How strategies for managing patient visit time affect physician job satisfaction: a qualitative analysis

Application of a user experience design approach for an EHR-based clinical decision support system

Objective

We applied a user experience (UX) design approach to clinical decision support (CDS) tool development for the specific use case of pediatric asthma. Our objective was to understand physicians' workflows, decision-making processes, barriers (ie, pain points), and facilitators to increase usability of the tool.

Materials and methods

We used a mixed-methods approach with semi-structured interviews and surveys. The coded interviews were synthesized into physician-user journey maps (ie, visualization of a process to accomplish goals) and personas (ie, user types). Interviews were conducted via video. We developed physician journey maps and user personas informed by their goals, systems interactions, and experiences with pediatric asthma management.

Results

The physician end-user personas identified were: efficiency, relationship, and learning. Features of a potential asthma CDS tool sought varied by physician practice type and persona. It was important to the physician end-user that the asthma CDS tool demonstrate value by lowering workflow friction (ie, difficulty or obstacles), improving the environment surrounding physicians and patients, and using it as a teaching tool. Customizability versus standardization were important considerations for uptake.

Discussion

Different values and motivations of physicians influence their use and interaction with the EHR and CDS tools. These different perspectives can be captured by applying a UX design approach to the development process. For example, with the importance of customizability, one approach may be to build a core module with variations depending on end-user preference.

Conclusion

A UX approach can drive design to help understand physician-users and meet their needs; ultimately with the goal of increased uptake.

Using Normative Rhetorical Theory to Identify Dilemmas and Responses in Internal Medicine Patient-Provider Communication

Drawing on normative rhetorical theory (NRT), we examined communication dilemmas that internal medicine residents (IMRs) experience when interacting with patients and responses they adopt to manage these dilemmas. We conducted semi-structured, intensive interviews with 15 IMRs and analyzed the data using the phronetic iterative approach. Findings suggested that IMRs experienced two interpersonal dilemmas: (a) asserting expertise while respecting patients and (b) discussing patient behaviors without indicating deviance. The two dilemmas were more salient for international IMRs who were less familiar with the local culture and embraced a different perspective of the IMR-patient relationship. The two interpersonal dilemmas were connected to a supra-level dilemma of practicing tasks required by evidence-based medicine while being patient-centered. IMRs reported engaging in an interpretive lens to view patients as "people" and communicative responses to manage the dilemmas. By applying NRT to a novel context, our findings demonstrate the impact of macro-level paradigms on IMRs' conflicting purposes in medical encounters and offer practical implications for communication interventions for IMRs.

A Web-Based eHealth Intervention to Improve the Quality of Life of Older Adults With Multiple Chronic Conditions: Protocol for a Randomized Controlled Trial

Background

Multiple chronic conditions (MCCs) are common among older adults and expensive to manage. Two-thirds of Medicare beneficiaries have multiple conditions (eg, diabetes and osteoarthritis) and account for more than 90% of Medicare spending. Patients with MCCs also experience lower quality of life and worse medical and psychiatric outcomes than patients without MCCs. In primary care settings, where MCCs are generally treated, care often focuses on laboratory results and medication management, and not quality of life, due in part to time constraints. eHealth systems, which have been shown to improve multiple outcomes, may be able to fill the gap, supplementing primary care and improving these patients’ lives.

Objective

This study aims to assess the effects of ElderTree (ET), an eHealth intervention for older adults with MCCs, on quality of life and related measures.

Methods

In this unblinded study, 346 adults aged 65 years and older with at least 3 of 5 targeted high-risk chronic conditions (hypertension, hyperlipidemia, diabetes, osteoarthritis, and BMI ≥30 kg/m2) were recruited from primary care clinics and randomized in a ratio of 1:1 to one of 2 conditions: usual care (UC) plus laptop computer, internet service, and ET or a control consisting of UC plus laptop and internet but no ET. Patients with ET have access for 12 months and will be followed up for an additional 6 months, for a total of 18 months. The primary outcomes of this study are the differences between the 2 groups with regard to measures of quality of life, psychological well-being, and loneliness. The secondary outcomes are between-group differences in laboratory scores, falls, symptom distress, medication adherence, and crisis and long-term health care use. We will also examine the mediators and moderators of the effects of ET. At baseline and months 6, 12, and 18, patients complete written surveys comprising validated scales selected for good psychometric properties with similar populations; laboratory data are collected from eHealth records; health care use and chronic conditions are collected from health records and patient surveys; and ET use data are collected continuously in system logs. We will use general linear models and linear mixed models to evaluate primary and secondary outcomes over time, with treatment condition as a between-subjects factor. Separate analyses will be conducted for outcomes that are noncontinuous or not correlated with other outcomes.

Results

Recruitment was conducted from January 2018 to December 2019, and 346 participants were recruited. The intervention period will end in June 2021.

