The Supply of Surgical Specialists and Subspecialists to the U.S. Medicare Population: National Trends from 2013 to 2019

PURPOSE

The U.S. population is rapidly aging. The supply of surgeons needed to meet this demand should be evaluated. This study evaluated the trends in supply of Medicare surgeons by specialty and by U.S. state and region.

METHOD

All surgeons associated with a National Provider Identifier for cardiothoracic surgery, colorectal surgery, general surgery, gynecologic oncology, hand surgery, neurosurgery, obstetrics-gynecology, ophthalmology, oral and maxillofacial surgery, orthopedic surgery, otolaryngology, plastic and reconstructive surgery, surgical oncology, urology, and vascular surgery from 2013 to 2019 on the Centers for Medicare & Medicaid Services website were included. The absolute number of physicians was adjusted per 100,000 Medicare beneficiaries. Annual change was calculated by linear regression model, and the compound annual growth rate (CAGR) was calculated per specialty.

RESULTS

The absolute number of physicians per 100,000 beneficiaries increased in 6 of 15 specialties during the study period. Vascular surgery had the largest annual increase (+0.23; CAGR, +2.75%), and obstetrics-gynecology had the largest annual decrease (-1.08; CAGR, -1.44%). Surgical oncology showed the largest positive CAGR (+4.20%). Oral and maxillofacial surgery had the largest negative CAGR (-2.86%). The Northeast was above the national average in supply for each specialty. The Midwest had the most specialties with positive CAGRs. The South did not meet the national average for physicians in any specialty.

CONCLUSIONS

This analysis of 15 surgical specialties provides important context to predicted physician shortages to the Medicare population. The study found geographic variation by region across specialty, which has important implications for health care planning from the level of undergraduate medical education to provision of hospital resources. Overall, the supply of surgeons across all specialties may not be sufficient to meet the demand of the rapidly aging U.S. population. Future study is needed to evaluate why surgeons are leaving the Medicare program.

Evaluation of the clinical utility of the PromarkerD in-vitro test in predicting diabetic kidney disease and rapid renal decline through a conjoint analysis

BACKGROUND

Early identification of patients at risk of developing diabetic kidney disease or rapid renal decline is imperative for appropriate patient management, but traditional methods of predicting renal decline are limited.

OBJECTIVE

This study evaluated the impact of PromarkerD, a biomarker-based blood test predicting the risk of diabetic kidney disease (DKD) and rapid renal decline.

METHODS

Conjoint analysis clarified the importance of PromarkerD and other patient attributes to physician decisions for type 2 diabetes patients. Forty-two patient profiles were generated, with varying levels of albuminuria, estimated glomerular filtration rate (eGFR), blood pressure, hemoglobin A1c (HbA1c), age, and PromarkerD result. A web-based survey asked each physician to make monitoring/treatment decisions about eight randomly selected profiles. Data were analyzed using multivariable logit models.

RESULTS

Two hundred three primary care physicians and 197 endocrinologists completed the survey. PromarkerD result was most important for increasing the frequency of risk factor monitoring. PromarkerD was second to HbA1c in importance for deciding to prescribe sodium/glucose cotransporter-2 inhibitors (SGLT2s) with a DKD indication, second to blood pressure for increasing the dose of lisinopril, and second to eGFR for replacing ibuprofen with a non-nephrotoxic medication. Compared with no PromarkerD results, a high-risk PromarkerD result was associated with significantly higher odds of increasing monitoring frequency (odds ratio [OR]: 2.56, 95% confidence interval: 1.90-3.45), prescribing SGLT2s (OR: 1.98 [1.56-2.52]), increasing lisinopril dose (OR: 1.48 [1.17-1.87]), and replacing ibuprofen (OR: 1.78 [1.32-2.40]). A low-risk PromarkerD result was associated with significantly lower odds of increasing monitoring frequency (OR: 0.48 [0.37-0.64]), prescribing SGLT2s (OR: 0.70 [0.56-0.88]), and replacing ibuprofen (OR: 0.75 [0.57-0.99]).

CONCLUSION

PromarkerD could increase adoption of renoprotective interventions in patients at high risk for renal decline and lower the likelihood of aggressive treatment in those at low risk. Further studies are needed to assess patient outcomes with PromarkerD in real-world practice.

