the System Usability Scale (SUS), “favored as an industry standard as a short, simple, and reliable measurement of technology usability with solid benchmarks to easily interpret its results, as the measure in this research, Edward Melnick, MD, of Yale University, New Haven, Conn., and colleagues wrote in Mayo Clinic Proceedings.

“The previous studies have definitely hinted at [the link between EHRs and burnout], but never really quantified it,” Dr. Melnick said in an interview.

Among the 870 physicians evaluating their EHRs’ usability, the mean score on a scale of 0-100 (higher being more usable) was 45.9. As a point of comparison, Microsoft Excel has an SUS score of 57, digital video recorders score 74, Amazon scores 82, microwave ovens score 87, and Google search scores 93.

“A score of 45.9 is in the bottom 9% of usability scores across studies in other industries and is categorized as in the ‘not acceptable’ range with a grade of F,” the authors wrote. “In aggregate, 733 of 870 (84.2%) of respondents rated their EHR less than 68 on the SUS, the average score across industries.”

In tying the SUS results to burnout, which was measured using the Maslach Burnout Inventory, the authors noted that the scores “were strongly and independently associated with physician burnout in a dose-response relationship. The odds of burnout were lower for each 1 point more favorable SUS score, a finding that persisted after adjusting for an extensive array of other personal and professional characteristics. The relationship between SUS score and burnout also persisted when emotional exhaustion and depersonalization were treated as continuous variables.”

The authors did note that, despite the strong relationship, they could not determine a causation given the cross-sectional nature of the data.

“I’m hoping that this paper will spark conversation and drive change and be a way of tracking improvements,” Dr. Melnick said. “So, if you bring in something new and say this is going to be better, how do you know it is going to be better? Well maybe you measure it using the System Usability Scale” to give it a quantifiable measure of improvement. He said it is an advantage “of having a metric that has been standardized and used in other industries,” allowing EHR stakeholders to measure improvement. “Once you can measure it, you can manage it and make improvements faster.”

The findings “will not come as a surprise to anyone who practices medicine,” Patrice Harris, MD, president of the American Medical Association, said in a statement. “It is a national imperative to overhaul the design and use of EHRs and reframe the technology to focus primarily on its most critical function: helping physicians care for patients. Significantly enhancing EHR usability is key and the AMA is working to ensure a new generation of EHRs are designed to prioritize time with patients, rather than overload physicians with type-and-click tasks.”

Funding for the study was provided by the Stanford Medicine WebMD Center, AMA, and the Mayo Clinic Department of Medicine Program on Physician Well-Being. No conflicts of interest were reported by the authors.

[email protected]

SOURCE: Melnick E et al. Mayo Clinic Proceedings 2019 Nov 14. doi: 10.1016/j.mayocp.2019.09.024.

While plenty of anecdotal and other evidence exists to connect the use of electronic health records to physician burnout, new research puts a more standard, quantifiable measure to it in an effort to help measure progress in improving the usability of EHRs.

Leah-Anne Thompson/Thinkstock

Researchers used the System Usability Scale (SUS), “favored as an industry standard as a short, simple, and reliable measurement of technology usability with solid benchmarks to easily interpret its results, as the measure in this research, Edward Melnick, MD, of Yale University, New Haven, Conn., and colleagues wrote in Mayo Clinic Proceedings.

“The previous studies have definitely hinted at [the link between EHRs and burnout], but never really quantified it,” Dr. Melnick said in an interview.

Among the 870 physicians evaluating their EHRs’ usability, the mean score on a scale of 0-100 (higher being more usable) was 45.9. As a point of comparison, Microsoft Excel has an SUS score of 57, digital video recorders score 74, Amazon scores 82, microwave ovens score 87, and Google search scores 93.

“A score of 45.9 is in the bottom 9% of usability scores across studies in other industries and is categorized as in the ‘not acceptable’ range with a grade of F,” the authors wrote. “In aggregate, 733 of 870 (84.2%) of respondents rated their EHR less than 68 on the SUS, the average score across industries.”

In tying the SUS results to burnout, which was measured using the Maslach Burnout Inventory, the authors noted that the scores “were strongly and independently associated with physician burnout in a dose-response relationship. The odds of burnout were lower for each 1 point more favorable SUS score, a finding that persisted after adjusting for an extensive array of other personal and professional characteristics. The relationship between SUS score and burnout also persisted when emotional exhaustion and depersonalization were treated as continuous variables.”

The authors did note that, despite the strong relationship, they could not determine a causation given the cross-sectional nature of the data.

“I’m hoping that this paper will spark conversation and drive change and be a way of tracking improvements,” Dr. Melnick said. “So, if you bring in something new and say this is going to be better, how do you know it is going to be better? Well maybe you measure it using the System Usability Scale” to give it a quantifiable measure of improvement. He said it is an advantage “of having a metric that has been standardized and used in other industries,” allowing EHR stakeholders to measure improvement. “Once you can measure it, you can manage it and make improvements faster.”

The findings “will not come as a surprise to anyone who practices medicine,” Patrice Harris, MD, president of the American Medical Association, said in a statement. “It is a national imperative to overhaul the design and use of EHRs and reframe the technology to focus primarily on its most critical function: helping physicians care for patients. Significantly enhancing EHR usability is key and the AMA is working to ensure a new generation of EHRs are designed to prioritize time with patients, rather than overload physicians with type-and-click tasks.”

Funding for the study was provided by the Stanford Medicine WebMD Center, AMA, and the Mayo Clinic Department of Medicine Program on Physician Well-Being. No conflicts of interest were reported by the authors.

[email protected]

SOURCE: Melnick E et al. Mayo Clinic Proceedings 2019 Nov 14. doi: 10.1016/j.mayocp.2019.09.024.

While plenty of anecdotal and other evidence exists to connect the use of electronic health records to physician burnout, new research puts a more standard, quantifiable measure to it in an effort to help measure progress in improving the usability of EHRs.

Leah-Anne Thompson/Thinkstock

Researchers used the System Usability Scale (SUS), “favored as an industry standard as a short, simple, and reliable measurement of technology usability with solid benchmarks to easily interpret its results, as the measure in this research, Edward Melnick, MD, of Yale University, New Haven, Conn., and colleagues wrote in Mayo Clinic Proceedings.

“The previous studies have definitely hinted at [the link between EHRs and burnout], but never really quantified it,” Dr. Melnick said in an interview.

Among the 870 physicians evaluating their EHRs’ usability, the mean score on a scale of 0-100 (higher being more usable) was 45.9. As a point of comparison, Microsoft Excel has an SUS score of 57, digital video recorders score 74, Amazon scores 82, microwave ovens score 87, and Google search scores 93.

“A score of 45.9 is in the bottom 9% of usability scores across studies in other industries and is categorized as in the ‘not acceptable’ range with a grade of F,” the authors wrote. “In aggregate, 733 of 870 (84.2%) of respondents rated their EHR less than 68 on the SUS, the average score across industries.”

In tying the SUS results to burnout, which was measured using the Maslach Burnout Inventory, the authors noted that the scores “were strongly and independently associated with physician burnout in a dose-response relationship. The odds of burnout were lower for each 1 point more favorable SUS score, a finding that persisted after adjusting for an extensive array of other personal and professional characteristics. The relationship between SUS score and burnout also persisted when emotional exhaustion and depersonalization were treated as continuous variables.”

The authors did note that, despite the strong relationship, they could not determine a causation given the cross-sectional nature of the data.

“I’m hoping that this paper will spark conversation and drive change and be a way of tracking improvements,” Dr. Melnick said. “So, if you bring in something new and say this is going to be better, how do you know it is going to be better? Well maybe you measure it using the System Usability Scale” to give it a quantifiable measure of improvement. He said it is an advantage “of having a metric that has been standardized and used in other industries,” allowing EHR stakeholders to measure improvement. “Once you can measure it, you can manage it and make improvements faster.”

The findings “will not come as a surprise to anyone who practices medicine,” Patrice Harris, MD, president of the American Medical Association, said in a statement. “It is a national imperative to overhaul the design and use of EHRs and reframe the technology to focus primarily on its most critical function: helping physicians care for patients. Significantly enhancing EHR usability is key and the AMA is working to ensure a new generation of EHRs are designed to prioritize time with patients, rather than overload physicians with type-and-click tasks.”

Funding for the study was provided by the Stanford Medicine WebMD Center, AMA, and the Mayo Clinic Department of Medicine Program on Physician Well-Being. No conflicts of interest were reported by the authors.

[email protected]

SOURCE: Melnick E et al. Mayo Clinic Proceedings 2019 Nov 14. doi: 10.1016/j.mayocp.2019.09.024.

PHM19 session

MOC Part 4 projects for community pediatric hospitalists

Presenters

Jack M. Percelay, MD, MPH, FAAP, MHM

Nancy Chen, MD, FAAP

Elizabeth Dobler, MD, FAAP

Lindsay Fox, MD

Beth C. Natt, MD, MPH, SFHM

Clota Snow, MD, FAAP

Session summary

Dr. Jack Percelay, of Sutter Health in San Francisco, started this session at Pediatric Hospital Medicine 2019 by outlining the process of submitting a small group (n = 1-10) project for Maintenance of Certification (MOC) Part 4 credit including the basics of what is needed for the application:

• Aim statement.
• Metrics used.
• Data required (3 data points: pre, post, and sustain).