Conclusions

With self-management and motivational strategies, health tracking, educational tools, and peer community and support, ET may help improve outcomes for patients coping with ongoing, complex MCCs. In addition, it may relieve some stress on the primary care system, with potential cost implications.

Trial Registration

ClinicalTrials.gov NCT03387735; https://www.clinicaltrials.gov/ct2/show/NCT03387735.

International Registered Report Identifier (IRRID)

DERR1-10.2196/25175

The Communicative Ecology of Chinese Patients' Experiences with Health Care

Patient satisfaction and trust are important intermediate outcomes along pathways linking clinician-patient communication to improve well-being, but they are difficult to achieve in Chinese health care. Problematic physician-patient interactions, questionable health-care organizational practices, and media coverage of medical scandals may have contributed to this problem. Nevertheless, there isscant literature documenting reasons underlying dissatisfaction with Chinese health care. Using Street's ecological model of communication in medical encounters as a conceptual framework, this study explores how media and organizational factors affect Chinese patients' satisfaction and trust both directly and as mediated by the quality of patients' past communication experiences with clinicians. A survey was conducted among 257 Ob-gyn patients in a top-tier hospital in Sichuan, China. The results show that several organizational and media factors, along with patients' experiences with physician communication, predict patient satisfaction and trust. Perceptions of physician communication mediated some of the relationships between organizational and media factors with outcomes. Theoretical and practical implications are discussed, particularly with respect to improving health-care services in China.

Perceptions of time constraints among primary care physicians in Germany

Background

Time constraints during patient visits play a major role for the work stress of primary care physicians. Several studies suggest that there is a critical situation in terms of time constraints in primary care in Germany. Therefore, the following research questions are addressed: (1) What is the time allocated and needed for different types of consultations among primary care physicians in an urban area in Germany? (2) What is the extent of time stress? (3) Are there differences in time stress according to physician characteristics (gender and length of experience) and practice type (single vs. group/shared practice)?

Methods

Data stem from a face-to-face survey of primary care doctors in Hamburg and adjacent regions. A sample of 128 physicians stratified by a combination of physicians’ gender and length of experience (≤15 years or > 15 years) was used. Physicians were asked about the time needed (in minutes) to provide high quality of care for patients regarding six types of consultations: (1) new patient appointment, (2) routine consultation, (3) complete physical examination, (4) symptom-oriented examination, (5) check-up, and (6) home visit (without drive). Afterwards, they were asked about the average minutes allocated for the six consultations. Time stress was measured by calculating minutes needed minus minutes available.

Results

Average perceived time needed was higher than time allocated for all six types of consultation. However, there were differences in the magnitude of time stress between the consultation types. Time stress was most pronounced and most prevalent in case of a new patient visit. No significant differences in time stress between male and female primary care physicians were found, while less experienced physicians reported more time stress than those with more experience (> 15 years). Physicians working in a single practice had less time stress than those working in a group or shared practice in case of a check-up visit.

Conclusions

Perceived time needed is higher than time allocated for various types of consultation among primary care physicians in Germany. Time stress in primary care is particularly pronounced in case of new patient appointments. Early-career physicians are particularly affected by time stress.

Average medical visit time in Iran: A systematic review and meta-analysis

Background: Visit length is an indicator that can be used to assess patients' satisfaction of the health care services. In recent years, some studies have focused on the mean visit time in Iran. This study aimed at determining the average visit time in Iran by performing a systematic review and meta-analysis. Methods: In this study, Embase, PubMed/MEDLINE, Scopus, ISI/Web of Science databases, and Google Scholar search engine, as well as Iranian national databases/thesauri, such as MagIran, SID, and Irandoc were used. These databases were searched from their inception until September 2017. The quality of retained studies was assessed using the STROBE checklist. Average visit length was reported using stochastic model with 95% confidence interval (CI). I2 and Q tests were used to assess the heterogeneity of the studies. A sensitivity analysis was conducted to ensure the stability of the results. Results: After searching the scholarly databases and reviewing the articles based on inclusion and exclusion criteria, 6 studies were finally selected. Based on the random model, the mean visit time was 4.89 minutes in Iran, ranging from 4.66 to 5.12 minutes (p=0.82). The most time visit in specialists belonged to psychiatrists with 9.12 (7.28 to 10.96) minutes (p=0.19) and the lowest belonged to internists with 3.59 (2.24 to 4.95) minutes (p=0.00), respectively. Conclusion: The average visit time in Iran was estimated to be 4.89 minutes. To increase patients' satisfaction and provide a better disease treatment and management in Iran, the following suggestions could be helpful: properly distributing physicians across the country, reducing waiting lists, and implementing the use of guidelines to standardize the visit time.