He also shared the requirement of “meaningful participation” for participants to be eligible for MOC Part 4 credit.
 

Examples of successful projects were shared by members of the presenting group:

• Dr. Natt: Improving the timing of the birth dose of the hepatitis B vaccination.
• Dr. Dobler: Improving the hepatitis B vaccination rate within 24 hours of birth.
• Dr. Snow: Supplementing vitamin D in the newborn nursery.
• Dr. Fox: Improving newborn discharge efficiency, improving screening for smoking exposure, and offering smoking cessation.
• Dr. Percelay: Improving hospitalist billing and coding using time as a factor.
• Dr. Chen: Improving patient satisfaction through improvement of family-centered rounds.

The workshop audience divided into groups to brainstorm/troubleshoot projects and to elicit general advice regarding the process. Sample submissions were provided.
 

Key takeaways

• Even small projects (i.e. single metric) can be submitted/accepted with pre- and postintervention data.
• Be creative! Think about changes you are making at your institution and gather the data to support the intervention.
• Always double-dip on QI projects to gain valuable MOC Part 4 credit!

Dr. Fox is site director, Pediatric Hospital Medicine Division at MetroWest Medical Center, Framingham, Mass.

PHM19 session

MOC Part 4 projects for community pediatric hospitalists

Presenters

Jack M. Percelay, MD, MPH, FAAP, MHM

Nancy Chen, MD, FAAP

Elizabeth Dobler, MD, FAAP

Lindsay Fox, MD

Beth C. Natt, MD, MPH, SFHM

Clota Snow, MD, FAAP

Session summary

Dr. Jack Percelay, of Sutter Health in San Francisco, started this session at Pediatric Hospital Medicine 2019 by outlining the process of submitting a small group (n = 1-10) project for Maintenance of Certification (MOC) Part 4 credit including the basics of what is needed for the application:

• Aim statement.
• Metrics used.
• Data required (3 data points: pre, post, and sustain).

He also shared the requirement of “meaningful participation” for participants to be eligible for MOC Part 4 credit.
 

Examples of successful projects were shared by members of the presenting group:

• Dr. Natt: Improving the timing of the birth dose of the hepatitis B vaccination.
• Dr. Dobler: Improving the hepatitis B vaccination rate within 24 hours of birth.
• Dr. Snow: Supplementing vitamin D in the newborn nursery.
• Dr. Fox: Improving newborn discharge efficiency, improving screening for smoking exposure, and offering smoking cessation.
• Dr. Percelay: Improving hospitalist billing and coding using time as a factor.
• Dr. Chen: Improving patient satisfaction through improvement of family-centered rounds.

The workshop audience divided into groups to brainstorm/troubleshoot projects and to elicit general advice regarding the process. Sample submissions were provided.
 

Key takeaways

• Even small projects (i.e. single metric) can be submitted/accepted with pre- and postintervention data.
• Be creative! Think about changes you are making at your institution and gather the data to support the intervention.
• Always double-dip on QI projects to gain valuable MOC Part 4 credit!

Dr. Fox is site director, Pediatric Hospital Medicine Division at MetroWest Medical Center, Framingham, Mass.

PHM19 session

MOC Part 4 projects for community pediatric hospitalists

Presenters

Jack M. Percelay, MD, MPH, FAAP, MHM

Nancy Chen, MD, FAAP

Elizabeth Dobler, MD, FAAP

Lindsay Fox, MD

Beth C. Natt, MD, MPH, SFHM

Clota Snow, MD, FAAP

Session summary

Dr. Jack Percelay, of Sutter Health in San Francisco, started this session at Pediatric Hospital Medicine 2019 by outlining the process of submitting a small group (n = 1-10) project for Maintenance of Certification (MOC) Part 4 credit including the basics of what is needed for the application:

• Aim statement.
• Metrics used.
• Data required (3 data points: pre, post, and sustain).

He also shared the requirement of “meaningful participation” for participants to be eligible for MOC Part 4 credit.
 

Examples of successful projects were shared by members of the presenting group:

• Dr. Natt: Improving the timing of the birth dose of the hepatitis B vaccination.
• Dr. Dobler: Improving the hepatitis B vaccination rate within 24 hours of birth.
• Dr. Snow: Supplementing vitamin D in the newborn nursery.
• Dr. Fox: Improving newborn discharge efficiency, improving screening for smoking exposure, and offering smoking cessation.
• Dr. Percelay: Improving hospitalist billing and coding using time as a factor.
• Dr. Chen: Improving patient satisfaction through improvement of family-centered rounds.

The workshop audience divided into groups to brainstorm/troubleshoot projects and to elicit general advice regarding the process. Sample submissions were provided.
 

Key takeaways

• Even small projects (i.e. single metric) can be submitted/accepted with pre- and postintervention data.
• Be creative! Think about changes you are making at your institution and gather the data to support the intervention.
• Always double-dip on QI projects to gain valuable MOC Part 4 credit!

Dr. Fox is site director, Pediatric Hospital Medicine Division at MetroWest Medical Center, Framingham, Mass.

NEW ORLEANS – When Timothy P. Brigham, MDiv, PhD, thinks about the impact of burnout and stress on the ability of physicians to practice medicine, Lewin’s equation comes to mind.

FatCamera/Getty Images

Developed by psychologist Kurt Lewin in 1936, the equation holds that behavior stems from a person’s personality and the environment that person inhabits.

“We suspect that 70%-80% of the problem with burnout and stress in medicine is environmental,” Dr. Brigham, chief of staff and chief education and organizational development officer at the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), said at the annual meeting of the American Academy of Pediatrics.

“It’s a toxic mine, in some ways. What we tend to do is when we detect that physicians in general are, or a particular residency program is, too stressed out or burned out, we give them resilience training. Not that that’s unimportant, but it’s like putting a canary in a toxic mine full of poison and saying, ‘We’re going to teach you to hold your breath a little bit longer.’ Our job is to detoxify the mine.”

Troubled by the rise of suicides among physicians in recent years as well as mounting evidence about the adverse impact of burnout and stress on the practice of medicine, Dr. Brigham said that the ACGME is deepening its commitment to the well-being of faculty, residents, patients, and all members of the health care team. Since launching a “call to arms” on the topic at its annual educational conference in 2015, the ACGME has added courses on well-being to its annual meeting and remolded its Clinical Learning Environmental Review program to include all clinicians, “because everybody is affected by this: nurses, coordinators, et cetera,” he said. The ACGME also has revised Common Program Requirements, disseminated tools and resources to promote well-being and new knowledge on the topic, and partnered with the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience – all in an effort to bring about culture change.

“But we’re well aware that the ACGME can’t do this alone,” Dr. Brigham said. “We can’t ‘requirement’ our way out of this problem. It’s going to take a culture shift. Only you physicians, in collaboration with everyone in your community of learning, can create the systemic change required to improve our culture. We have a good handle on the problem at this point, but the solutions are a little bit more difficult to get a hold of. As Martin Luther King Jr. once said, ‘You don’t have to see the whole staircase, just take the first step.’ ”

The ACGME wants to work with physicians “to collect data and do joint research, to share insights, and to share tools and resources to create a better world for practicing physicians, for other members of the health care team, and for patients. After all, clinicians who care for themselves provide better care for others. They’re less likely to make errors or leave the profession,” Dr. Brigham told attendees.

He added that clinicians can gauge their risk for burnout by asking themselves three simple questions about their work environment: Does it support self-care? Does it increase and support connection with colleagues? Does it connect people to purpose and meaningful work?

“One of the problems with our resident clinical work hours is not terrible program directors saying, ‘work longer.’ It’s residents who want to take care of families for 1 more hour,” Dr. Brigham continued. “It’s residents who want to take care of patients who are going through a difficult time. You represent the top 2% in the world in terms of your intelligence and achievement, yet that’s not what makes you special. What makes you special is that the level of self-doubt in this room exceeds that of the general population by about 10 times. You also tend to run toward what everyone else runs away from: disease, despair, people who are injured and suffering. That takes a toll.”

Courtesy AAP

He emphasized that positive social relationships with others are crucial to joy and well-being in the practice of medicine. “Burnout isn’t just about exhaustion; it’s about loneliness,” Dr. Brigham said. “There’s a surprising power in just asking people how they’re doing, and really wanting to know the answer.”

Negative social connections are highly correlated with burnout and depression, such as harassment, bullying, mistreatment, discrimination, “and using the power gradient to squash somebody who’s trying their best to be a physician,” he said.

Dr. Brigham acknowledged the tall task of bringing a spotlight to well-being as physicians continue to engage in tasks such as the burden and lack of standardization of prior authorization requirements, the burden of clinical documentation requirements, electronic health records and related work flow, and quality payment programs. “This is what we need to shift; this is what we need to take away so you can get back in touch with why you became a physician in the first place.”

Dr. Brigham reported having no financial disclosures.

[email protected]

NEW ORLEANS – When Timothy P. Brigham, MDiv, PhD, thinks about the impact of burnout and stress on the ability of physicians to practice medicine, Lewin’s equation comes to mind.

FatCamera/Getty Images

Developed by psychologist Kurt Lewin in 1936, the equation holds that behavior stems from a person’s personality and the environment that person inhabits.

“We suspect that 70%-80% of the problem with burnout and stress in medicine is environmental,” Dr. Brigham, chief of staff and chief education and organizational development officer at the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), said at the annual meeting of the American Academy of Pediatrics.