The Mediating Effects of Job Satisfaction on the Association between Doctor-patient Relationship and OCB among Physicians in China

BACKGROUND

The aim of this study was to investigate OCB among physicians in China and explore whether their job satisfaction mediates the association between doctor-patient relationship (DPR) and organizational citizenship behavior (OCB).

METHODS

This cross-sectional, questionnaire-based survey was conducted among 1400 physicians in Shaanxi, China in 2014. The subjects were selected using a multi-stage cluster sampling methodology. The self-administered questionnaires included OCB Scale, DDPRQ, and PJSQ. Hierarchical linear regression analysis was used to estimate the effects of job satisfaction on the association between DPR and OCB.

RESULTS

DPR negatively predicted four dimensions of OCB, including conscientiousness, sportsmanship, civic virtue, and altruism. DPR was negatively related to five job satisfaction dimensions, namely work satisfaction (WS), promotion satisfaction (PS), reward satisfaction (RS), supervision satisfaction (SS), and environment satisfaction (ES). WS was positively correlated with conscientiousness and civic virtue; PS and SS were positively related to all four OCB dimensions; RS was positively related with civic virtue and altruism, and ES was positively correlated with conscientiousness and civic virtue. WS and PS partially mediated the association between DPR and conscientiousness; PS and SS partially mediated the relation between DPR and sportsmanship; PS, SS, and ES mediated the association between DPR and civic virtue; and PS, RS and SS partially mediated the relation between DPR and altruism.

CONCLUSION

Job satisfaction mediated the association between DPR and OCB among Chinese physicians. The poor DPR possibly reduce physicians' job satisfaction, thereby causing a decline of OCB in hospitals. Therefore, DPR improvement and job satisfaction have a great potential to promote physicians' job performance in China.

Development and Impact of a Novel Academic Primary Care Compensation Model

BACKGROUND

Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits.

OBJECTIVE

To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes.

DESIGN

Observational study.

PARTICIPANTS

Forty-seven general internists who practice in affiliated academic and community clinics.

MAIN MEASURES

Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity.

KEY RESULTS

The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %.

CONCLUSIONS

An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population.

Analyzing Rural Versus Urban Differences in Career Dissatisfaction and Plans to Leave Among Pennsylvanian Physicians

PURPOSE

This study estimates whether physicians in rural Pennsylvania have higher odds of career dissatisfaction and plans to leave patient care in the next 6 years, compared to their urban counterparts. Rural-urban differences were estimated across specific subgroups of physicians (gender, race, and specialty) and with regard to specific sources of career dissatisfaction.

METHODS

The 2012 Pennsylvania Health Workforce Survey of Physicians allowed for analysis of 17,444 physicians younger than 55 years old actively practicing patient care. Multivariate, logistic regression was performed to estimate the associations with 2 outcome areas: career dissatisfaction and plans to leave patient care in the next 6 years. Controls included rural setting, age, sex, race, work hours, specialty, and practice characteristics.

RESULTS

Over 12% of under-55 physicians are dissatisfied with their careers and over 18% report plans to leave patient care in the next 6 years. Rural physicians in Pennsylvania have 18.6% higher odds of reporting career dissatisfaction and 29.5% higher odds of leaving patient care in the next 6 years (P < .01 for each) versus their urban counterparts.

CONCLUSIONS

Rates of dissatisfaction and potential attrition among younger physicians are not insignificant, with a stronger association with rural practice. Given the large number of rural health shortage areas, better understanding this association is important to health care providers and policy makers. Regression results suggest that higher rural odds are related more to physician work (i.e., stress, practice demands, and lack of autonomy) and family situations and less related to income concerns.

Effects of time constraints on clinician-computer interaction: a study on information synthesis from EHR clinical notes

BACKGROUND

Time is a measurable and critical resource that affects the quality of services provided in clinical practice. There is limited insight into the effects of time restrictions on clinicians' cognitive processes with the electronic health record (EHR) in providing ambulatory care.

OBJECTIVE

To understand the impact of time constraints on clinicians' synthesis of text-based EHR clinical notes.

METHODS

We used an established clinician cognitive framework based on a think-aloud protocol. We studied interns' thought processes as they accomplished a set of four preformed ambulatory care clinical scenarios with and without time restrictions in a controlled setting.

RESULTS

Interns most often synthesized details relevant to patients' problems and treatment, regardless of whether or not the time available for task performance was restricted. In contrast to previous findings, subsequent information commonly synthesized by clinicians related most commonly to the chronology of clinical events for the unrestricted time observations and to investigative procedures for the time-restricted sessions. There was no significant difference in the mean number of omission errors and incorrect deductions when interns synthesized the EHR clinical notes with and without time restrictions (3.5±0.5 vs. 2.3±0.5, p=0.14).