“It’s a toxic mine, in some ways. What we tend to do is when we detect that physicians in general are, or a particular residency program is, too stressed out or burned out, we give them resilience training. Not that that’s unimportant, but it’s like putting a canary in a toxic mine full of poison and saying, ‘We’re going to teach you to hold your breath a little bit longer.’ Our job is to detoxify the mine.”

Troubled by the rise of suicides among physicians in recent years as well as mounting evidence about the adverse impact of burnout and stress on the practice of medicine, Dr. Brigham said that the ACGME is deepening its commitment to the well-being of faculty, residents, patients, and all members of the health care team. Since launching a “call to arms” on the topic at its annual educational conference in 2015, the ACGME has added courses on well-being to its annual meeting and remolded its Clinical Learning Environmental Review program to include all clinicians, “because everybody is affected by this: nurses, coordinators, et cetera,” he said. The ACGME also has revised Common Program Requirements, disseminated tools and resources to promote well-being and new knowledge on the topic, and partnered with the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience – all in an effort to bring about culture change.

“But we’re well aware that the ACGME can’t do this alone,” Dr. Brigham said. “We can’t ‘requirement’ our way out of this problem. It’s going to take a culture shift. Only you physicians, in collaboration with everyone in your community of learning, can create the systemic change required to improve our culture. We have a good handle on the problem at this point, but the solutions are a little bit more difficult to get a hold of. As Martin Luther King Jr. once said, ‘You don’t have to see the whole staircase, just take the first step.’ ”

The ACGME wants to work with physicians “to collect data and do joint research, to share insights, and to share tools and resources to create a better world for practicing physicians, for other members of the health care team, and for patients. After all, clinicians who care for themselves provide better care for others. They’re less likely to make errors or leave the profession,” Dr. Brigham told attendees.

He added that clinicians can gauge their risk for burnout by asking themselves three simple questions about their work environment: Does it support self-care? Does it increase and support connection with colleagues? Does it connect people to purpose and meaningful work?

“One of the problems with our resident clinical work hours is not terrible program directors saying, ‘work longer.’ It’s residents who want to take care of families for 1 more hour,” Dr. Brigham continued. “It’s residents who want to take care of patients who are going through a difficult time. You represent the top 2% in the world in terms of your intelligence and achievement, yet that’s not what makes you special. What makes you special is that the level of self-doubt in this room exceeds that of the general population by about 10 times. You also tend to run toward what everyone else runs away from: disease, despair, people who are injured and suffering. That takes a toll.”

Courtesy AAP

He emphasized that positive social relationships with others are crucial to joy and well-being in the practice of medicine. “Burnout isn’t just about exhaustion; it’s about loneliness,” Dr. Brigham said. “There’s a surprising power in just asking people how they’re doing, and really wanting to know the answer.”

Negative social connections are highly correlated with burnout and depression, such as harassment, bullying, mistreatment, discrimination, “and using the power gradient to squash somebody who’s trying their best to be a physician,” he said.

Dr. Brigham acknowledged the tall task of bringing a spotlight to well-being as physicians continue to engage in tasks such as the burden and lack of standardization of prior authorization requirements, the burden of clinical documentation requirements, electronic health records and related work flow, and quality payment programs. “This is what we need to shift; this is what we need to take away so you can get back in touch with why you became a physician in the first place.”

Dr. Brigham reported having no financial disclosures.

[email protected]

NEW ORLEANS – When Timothy P. Brigham, MDiv, PhD, thinks about the impact of burnout and stress on the ability of physicians to practice medicine, Lewin’s equation comes to mind.

FatCamera/Getty Images

Developed by psychologist Kurt Lewin in 1936, the equation holds that behavior stems from a person’s personality and the environment that person inhabits.

“We suspect that 70%-80% of the problem with burnout and stress in medicine is environmental,” Dr. Brigham, chief of staff and chief education and organizational development officer at the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), said at the annual meeting of the American Academy of Pediatrics.

“It’s a toxic mine, in some ways. What we tend to do is when we detect that physicians in general are, or a particular residency program is, too stressed out or burned out, we give them resilience training. Not that that’s unimportant, but it’s like putting a canary in a toxic mine full of poison and saying, ‘We’re going to teach you to hold your breath a little bit longer.’ Our job is to detoxify the mine.”

Troubled by the rise of suicides among physicians in recent years as well as mounting evidence about the adverse impact of burnout and stress on the practice of medicine, Dr. Brigham said that the ACGME is deepening its commitment to the well-being of faculty, residents, patients, and all members of the health care team. Since launching a “call to arms” on the topic at its annual educational conference in 2015, the ACGME has added courses on well-being to its annual meeting and remolded its Clinical Learning Environmental Review program to include all clinicians, “because everybody is affected by this: nurses, coordinators, et cetera,” he said. The ACGME also has revised Common Program Requirements, disseminated tools and resources to promote well-being and new knowledge on the topic, and partnered with the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience – all in an effort to bring about culture change.

“But we’re well aware that the ACGME can’t do this alone,” Dr. Brigham said. “We can’t ‘requirement’ our way out of this problem. It’s going to take a culture shift. Only you physicians, in collaboration with everyone in your community of learning, can create the systemic change required to improve our culture. We have a good handle on the problem at this point, but the solutions are a little bit more difficult to get a hold of. As Martin Luther King Jr. once said, ‘You don’t have to see the whole staircase, just take the first step.’ ”

The ACGME wants to work with physicians “to collect data and do joint research, to share insights, and to share tools and resources to create a better world for practicing physicians, for other members of the health care team, and for patients. After all, clinicians who care for themselves provide better care for others. They’re less likely to make errors or leave the profession,” Dr. Brigham told attendees.

He added that clinicians can gauge their risk for burnout by asking themselves three simple questions about their work environment: Does it support self-care? Does it increase and support connection with colleagues? Does it connect people to purpose and meaningful work?

“One of the problems with our resident clinical work hours is not terrible program directors saying, ‘work longer.’ It’s residents who want to take care of families for 1 more hour,” Dr. Brigham continued. “It’s residents who want to take care of patients who are going through a difficult time. You represent the top 2% in the world in terms of your intelligence and achievement, yet that’s not what makes you special. What makes you special is that the level of self-doubt in this room exceeds that of the general population by about 10 times. You also tend to run toward what everyone else runs away from: disease, despair, people who are injured and suffering. That takes a toll.”

Courtesy AAP

He emphasized that positive social relationships with others are crucial to joy and well-being in the practice of medicine. “Burnout isn’t just about exhaustion; it’s about loneliness,” Dr. Brigham said. “There’s a surprising power in just asking people how they’re doing, and really wanting to know the answer.”

Negative social connections are highly correlated with burnout and depression, such as harassment, bullying, mistreatment, discrimination, “and using the power gradient to squash somebody who’s trying their best to be a physician,” he said.

Dr. Brigham acknowledged the tall task of bringing a spotlight to well-being as physicians continue to engage in tasks such as the burden and lack of standardization of prior authorization requirements, the burden of clinical documentation requirements, electronic health records and related work flow, and quality payment programs. “This is what we need to shift; this is what we need to take away so you can get back in touch with why you became a physician in the first place.”

Dr. Brigham reported having no financial disclosures.

[email protected]

In November 2019, more than 1,500 pediatric hospitalists will be first to take the subspecialty exam approved by the American Board of Pediatrics (ABP) for certification in pediatric hospital medicine (PHM). This landmark signifies the recognition of hospital medicine as an essential component of the health care landscape and further acknowledges the importance of our expanding field.

But recent controversy over the requirements set by the ABP to sit for the exam has highlighted the new considerations for practice management that will be associated with this change. The need to analyze and understand how PHM programs function has never been more important for hospital medicine groups that care for children. This information is essential if they are to remain nimble in their approach to the changes that will occur in the years ahead.

To understand the impact that the new subspecialty board exam will have on groups that care for children, we need to first understand the criteria for eligibility. As for all ABP subspecialty boards, applicants must be Pediatric Board certified. The ABP has established three pathways by which practitioners can attain eligibility to sit for the PHM exam.¹ Most currently practicing hospitalists have applied to take the exam under the “practice pathway,” which will be available temporarily to allow candidates to apply for the certifying exam based on experience rather than fellowship training. This temporary period will span the first three examination cycles (2019, 2021, 2023). The requirements for inclusion via this pathway, recently modified by the ABP in response to concerns voiced by the PHM community at large,² consist of the following:

1. Practice period of 4 years (with a start date of July 2015 to be eligible for the November 2019 exam.

2. Work hours for all PHM professional activities of more than 900-1000 hours/year.

3. Patient care hours in PHM of more than 450-500 hours per year, every year for the preceding 4 years.

4. Scope of practice covering the full range of hospitalized children.

5. Practice experience and hours acquired in the United States or Canada.

This set of criteria raises several questions about the eligibility of the physicians currently caring for children in the hospital setting. The State of Hospital Medicine Report is an excellent source of information about hospital medicine trends in staffing and much more. While the response to the survey is more robust from practices that care for adults only, important information can be gleaned from the participant groups that care for children.

Question 1: How many clinicians that care for children in the hospital are trained in pediatrics, thereby meeting the first criteria to sit for the boards?

Based on the 2018 State of Hospital Medicine Report, 100% of groups that treat only children had physicians trained in pediatrics, 41.7% employed physicians trained in med/peds, and 5.6% had clinicians trained in internal medicine.