CONCLUSION

Our results suggest that the incidence of errors during clinicians' synthesis of EHR clinical notes is not increased with modest time restrictions, possibly due to effective adjustments of information processing strategies learned from the usual time-constrained nature of patient visits. Further research is required to investigate the effects of similar or more extreme time variations on cognitive processes employed with different levels of expertise, specialty, and with different care settings.

Healthcare Provider Communication Patterns during Consultations about Treating Localized Prostate Cancer

BACKGROUND

Disparities in mortality in prostate cancer may reflect differences in healthcare providers' communication.

OBJECTIVE

This study examined physicians' communication with African American and Caucasian men when making decisions about treatment for localized prostate cancer to determine whether information-giving and partnership-building behaviors varied by the age, education level, and race of the patient.

METHODS

The study was a secondary analysis of data from a larger study examining decisionmaking among men with prostate cancer. Verbatim transcripts of physician communication with 13 African American and 32 Caucasian patients were coded using a well-established scheme.

RESULTS

Physicians tended to use information-giving and partnership-building behaviors more often with patients who were Caucasian, but this practice was tempered by the patient's age or education level.

CONCLUSION

Information-giving and partnership-building behaviors should be studied relative to patient outcomes, such as treatment adherence and satisfaction. Communication is a two-way interaction, and patients' perceptions should be included in future studies.

PRACTICE IMPLICATIONS

Biases, assumptions, and differential behavior toward patients who are older, minorities, or less educated must be addressed during all healthcare providers' socialization and education. All will benefit from their education in communication and partnership-building with patients.

Pleasure in medical practice

It is time to challenge the issue of pleasure associated with the core of medical practice. Its importance is made clear through its opposite: unhappiness--something which affects doctors in a rather worrying way. The paper aims to provide a discussion on pleasure on reliable grounds. Plato's conception of techne is a convenient model that offers insights into the unique practice of medicine, which embraces in a single purposive action several heterogeneous dimensions. In Aristotle's Ethics, pleasure appears to play a central role for action's assessment and intensification. Pleasure is also tightly associated with the Kantian faculty of reflective judgment, which operates at the heart of clinical reasoning. Indeed, practicing medicine means to deal with the particular and the manifold, requiring clinical judgment, but also relying on embodied habitus. With Bourdieu's notion of habitus, pleasure is the mark of a happy practice, which presupposes a deep involvement in one's field. Throughout our inquiry, the question of pleasure comes to offer a critical reappraisal of real medical practice and leads to consider ethics more as a component of techne than as a separate realm of concern.

Academic retainer medicine: an innovative business model for cross-subsidizing primary care

Retainer-medicine primary care practices, commonly referred to as "luxury" or "concierge" practices, provide enhanced services to patients beyond those available in traditional practices for a yearly retainer fee. Adoption of retainer practices has been largely absent in academic health centers (AHCs). Reasons for this trend stem primarily from ethical concerns, such as the potential for patient abandonment when physicians downsize from larger, traditional practices to smaller, retainer-medicine practices.In 2004, the Department of Medicine at Tufts Medical Center developed an academic retainer-medicine primary care practice within the Division of General Medicine that not only generates financial support for the division but also incorporates a clinical and business model that is aligned with the mission and ethics of an academic institution.In contrast to private retainer-medicine practices, this unique business model addresses several of the ethical issues associated with traditional retainer practices-it does not restrict net access to care and it neutralizes concerns about patient abandonment. Addressing the growing primary care shortage, the model also presents the opportunity for a retainer practice to cross-subsidize the expansion of general medicine in an academic medical setting. The authors elucidate the benefits, as well as the inherent challenges, of embedding an academic retainer-medicine practice within an AHC.

Self-management support and communication from nurse care managers compared with primary care physicians: a focus group study of patients with chronic musculoskeletal pain

Pain is a critical health problem, with over half of Americans suffering from chronic or recurrent pain. Many patients also experience comorbid depression. Although numerous self-management interventions have been implemented in an effort to improve pain outcomes, little attention has been devoted to the role of the provider of these services, typically a nurse care manager (NCM). Given the robust literature pointing to a link between physician-patient communication and patient outcomes, NCM-patient communication merits closer examination. This paper reports chronic pain patients' perceptions of the communication with NCMs in a pain self-management trial and patients' perceptions of the communication they experienced in primary care. Eighteen patients suffering from chronic musculoskeletal pain and depression participated in four focus groups designed to ascertain their perceptions of the intervention. A key emergent theme from these focus groups was the contrast in patients' perceptions of the communication with their primary care physicians versus with the NCMs. Patients reported feeling supported, encouraged, and listened to by their NCMs, whereas they tended to be dissatisfied with their primary care physicians, citing issues such as lack of continuity of care, poor listening skills, and under- or overprescribing of medication. The results of this study underscore the importance of the NCM, particularly for patients with chronic conditions such as pain.