In groups that treat both children and adults the variation in practitioner type was much broader. While 85.7% of groups reported employing physicians trained in internal medicine and 64.3% employed family medicine practitioners, only 35.7% reported employing physicians trained in pediatrics and 46.4% with training in med/peds. A smattering of other clinician types was also noted, most of which were not likely to be pediatrics trained.

If information based on this relatively small number of respondents is generalizable, it means that a large number of the practitioners currently caring for hospitalized children are not pediatrics board-certified and therefore will not be eligible to sit for the subspecialty exam.

Question 2: What portion of the current PHM new hires are fellowship trained?

The 2018 State of Hospital Medicine Report notes that over 50% of new physicians joining a group treating only children come directly from residency, while only 5.1% come from a hospital medicine fellowship. For groups that treat adults and children, this percentage is even more significant, with 63% coming directly from residency and only 2.2% coming from a fellowship program.

The residents who recently graduated in 2019 are the last to be eligible to meet the practice duration criteria (4 years) during the “practice pathway” temporary period, thereby allowing them to sit for the subspecialty board exam without completing a fellowship. Recent surveys have shown that over 10% of graduating residents in pediatrics plan to pursue a career in PHM (over 280 respondents), however only under 75 fellows graduate from PHM fellowships each year.³ As the current number of fellowship positions in PHM are not adequate to meet the demand of the rapidly expanding workforce, groups treating children will need to continue to fill staff vacancies with variably trained clinicians.

In the years to come, information from the State of Hospital Medicine Report will be increasingly important, as programs that care for children meet the challenge of blending their workforce to include members with variable board certification and eligibility.

Question 3: How do the “patient care hours” and “work hours for all PHM activities” requirements affect currently practicing hospitalists in terms of their board eligibility?

Because of rigorous ABP criteria to sit for the PHM subspecialty exam, especially those regarding the minimum clinical and overall work hours in the care of children, many part time and med-peds practitioners may find that they are not board eligible. Variations in clinical coverage needs at individual sites, as well as competing nonclinical tasks in the adult setting, may limit pediatric-specific work hours for med/peds trained hospitalists.

As noted above, in groups that treat only children and groups that treat both adults and children, the 2018 State of Hospital Medicine Report shows that over 40% had physicians trained in med-peds. These highly trained and capable physicians will continue to be assets to their group; however, they may wish to find other ways to achieve merit-based distinction. For these physicians, the Fellow designation through SHM may provide an alternate means of recognition.

With the increasing complexity of staffing a workforce for the treatment of children that the PHM board subspecialty exam brings, the SHM Practice Analysis Committee developed a task force of pediatric leaders from across the country to aid in the development of additional pediatric-specific questions for the 2020 version of the State of Hospital Medicine Report. The questions to be included in the 2020 version will request information about the number of clinical hours (rather than shifts) per year required for full-time faculty, the percentage of the workforce that is part time, and the percentage of personnel in each group that is board certified in pediatric hospital medicine.

It is our hope that all groups treating children will respond to the 2020 State of Hospital Medicine survey, as a robust response will provide meaningful information to direct the leaders of these groups in the changing days ahead.

Dr. Gage is associate division chief, department of hospital medicine, at Phoenix Children’s Hospital and clinical associate professor, University of Arizona, Phoenix. She is a member of the SHM Practice Analysis Committee.

References

1. American Board of Pediatrics. Pediatric Hospital Medicine Certification. 2019 Edition.

2. American Board of Pediatrics. ABP responds to pediatric hospital medicine petition. 2019 Aug 29.

3. Pediatric Hospital Medicine Fellows. 2019 Edition.

In November 2019, more than 1,500 pediatric hospitalists will be first to take the subspecialty exam approved by the American Board of Pediatrics (ABP) for certification in pediatric hospital medicine (PHM). This landmark signifies the recognition of hospital medicine as an essential component of the health care landscape and further acknowledges the importance of our expanding field.

But recent controversy over the requirements set by the ABP to sit for the exam has highlighted the new considerations for practice management that will be associated with this change. The need to analyze and understand how PHM programs function has never been more important for hospital medicine groups that care for children. This information is essential if they are to remain nimble in their approach to the changes that will occur in the years ahead.

To understand the impact that the new subspecialty board exam will have on groups that care for children, we need to first understand the criteria for eligibility. As for all ABP subspecialty boards, applicants must be Pediatric Board certified. The ABP has established three pathways by which practitioners can attain eligibility to sit for the PHM exam.¹ Most currently practicing hospitalists have applied to take the exam under the “practice pathway,” which will be available temporarily to allow candidates to apply for the certifying exam based on experience rather than fellowship training. This temporary period will span the first three examination cycles (2019, 2021, 2023). The requirements for inclusion via this pathway, recently modified by the ABP in response to concerns voiced by the PHM community at large,² consist of the following:

1. Practice period of 4 years (with a start date of July 2015 to be eligible for the November 2019 exam.

2. Work hours for all PHM professional activities of more than 900-1000 hours/year.

3. Patient care hours in PHM of more than 450-500 hours per year, every year for the preceding 4 years.

4. Scope of practice covering the full range of hospitalized children.

5. Practice experience and hours acquired in the United States or Canada.

This set of criteria raises several questions about the eligibility of the physicians currently caring for children in the hospital setting. The State of Hospital Medicine Report is an excellent source of information about hospital medicine trends in staffing and much more. While the response to the survey is more robust from practices that care for adults only, important information can be gleaned from the participant groups that care for children.

Question 1: How many clinicians that care for children in the hospital are trained in pediatrics, thereby meeting the first criteria to sit for the boards?

Based on the 2018 State of Hospital Medicine Report, 100% of groups that treat only children had physicians trained in pediatrics, 41.7% employed physicians trained in med/peds, and 5.6% had clinicians trained in internal medicine.

In groups that treat both children and adults the variation in practitioner type was much broader. While 85.7% of groups reported employing physicians trained in internal medicine and 64.3% employed family medicine practitioners, only 35.7% reported employing physicians trained in pediatrics and 46.4% with training in med/peds. A smattering of other clinician types was also noted, most of which were not likely to be pediatrics trained.

If information based on this relatively small number of respondents is generalizable, it means that a large number of the practitioners currently caring for hospitalized children are not pediatrics board-certified and therefore will not be eligible to sit for the subspecialty exam.

Question 2: What portion of the current PHM new hires are fellowship trained?

The 2018 State of Hospital Medicine Report notes that over 50% of new physicians joining a group treating only children come directly from residency, while only 5.1% come from a hospital medicine fellowship. For groups that treat adults and children, this percentage is even more significant, with 63% coming directly from residency and only 2.2% coming from a fellowship program.

The residents who recently graduated in 2019 are the last to be eligible to meet the practice duration criteria (4 years) during the “practice pathway” temporary period, thereby allowing them to sit for the subspecialty board exam without completing a fellowship. Recent surveys have shown that over 10% of graduating residents in pediatrics plan to pursue a career in PHM (over 280 respondents), however only under 75 fellows graduate from PHM fellowships each year.³ As the current number of fellowship positions in PHM are not adequate to meet the demand of the rapidly expanding workforce, groups treating children will need to continue to fill staff vacancies with variably trained clinicians.

In the years to come, information from the State of Hospital Medicine Report will be increasingly important, as programs that care for children meet the challenge of blending their workforce to include members with variable board certification and eligibility.

Question 3: How do the “patient care hours” and “work hours for all PHM activities” requirements affect currently practicing hospitalists in terms of their board eligibility?

Because of rigorous ABP criteria to sit for the PHM subspecialty exam, especially those regarding the minimum clinical and overall work hours in the care of children, many part time and med-peds practitioners may find that they are not board eligible. Variations in clinical coverage needs at individual sites, as well as competing nonclinical tasks in the adult setting, may limit pediatric-specific work hours for med/peds trained hospitalists.

As noted above, in groups that treat only children and groups that treat both adults and children, the 2018 State of Hospital Medicine Report shows that over 40% had physicians trained in med-peds. These highly trained and capable physicians will continue to be assets to their group; however, they may wish to find other ways to achieve merit-based distinction. For these physicians, the Fellow designation through SHM may provide an alternate means of recognition.

With the increasing complexity of staffing a workforce for the treatment of children that the PHM board subspecialty exam brings, the SHM Practice Analysis Committee developed a task force of pediatric leaders from across the country to aid in the development of additional pediatric-specific questions for the 2020 version of the State of Hospital Medicine Report. The questions to be included in the 2020 version will request information about the number of clinical hours (rather than shifts) per year required for full-time faculty, the percentage of the workforce that is part time, and the percentage of personnel in each group that is board certified in pediatric hospital medicine.

It is our hope that all groups treating children will respond to the 2020 State of Hospital Medicine survey, as a robust response will provide meaningful information to direct the leaders of these groups in the changing days ahead.

Dr. Gage is associate division chief, department of hospital medicine, at Phoenix Children’s Hospital and clinical associate professor, University of Arizona, Phoenix. She is a member of the SHM Practice Analysis Committee.

References

1. American Board of Pediatrics. Pediatric Hospital Medicine Certification. 2019 Edition.

2. American Board of Pediatrics. ABP responds to pediatric hospital medicine petition. 2019 Aug 29.

3. Pediatric Hospital Medicine Fellows. 2019 Edition.

In November 2019, more than 1,500 pediatric hospitalists will be first to take the subspecialty exam approved by the American Board of Pediatrics (ABP) for certification in pediatric hospital medicine (PHM). This landmark signifies the recognition of hospital medicine as an essential component of the health care landscape and further acknowledges the importance of our expanding field.

But recent controversy over the requirements set by the ABP to sit for the exam has highlighted the new considerations for practice management that will be associated with this change. The need to analyze and understand how PHM programs function has never been more important for hospital medicine groups that care for children. This information is essential if they are to remain nimble in their approach to the changes that will occur in the years ahead.

To understand the impact that the new subspecialty board exam will have on groups that care for children, we need to first understand the criteria for eligibility. As for all ABP subspecialty boards, applicants must be Pediatric Board certified. The ABP has established three pathways by which practitioners can attain eligibility to sit for the PHM exam.¹ Most currently practicing hospitalists have applied to take the exam under the “practice pathway,” which will be available temporarily to allow candidates to apply for the certifying exam based on experience rather than fellowship training. This temporary period will span the first three examination cycles (2019, 2021, 2023). The requirements for inclusion via this pathway, recently modified by the ABP in response to concerns voiced by the PHM community at large,² consist of the following:

1. Practice period of 4 years (with a start date of July 2015 to be eligible for the November 2019 exam.

2. Work hours for all PHM professional activities of more than 900-1000 hours/year.

3. Patient care hours in PHM of more than 450-500 hours per year, every year for the preceding 4 years.

4. Scope of practice covering the full range of hospitalized children.

5. Practice experience and hours acquired in the United States or Canada.

This set of criteria raises several questions about the eligibility of the physicians currently caring for children in the hospital setting. The State of Hospital Medicine Report is an excellent source of information about hospital medicine trends in staffing and much more. While the response to the survey is more robust from practices that care for adults only, important information can be gleaned from the participant groups that care for children.

Question 1: How many clinicians that care for children in the hospital are trained in pediatrics, thereby meeting the first criteria to sit for the boards?

Based on the 2018 State of Hospital Medicine Report, 100% of groups that treat only children had physicians trained in pediatrics, 41.7% employed physicians trained in med/peds, and 5.6% had clinicians trained in internal medicine.

In groups that treat both children and adults the variation in practitioner type was much broader. While 85.7% of groups reported employing physicians trained in internal medicine and 64.3% employed family medicine practitioners, only 35.7% reported employing physicians trained in pediatrics and 46.4% with training in med/peds. A smattering of other clinician types was also noted, most of which were not likely to be pediatrics trained.

If information based on this relatively small number of respondents is generalizable, it means that a large number of the practitioners currently caring for hospitalized children are not pediatrics board-certified and therefore will not be eligible to sit for the subspecialty exam.

Question 2: What portion of the current PHM new hires are fellowship trained?

The 2018 State of Hospital Medicine Report notes that over 50% of new physicians joining a group treating only children come directly from residency, while only 5.1% come from a hospital medicine fellowship. For groups that treat adults and children, this percentage is even more significant, with 63% coming directly from residency and only 2.2% coming from a fellowship program.

The residents who recently graduated in 2019 are the last to be eligible to meet the practice duration criteria (4 years) during the “practice pathway” temporary period, thereby allowing them to sit for the subspecialty board exam without completing a fellowship. Recent surveys have shown that over 10% of graduating residents in pediatrics plan to pursue a career in PHM (over 280 respondents), however only under 75 fellows graduate from PHM fellowships each year.³ As the current number of fellowship positions in PHM are not adequate to meet the demand of the rapidly expanding workforce, groups treating children will need to continue to fill staff vacancies with variably trained clinicians.

In the years to come, information from the State of Hospital Medicine Report will be increasingly important, as programs that care for children meet the challenge of blending their workforce to include members with variable board certification and eligibility.

Question 3: How do the “patient care hours” and “work hours for all PHM activities” requirements affect currently practicing hospitalists in terms of their board eligibility?

Because of rigorous ABP criteria to sit for the PHM subspecialty exam, especially those regarding the minimum clinical and overall work hours in the care of children, many part time and med-peds practitioners may find that they are not board eligible. Variations in clinical coverage needs at individual sites, as well as competing nonclinical tasks in the adult setting, may limit pediatric-specific work hours for med/peds trained hospitalists.

As noted above, in groups that treat only children and groups that treat both adults and children, the 2018 State of Hospital Medicine Report shows that over 40% had physicians trained in med-peds. These highly trained and capable physicians will continue to be assets to their group; however, they may wish to find other ways to achieve merit-based distinction. For these physicians, the Fellow designation through SHM may provide an alternate means of recognition.

With the increasing complexity of staffing a workforce for the treatment of children that the PHM board subspecialty exam brings, the SHM Practice Analysis Committee developed a task force of pediatric leaders from across the country to aid in the development of additional pediatric-specific questions for the 2020 version of the State of Hospital Medicine Report. The questions to be included in the 2020 version will request information about the number of clinical hours (rather than shifts) per year required for full-time faculty, the percentage of the workforce that is part time, and the percentage of personnel in each group that is board certified in pediatric hospital medicine.

It is our hope that all groups treating children will respond to the 2020 State of Hospital Medicine survey, as a robust response will provide meaningful information to direct the leaders of these groups in the changing days ahead.

Dr. Gage is associate division chief, department of hospital medicine, at Phoenix Children’s Hospital and clinical associate professor, University of Arizona, Phoenix. She is a member of the SHM Practice Analysis Committee.

References

1. American Board of Pediatrics. Pediatric Hospital Medicine Certification. 2019 Edition.

2. American Board of Pediatrics. ABP responds to pediatric hospital medicine petition. 2019 Aug 29.

3. Pediatric Hospital Medicine Fellows. 2019 Edition.

PHM19 session

Apps for busy pediatric hospitalists 2.0

Presenters

Tosin Adeyanju, MD, FAAP

Alexander Hogan, MD

Jane Im, MD, FAAP

Kim O’Hara, MD

Michael Tchou, MD, FAAP
 

Session summary

This presentation at Pediatric Hospital Medicine 2019 started with the sharing of learning tools to help physicians stay current and organized with the ever-expanding body of medical literature.

The instructors shared content aggregators, such as Read by QxMD, that allow the user to follow multiple journals and highlight new articles based on the user’s preferences and chosen keywords. They also shared reference managers, such as Mendeley, which allows users to organize, store, and access their literature library from anywhere and can even be used to simplify citations and bibliographies in articles.

The presenters shared resources and applications that can be used to quickly access information on mobile devices. Applications, such as MDCalc and the CDC STD Tx Guide, can allow users to reference clinical calculators and treatment courses for teaching at the bedside. The presenters also introduced pharmaceutical applications like GoodRx, an application that allows patients and physicians to compare drug prices at various pharmacies. They also introduced the audience to Formulary Search by MMIT that helps users determine which medications are covered by an insurance plan. They also shared some applications that can help users deal with emergencies, like Ped Guide and Pedi Crisis. These apps can help users review emergency algorithms, dose emergency medications, and determine the sizes of emergency equipment.

The presenters closed by sharing teaching applications that allow users to increase interactions with presentation audiences or learners. Teaching tools like Kahoot! and Poll Everywhere allow users to gauge their audiences’ understanding of material. Online software, such as Slack.com and Microsoft.com, allows for collaboration and file sharing across institutions and integrate with many other services.
 

Key takeaways

• Content aggregators and reference managers help users organize and access literature from anywhere.

• Teaching tools encourage audience participation, immediate assessment of learners.

• Online software tools allow for easy collaboration and file sharing across institutions and easily integrate with many other services.

Dr. Gupta is a pediatric hospitalist at Phoenix Children’s Hospital.

PHM19 session

Apps for busy pediatric hospitalists 2.0

Presenters

Tosin Adeyanju, MD, FAAP

Alexander Hogan, MD

Jane Im, MD, FAAP

Kim O’Hara, MD

Michael Tchou, MD, FAAP
 

Session summary

This presentation at Pediatric Hospital Medicine 2019 started with the sharing of learning tools to help physicians stay current and organized with the ever-expanding body of medical literature.

The instructors shared content aggregators, such as Read by QxMD, that allow the user to follow multiple journals and highlight new articles based on the user’s preferences and chosen keywords. They also shared reference managers, such as Mendeley, which allows users to organize, store, and access their literature library from anywhere and can even be used to simplify citations and bibliographies in articles.

The presenters shared resources and applications that can be used to quickly access information on mobile devices. Applications, such as MDCalc and the CDC STD Tx Guide, can allow users to reference clinical calculators and treatment courses for teaching at the bedside. The presenters also introduced pharmaceutical applications like GoodRx, an application that allows patients and physicians to compare drug prices at various pharmacies. They also introduced the audience to Formulary Search by MMIT that helps users determine which medications are covered by an insurance plan. They also shared some applications that can help users deal with emergencies, like Ped Guide and Pedi Crisis. These apps can help users review emergency algorithms, dose emergency medications, and determine the sizes of emergency equipment.

The presenters closed by sharing teaching applications that allow users to increase interactions with presentation audiences or learners. Teaching tools like Kahoot! and Poll Everywhere allow users to gauge their audiences’ understanding of material. Online software, such as Slack.com and Microsoft.com, allows for collaboration and file sharing across institutions and integrate with many other services.
 

Key takeaways

• Content aggregators and reference managers help users organize and access literature from anywhere.

• Teaching tools encourage audience participation, immediate assessment of learners.

• Online software tools allow for easy collaboration and file sharing across institutions and easily integrate with many other services.

Dr. Gupta is a pediatric hospitalist at Phoenix Children’s Hospital.

PHM19 session

Apps for busy pediatric hospitalists 2.0

Presenters

Tosin Adeyanju, MD, FAAP

Alexander Hogan, MD

Jane Im, MD, FAAP

Kim O’Hara, MD

Michael Tchou, MD, FAAP
 

Session summary

This presentation at Pediatric Hospital Medicine 2019 started with the sharing of learning tools to help physicians stay current and organized with the ever-expanding body of medical literature.

The instructors shared content aggregators, such as Read by QxMD, that allow the user to follow multiple journals and highlight new articles based on the user’s preferences and chosen keywords. They also shared reference managers, such as Mendeley, which allows users to organize, store, and access their literature library from anywhere and can even be used to simplify citations and bibliographies in articles.

The presenters shared resources and applications that can be used to quickly access information on mobile devices. Applications, such as MDCalc and the CDC STD Tx Guide, can allow users to reference clinical calculators and treatment courses for teaching at the bedside. The presenters also introduced pharmaceutical applications like GoodRx, an application that allows patients and physicians to compare drug prices at various pharmacies. They also introduced the audience to Formulary Search by MMIT that helps users determine which medications are covered by an insurance plan. They also shared some applications that can help users deal with emergencies, like Ped Guide and Pedi Crisis. These apps can help users review emergency algorithms, dose emergency medications, and determine the sizes of emergency equipment.

The presenters closed by sharing teaching applications that allow users to increase interactions with presentation audiences or learners. Teaching tools like Kahoot! and Poll Everywhere allow users to gauge their audiences’ understanding of material. Online software, such as Slack.com and Microsoft.com, allows for collaboration and file sharing across institutions and integrate with many other services.
 

Key takeaways

• Content aggregators and reference managers help users organize and access literature from anywhere.

• Teaching tools encourage audience participation, immediate assessment of learners.

• Online software tools allow for easy collaboration and file sharing across institutions and easily integrate with many other services.

Dr. Gupta is a pediatric hospitalist at Phoenix Children’s Hospital.

It’s always important for everyone to remember why we document things in the chart so that we are on the same page and ultimately do what is best for the patient. We document for insurance companies to prove the need for hospitalization, for legal purposes, and for other clinicians – to clearly communicate the acuity of each patient.

One of the diagnoses that we can often forget to use is acute respiratory failure. Documenting acute respiratory failure matters, regardless if it is, or is not, the primary diagnosis; it increases the estimated Length of Stay (LOS), Severity of Illness (SOI), and Risk of Mortality (ROM). This diagnosis adds an additional degree of specificity to patients with pneumonia, pleural effusions, chronic obstructive pulmonary disease (COPD) exacerbations, etc. While we may be hesitant to document this (perhaps feeling that this applies only to patients who are intubated in the ICU), the reader will hopefully have more confidence using it after reviewing the diagnostic criteria.

Acute respiratory failure can stem from impaired oxygenation or impaired ventilation. The following are some examples that follow these principles:

• Impaired oxygenation. Can be seen in pneumonia, pulmonary edema, and pulmonary embolism, and can present as a low O₂ saturation or a low pO₂ on an arterial blood gas (ABG) test.
• Impaired ventilation. Can be seen in COPD or asthma where there is increased effort to ventilate the lungs, which can lead to impaired CO₂ exchange and subsequent acidosis.

One needs to have two of the following three criteria to make a formal diagnosis of acute respiratory failure:

• pO₂ less than 60 mm Hg (hypoxemia).
• pCO₂ greater than 50 mm Hg (hypercapnia) with pH less than 7.35.
• Signs and symptoms of acute respiratory distress.

One may think that it would be difficult to meet criteria without an ABG. Although an ABG is the standard, a patient meets criteria 1 without a blood gas if an oxygen saturation less than or equal to 90% is documented. Therefore, in most cases, if you have a documented oxygen saturation less than or equal to 90% on room air with a physical exam showing signs of respiratory distress, your patient will qualify for the diagnosis of acute respiratory failure. This negates the need to always have an ABG.

It is important to document the symptoms and physical exam findings that go along with the diagnosis. Patients should have tachypnea with a respiratory rate (RR) greater than 20 or a decreased rate less than 10. They may have wheezing, difficulty moving air, nasal flaring, and accessory muscle use. All of these findings are extremely helpful to validate the diagnosis and would make it extremely difficult for it to be rejected by a biller or insurance company.

These patients are often given supplemental oxygen (nasal cannula, Venturi mask, non-rebreather) and other treatments including steroids, inhaled bronchodilators, mucolytics, and respiratory therapy. Documenting these interventions in your plans can assist reviewers trying to understand your thought process in the treatment of the patient. If your patient has to be initiated on bilevel positive airway pressure (i.e. – the patient was not on BIPAP at home, but needed to be started because of his/her respiratory status), this almost always means they have acute respiratory failure.

In the two tables accompanying this article, we see some examples of how documenting acute respiratory failure can improve LOS, ROM, SOI, and reimbursement. The number at the top is based off of a specific DRG (Diagnosis Related Group) that is used by coders.

Let’s say we have a 58-year-old male presenting with chest pain, shortness of breath, and concern for unstable angina. Given his symptoms, he is being taken to the cardiac catheterization lab. If we note only that he was hypoxic and required 3L for an O₂ saturation of 94%, one can see the ROM, SOI, estimated LOS, and reimbursement in the first column. However, if we write that his oxygen saturation on room air is 87%, he is using intercostal muscles to breathe, and he has marked dyspnea with conversation, we can say that he has acute respiratory failure. Making this distinction increases his expected LOS by almost 4 days and nearly doubles reimbursement.



For the second example, we have an 81-year-old female with diabetes type 2, hypertension, and chronic systolic congestive heart failure who presents with an acute systolic CHF exacerbation. The patient is saturating 85% on room air, has tachypnea (RR 34), and was given large doses of intravenous furosemide in the emergency department. She is stabilized with improvement in her respiratory rate and can go to the floor, but by documenting that this was acute respiratory failure, one can again see the significant improvements in the projected LOS, ROM, and reimbursement as opposed to documenting hypoxia. This has huge implications for our hospitals, and we should continue to strive to document this as clearly as possible.

 

Key take-home points for hospitalists

• Document accurately, including any comorbid conditions and major comorbid conditions that are applicable.
• Acute respiratory failure comes from impaired oxygenation, impaired ventilation, or both.
• One needs to document two of the three criteria to formally diagnose acute respiratory failure: pO₂ less than 60 mm Hg (or room air oxygen saturation less than or equal to 90%), pCO₂ greater than 50 mm Hg with pH less than 7.35, and signs/symptoms of respiratory distress.
• Document physical exam findings that correlate with acute respiratory failure (RR greater than 20 or less than 10, wheezing, nasal flaring, accessory muscle use, etc).
• If your patient has to be initiated on BIPAP (i.e. – the patient was not on BIPAP at home, but needed to be started because of his/her respiratory status), they likely have acute respiratory failure.

Dr. DeCaro is a hospitalist and medical director for care coordination at Emory University in Atlanta.

It’s always important for everyone to remember why we document things in the chart so that we are on the same page and ultimately do what is best for the patient. We document for insurance companies to prove the need for hospitalization, for legal purposes, and for other clinicians – to clearly communicate the acuity of each patient.

One of the diagnoses that we can often forget to use is acute respiratory failure. Documenting acute respiratory failure matters, regardless if it is, or is not, the primary diagnosis; it increases the estimated Length of Stay (LOS), Severity of Illness (SOI), and Risk of Mortality (ROM). This diagnosis adds an additional degree of specificity to patients with pneumonia, pleural effusions, chronic obstructive pulmonary disease (COPD) exacerbations, etc. While we may be hesitant to document this (perhaps feeling that this applies only to patients who are intubated in the ICU), the reader will hopefully have more confidence using it after reviewing the diagnostic criteria.

Acute respiratory failure can stem from impaired oxygenation or impaired ventilation. The following are some examples that follow these principles:

• Impaired oxygenation. Can be seen in pneumonia, pulmonary edema, and pulmonary embolism, and can present as a low O₂ saturation or a low pO₂ on an arterial blood gas (ABG) test.
• Impaired ventilation. Can be seen in COPD or asthma where there is increased effort to ventilate the lungs, which can lead to impaired CO₂ exchange and subsequent acidosis.

One needs to have two of the following three criteria to make a formal diagnosis of acute respiratory failure:

• pO₂ less than 60 mm Hg (hypoxemia).
• pCO₂ greater than 50 mm Hg (hypercapnia) with pH less than 7.35.
• Signs and symptoms of acute respiratory distress.

One may think that it would be difficult to meet criteria without an ABG. Although an ABG is the standard, a patient meets criteria 1 without a blood gas if an oxygen saturation less than or equal to 90% is documented. Therefore, in most cases, if you have a documented oxygen saturation less than or equal to 90% on room air with a physical exam showing signs of respiratory distress, your patient will qualify for the diagnosis of acute respiratory failure. This negates the need to always have an ABG.

It is important to document the symptoms and physical exam findings that go along with the diagnosis. Patients should have tachypnea with a respiratory rate (RR) greater than 20 or a decreased rate less than 10. They may have wheezing, difficulty moving air, nasal flaring, and accessory muscle use. All of these findings are extremely helpful to validate the diagnosis and would make it extremely difficult for it to be rejected by a biller or insurance company.

These patients are often given supplemental oxygen (nasal cannula, Venturi mask, non-rebreather) and other treatments including steroids, inhaled bronchodilators, mucolytics, and respiratory therapy. Documenting these interventions in your plans can assist reviewers trying to understand your thought process in the treatment of the patient. If your patient has to be initiated on bilevel positive airway pressure (i.e. – the patient was not on BIPAP at home, but needed to be started because of his/her respiratory status), this almost always means they have acute respiratory failure.

In the two tables accompanying this article, we see some examples of how documenting acute respiratory failure can improve LOS, ROM, SOI, and reimbursement. The number at the top is based off of a specific DRG (Diagnosis Related Group) that is used by coders.

Let’s say we have a 58-year-old male presenting with chest pain, shortness of breath, and concern for unstable angina. Given his symptoms, he is being taken to the cardiac catheterization lab. If we note only that he was hypoxic and required 3L for an O₂ saturation of 94%, one can see the ROM, SOI, estimated LOS, and reimbursement in the first column. However, if we write that his oxygen saturation on room air is 87%, he is using intercostal muscles to breathe, and he has marked dyspnea with conversation, we can say that he has acute respiratory failure. Making this distinction increases his expected LOS by almost 4 days and nearly doubles reimbursement.



For the second example, we have an 81-year-old female with diabetes type 2, hypertension, and chronic systolic congestive heart failure who presents with an acute systolic CHF exacerbation. The patient is saturating 85% on room air, has tachypnea (RR 34), and was given large doses of intravenous furosemide in the emergency department. She is stabilized with improvement in her respiratory rate and can go to the floor, but by documenting that this was acute respiratory failure, one can again see the significant improvements in the projected LOS, ROM, and reimbursement as opposed to documenting hypoxia. This has huge implications for our hospitals, and we should continue to strive to document this as clearly as possible.

 

Key take-home points for hospitalists

• Document accurately, including any comorbid conditions and major comorbid conditions that are applicable.
• Acute respiratory failure comes from impaired oxygenation, impaired ventilation, or both.
• One needs to document two of the three criteria to formally diagnose acute respiratory failure: pO₂ less than 60 mm Hg (or room air oxygen saturation less than or equal to 90%), pCO₂ greater than 50 mm Hg with pH less than 7.35, and signs/symptoms of respiratory distress.
• Document physical exam findings that correlate with acute respiratory failure (RR greater than 20 or less than 10, wheezing, nasal flaring, accessory muscle use, etc).
• If your patient has to be initiated on BIPAP (i.e. – the patient was not on BIPAP at home, but needed to be started because of his/her respiratory status), they likely have acute respiratory failure.

Dr. DeCaro is a hospitalist and medical director for care coordination at Emory University in Atlanta.

It’s always important for everyone to remember why we document things in the chart so that we are on the same page and ultimately do what is best for the patient. We document for insurance companies to prove the need for hospitalization, for legal purposes, and for other clinicians – to clearly communicate the acuity of each patient.

One of the diagnoses that we can often forget to use is acute respiratory failure. Documenting acute respiratory failure matters, regardless if it is, or is not, the primary diagnosis; it increases the estimated Length of Stay (LOS), Severity of Illness (SOI), and Risk of Mortality (ROM). This diagnosis adds an additional degree of specificity to patients with pneumonia, pleural effusions, chronic obstructive pulmonary disease (COPD) exacerbations, etc. While we may be hesitant to document this (perhaps feeling that this applies only to patients who are intubated in the ICU), the reader will hopefully have more confidence using it after reviewing the diagnostic criteria.

Acute respiratory failure can stem from impaired oxygenation or impaired ventilation. The following are some examples that follow these principles:

• Impaired oxygenation. Can be seen in pneumonia, pulmonary edema, and pulmonary embolism, and can present as a low O₂ saturation or a low pO₂ on an arterial blood gas (ABG) test.
• Impaired ventilation. Can be seen in COPD or asthma where there is increased effort to ventilate the lungs, which can lead to impaired CO₂ exchange and subsequent acidosis.

One needs to have two of the following three criteria to make a formal diagnosis of acute respiratory failure:

• pO₂ less than 60 mm Hg (hypoxemia).
• pCO₂ greater than 50 mm Hg (hypercapnia) with pH less than 7.35.
• Signs and symptoms of acute respiratory distress.

One may think that it would be difficult to meet criteria without an ABG. Although an ABG is the standard, a patient meets criteria 1 without a blood gas if an oxygen saturation less than or equal to 90% is documented. Therefore, in most cases, if you have a documented oxygen saturation less than or equal to 90% on room air with a physical exam showing signs of respiratory distress, your patient will qualify for the diagnosis of acute respiratory failure. This negates the need to always have an ABG.

It is important to document the symptoms and physical exam findings that go along with the diagnosis. Patients should have tachypnea with a respiratory rate (RR) greater than 20 or a decreased rate less than 10. They may have wheezing, difficulty moving air, nasal flaring, and accessory muscle use. All of these findings are extremely helpful to validate the diagnosis and would make it extremely difficult for it to be rejected by a biller or insurance company.

These patients are often given supplemental oxygen (nasal cannula, Venturi mask, non-rebreather) and other treatments including steroids, inhaled bronchodilators, mucolytics, and respiratory therapy. Documenting these interventions in your plans can assist reviewers trying to understand your thought process in the treatment of the patient. If your patient has to be initiated on bilevel positive airway pressure (i.e. – the patient was not on BIPAP at home, but needed to be started because of his/her respiratory status), this almost always means they have acute respiratory failure.

In the two tables accompanying this article, we see some examples of how documenting acute respiratory failure can improve LOS, ROM, SOI, and reimbursement. The number at the top is based off of a specific DRG (Diagnosis Related Group) that is used by coders.

Let’s say we have a 58-year-old male presenting with chest pain, shortness of breath, and concern for unstable angina. Given his symptoms, he is being taken to the cardiac catheterization lab. If we note only that he was hypoxic and required 3L for an O₂ saturation of 94%, one can see the ROM, SOI, estimated LOS, and reimbursement in the first column. However, if we write that his oxygen saturation on room air is 87%, he is using intercostal muscles to breathe, and he has marked dyspnea with conversation, we can say that he has acute respiratory failure. Making this distinction increases his expected LOS by almost 4 days and nearly doubles reimbursement.



For the second example, we have an 81-year-old female with diabetes type 2, hypertension, and chronic systolic congestive heart failure who presents with an acute systolic CHF exacerbation. The patient is saturating 85% on room air, has tachypnea (RR 34), and was given large doses of intravenous furosemide in the emergency department. She is stabilized with improvement in her respiratory rate and can go to the floor, but by documenting that this was acute respiratory failure, one can again see the significant improvements in the projected LOS, ROM, and reimbursement as opposed to documenting hypoxia. This has huge implications for our hospitals, and we should continue to strive to document this as clearly as possible.

 

Key take-home points for hospitalists

• Document accurately, including any comorbid conditions and major comorbid conditions that are applicable.
• Acute respiratory failure comes from impaired oxygenation, impaired ventilation, or both.
• One needs to document two of the three criteria to formally diagnose acute respiratory failure: pO₂ less than 60 mm Hg (or room air oxygen saturation less than or equal to 90%), pCO₂ greater than 50 mm Hg with pH less than 7.35, and signs/symptoms of respiratory distress.
• Document physical exam findings that correlate with acute respiratory failure (RR greater than 20 or less than 10, wheezing, nasal flaring, accessory muscle use, etc).
• If your patient has to be initiated on BIPAP (i.e. – the patient was not on BIPAP at home, but needed to be started because of his/her respiratory status), they likely have acute respiratory failure.

Dr. DeCaro is a hospitalist and medical director for care coordination at Emory University in Atlanta.

PHM19 session

Mitigating the harm we cause learners in medical education

Presenters

Benjamin Kinnear, MD, MEd

Andrew Olson, MD

Matthew Kelleher, MD, MEd

Session summary

Dr. Kinnear, Dr. Olson, and Dr. Kelleher expertly led this TED-Talk style session at Pediatric Hospital Medicine 2019, convincing the audience that medical educators persistently harm the learners under their supervision.

Dr. Kinnear, of Cincinnati Children’s Hospital, opened the session noting that the path through medical school presently has a perverse focus on grades as a necessary achievement. As an expert in competency-based assessment, he asserted that the current learner assessment strategy is neither valid nor robust enough to indicate actual competence. Summary assessments presented throughout medical school are lacking continuous constructive feedback, leaving early residents in a state of shock when receiving corrective or negative assessments. He also noted that structurally many rotations create both team and patient discontinuity, leaving the learner with a feeling of detachment and limited ownership of the human patient under his/her/their care.

Dr. Olson of the University of Minnesota next described the need for the USMLE STEP 1 exam to be transitioned to a pass/fail endeavor. He cited the error of measurement of 24 points (i.e., the same test taker could have a 220 one day and a 244 the next) and the potential loss of valuable rotation experiences during the several-month period of intense study. He challenged audience members to complete an esoteric exam question to prove his point and asserted that many learners are lacking in humility, communication skills, and professionalism, and seek only the honors designation on rotations. He likened the experience of medical students on rotation and residents on service weeks to a series of first dates and affirmed the value of longitudinal learner-educator relationships.

Further, he outlined the detachment of learners from patient outcomes, demonstrated by frequent hand-offs and rotation transitions. Dr Olson also cited medical pedagogy as failing to meet the known needs of adult learners to engage in deliberate progressive practice, reflective practice, or to use concepts such as spacing or interleaving to reinforce knowledge.

Dr. Kelleher, also of Cincinnati Children’s Hospital, ended the session by taking those in attendance on an imagined “what-if” journey where each of the wrongs currently done to early learners in medical education were corrected. This included engagement in daily reflection (5 minutes at a time), reporting system issues on rounds that had failed the patient, presenting learners with a CV of attending failures to reinforce the imperfection that is a reality in medicine, praising learners when they admit “they don’t know the answer” to a question posed on rounds, completing assessments in real time in the learner’s presence, rounding until specific feedback can be identified for each learner on the team, having a kiosk on each floor where ANY team member could provide feedback to learners, using cognitive science on rounds for teaching (i.e., Socratic) rather than pimping, modeling interprofessional teamwork daily using a culture of vulnerability rather than infallibility (i.e., airline culture), and by encouraging the attending to care for patients or complete tasks independently, showing the value of education over service and model ideal family-centered communication with the team.

One might wonder, if all of the above were accomplished at the request of our talented presenters, would a pass/fail USMLE world where medical education was learner centered and filled with longitudinal relationships with teams and patients, and outcomes were connected to education produce more engaged, knowledgeable, and holistic physicians? According to this team of presenters, yes.
 

Key takeaways

• Current processes in medical education are harming today’s adult learner.

• Harms include reliance on numerical rather than competency-based assessment, fragmented learning environments, focus on perfection rather than improvement, ignorance of updates in cognitive science for instructional methodology, and individualist rather than team-based learning.

• Reforms are needed to remedy harms in health professional education, including making USMLE pass/fail, creating a learning-centered rather than service-centered residency environment, encouraging longitudinal relationships between teacher and learner, and connecting education to clinical outcomes.

Dr. King is associate program director, University of Minnesota Pediatric Residency Program, Minneapolis.

PHM19 session

Mitigating the harm we cause learners in medical education

Presenters

Benjamin Kinnear, MD, MEd

Andrew Olson, MD

Matthew Kelleher, MD, MEd

Session summary

Dr. Kinnear, Dr. Olson, and Dr. Kelleher expertly led this TED-Talk style session at Pediatric Hospital Medicine 2019, convincing the audience that medical educators persistently harm the learners under their supervision.

Dr. Kinnear, of Cincinnati Children’s Hospital, opened the session noting that the path through medical school presently has a perverse focus on grades as a necessary achievement. As an expert in competency-based assessment, he asserted that the current learner assessment strategy is neither valid nor robust enough to indicate actual competence. Summary assessments presented throughout medical school are lacking continuous constructive feedback, leaving early residents in a state of shock when receiving corrective or negative assessments. He also noted that structurally many rotations create both team and patient discontinuity, leaving the learner with a feeling of detachment and limited ownership of the human patient under his/her/their care.

Dr. Olson of the University of Minnesota next described the need for the USMLE STEP 1 exam to be transitioned to a pass/fail endeavor. He cited the error of measurement of 24 points (i.e., the same test taker could have a 220 one day and a 244 the next) and the potential loss of valuable rotation experiences during the several-month period of intense study. He challenged audience members to complete an esoteric exam question to prove his point and asserted that many learners are lacking in humility, communication skills, and professionalism, and seek only the honors designation on rotations. He likened the experience of medical students on rotation and residents on service weeks to a series of first dates and affirmed the value of longitudinal learner-educator relationships.

Further, he outlined the detachment of learners from patient outcomes, demonstrated by frequent hand-offs and rotation transitions. Dr Olson also cited medical pedagogy as failing to meet the known needs of adult learners to engage in deliberate progressive practice, reflective practice, or to use concepts such as spacing or interleaving to reinforce knowledge.

Dr. Kelleher, also of Cincinnati Children’s Hospital, ended the session by taking those in attendance on an imagined “what-if” journey where each of the wrongs currently done to early learners in medical education were corrected. This included engagement in daily reflection (5 minutes at a time), reporting system issues on rounds that had failed the patient, presenting learners with a CV of attending failures to reinforce the imperfection that is a reality in medicine, praising learners when they admit “they don’t know the answer” to a question posed on rounds, completing assessments in real time in the learner’s presence, rounding until specific feedback can be identified for each learner on the team, having a kiosk on each floor where ANY team member could provide feedback to learners, using cognitive science on rounds for teaching (i.e., Socratic) rather than pimping, modeling interprofessional teamwork daily using a culture of vulnerability rather than infallibility (i.e., airline culture), and by encouraging the attending to care for patients or complete tasks independently, showing the value of education over service and model ideal family-centered communication with the team.

One might wonder, if all of the above were accomplished at the request of our talented presenters, would a pass/fail USMLE world where medical education was learner centered and filled with longitudinal relationships with teams and patients, and outcomes were connected to education produce more engaged, knowledgeable, and holistic physicians? According to this team of presenters, yes.
 

Key takeaways

• Current processes in medical education are harming today’s adult learner.

• Harms include reliance on numerical rather than competency-based assessment, fragmented learning environments, focus on perfection rather than improvement, ignorance of updates in cognitive science for instructional methodology, and individualist rather than team-based learning.

• Reforms are needed to remedy harms in health professional education, including making USMLE pass/fail, creating a learning-centered rather than service-centered residency environment, encouraging longitudinal relationships between teacher and learner, and connecting education to clinical outcomes.

Dr. King is associate program director, University of Minnesota Pediatric Residency Program, Minneapolis.

PHM19 session

Mitigating the harm we cause learners in medical education

Presenters

Benjamin Kinnear, MD, MEd

Andrew Olson, MD

Matthew Kelleher, MD, MEd

Session summary

Dr. Kinnear, Dr. Olson, and Dr. Kelleher expertly led this TED-Talk style session at Pediatric Hospital Medicine 2019, convincing the audience that medical educators persistently harm the learners under their supervision.

Dr. Kinnear, of Cincinnati Children’s Hospital, opened the session noting that the path through medical school presently has a perverse focus on grades as a necessary achievement. As an expert in competency-based assessment, he asserted that the current learner assessment strategy is neither valid nor robust enough to indicate actual competence. Summary assessments presented throughout medical school are lacking continuous constructive feedback, leaving early residents in a state of shock when receiving corrective or negative assessments. He also noted that structurally many rotations create both team and patient discontinuity, leaving the learner with a feeling of detachment and limited ownership of the human patient under his/her/their care.

Dr. Olson of the University of Minnesota next described the need for the USMLE STEP 1 exam to be transitioned to a pass/fail endeavor. He cited the error of measurement of 24 points (i.e., the same test taker could have a 220 one day and a 244 the next) and the potential loss of valuable rotation experiences during the several-month period of intense study. He challenged audience members to complete an esoteric exam question to prove his point and asserted that many learners are lacking in humility, communication skills, and professionalism, and seek only the honors designation on rotations. He likened the experience of medical students on rotation and residents on service weeks to a series of first dates and affirmed the value of longitudinal learner-educator relationships.

Further, he outlined the detachment of learners from patient outcomes, demonstrated by frequent hand-offs and rotation transitions. Dr Olson also cited medical pedagogy as failing to meet the known needs of adult learners to engage in deliberate progressive practice, reflective practice, or to use concepts such as spacing or interleaving to reinforce knowledge.

Dr. Kelleher, also of Cincinnati Children’s Hospital, ended the session by taking those in attendance on an imagined “what-if” journey where each of the wrongs currently done to early learners in medical education were corrected. This included engagement in daily reflection (5 minutes at a time), reporting system issues on rounds that had failed the patient, presenting learners with a CV of attending failures to reinforce the imperfection that is a reality in medicine, praising learners when they admit “they don’t know the answer” to a question posed on rounds, completing assessments in real time in the learner’s presence, rounding until specific feedback can be identified for each learner on the team, having a kiosk on each floor where ANY team member could provide feedback to learners, using cognitive science on rounds for teaching (i.e., Socratic) rather than pimping, modeling interprofessional teamwork daily using a culture of vulnerability rather than infallibility (i.e., airline culture), and by encouraging the attending to care for patients or complete tasks independently, showing the value of education over service and model ideal family-centered communication with the team.

One might wonder, if all of the above were accomplished at the request of our talented presenters, would a pass/fail USMLE world where medical education was learner centered and filled with longitudinal relationships with teams and patients, and outcomes were connected to education produce more engaged, knowledgeable, and holistic physicians? According to this team of presenters, yes.
 

Key takeaways

• Current processes in medical education are harming today’s adult learner.

• Harms include reliance on numerical rather than competency-based assessment, fragmented learning environments, focus on perfection rather than improvement, ignorance of updates in cognitive science for instructional methodology, and individualist rather than team-based learning.

• Reforms are needed to remedy harms in health professional education, including making USMLE pass/fail, creating a learning-centered rather than service-centered residency environment, encouraging longitudinal relationships between teacher and learner, and connecting education to clinical outcomes.

Dr. King is associate program director, University of Minnesota Pediatric Residency Program, Minneapolis.

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.