Language of Medical Instruction in Palestine: A Mixed Method Approach of Students’ Perceptions

This mixed method study explores medical students' perceptions and attitudes regarding the language(s) of medical instruction in two Palestinian universities. The researcher aimed to identify the way medical students look at the language of medical education as well as the merits and drawbacks of the language(s) used in medical instruction. A 25-item descriptive, online questionnaire was built to explore the way university students evaluate and perceive the medium of medical instruction at the Faculty of Medicine. To complement and inform the quantitative findings, fifty-five students from each university were randomly selected, and their responses to an open question about the merits and drawbacks of the language(s) were analyzed using MAXQDA. Of the too many medical students enrolled in the two universities, 604 completed and returned the survey, and 55 students were selected to interpret their open responses qualitatively. The study findings suggest that the students are divided into two camps concerning what the language of medical instruction should be; some prefer Arabic, their mother tongue, while the others showed no reservations about using the medical academic vocabulary in English. Some statistically significant differences were found when some demographic variables, i.e., gender, specific major, and year of study, interact. Finally, study respondents highlighted several issues which the researcher sorted into advantages and disadvantages for each language. There is a considerable discrepancy in the choice of the language of medical instruction at the Faculty of Medicine. Each language has its pros and cons; consequently, a mixture of a mother and a foreign language (e.g., English) could be a suitable compromise in a country like Palestine.

Predictors of performance of foreign-trained medical doctors in the registration examination of the Ghana medical and dental council: A 5-year analysis

INTRODUCTION

Although the influx of foreign-trained medical doctors (FTMDs) can improve the doctor-to-patient ratio in Ghana, there is the need to ensure that the quality of training is maintained. We assessed the performance of FTMDs in registration examinations over a 5-year period.

METHODOLOGY

Data were extracted from Ghana Medical and Dental Council (GMDC) records from 2015 to 2019. Chi-squared tests assessed the association between the selected characteristics and the final grades. A multivariate logistic regression analysis determined significant predictors of the failure. The data were analysed using the statistical software IBM SPSS (version 26). The significance level was set at P < 0.05.

RESULTS

Of the 1356 doctors, majority (63.1%) were male, 64.3% were aged 21-30 years and 95.5% were Ghanaian. In all, there were 41 countries of training with majority training in China (35.4%) and Ukraine (31.9%). More than half (58.5%) failed the examination. Country of training, number of years from qualification to time of registration examination and number of previous attempts were statistically significantly associated with success at the examination. The logistic regression analysis showed that those who failed were more likely to have trained in Belarus (odds ratio [OR] = 3.20, 95% confidence interval [CI]; 1.50-6.82), Ukraine (OR = 2.47, 95% CI; 1.55-3.92), China OR = 2.06, 95% CI; 1.30-3.26) and Russia (OR = 1.98, 95% CI; 1.21-3.23) and were 0.58 times likely to have trained in Cuba.

CONCLUSION

The performance at the examination is low. The significant predictor of performance is country of training. The authors recommend that the GMDC provides counselling services for students who leave for medical training abroad.

Physician suicide demographics and the COVID-19 pandemic

OBJECTIVE

To identify suicide rates and how they relate to demographic factors (sex, race and ethnicity, age, location) among physicians compared to the general population when aggravated by the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

We searched U.S. databases to report global suicide rates and proportionate mortality ratios (PMRs) among U.S. physicians (and non-physicians in health occupations) using National Occupational Mortality Surveillance (NOMS) data and using Wide-ranging Online Data for Epidemiologic Research (WONDER) in the general population. We also reviewed the effects of age, suicide methods and locations, COVID-19 considerations, and potential solutions to current challenges.

RESULTS

Between NOMS1 (1985-1998) and NOMS2 (1999-2013), the PMRs for suicide increased in White male physicians (1.77 to 2.03) and Black male physicians (2.50 to 4.24) but decreased in White female physicians (2.66 to 2.42).

CONCLUSIONS

The interaction of non-modifiable risk factors, such as sex, race and ethnicity, age, education level/healthcare career, and location, require further investigation. Addressing systemic and organizational problems and personal resilience training are highly recommended, particularly during the additional strain from the COVID-19 pandemic.

Late-Career Pediatric Hospitalists: Programmatic Accommodations and Supports

BACKGROUND

As the number of late-career pediatric hospitalists increases, issues regarding aging and retirement will require more attention. Long shifts and overnight clinical responsibilities may be challenging for older physicians. Our study objectives include investigation of the current state of practice regarding work hours, night call responsibilities, productivity requirements, coronavirus disease 2019 (COVID-19) exposure modifications, and division chief knowledge about retirement supports for late-career pediatric hospitalists.

METHODS

This cross-sectional study used a web survey, distributed in spring of 2020 on the American Academy of Pediatrics, Section on Hospital Medicine, Division Chief listserv. The questionnaire asked about (1) program demographics, (2) overnight call responsibilities, (3) clinical schedules, (4) modifications for COVID-19, and (5) retirement benefits and supports. Data were analyzed by using descriptive statistics and the Fisher exact test.

RESULTS

The 47 responding programs employ 982 hospitalists in 728 full-time equivalent positions. Division chiefs estimated 117 (12%) individuals were aged 50 to 64 years and 16 (1.6%) were 65 years or older. Most programs (91%) had at least 1 member 50 to 64 years of age; 13 programs (28%) had a member aged 65 or older. Larger programs were more likely to allow older physicians to opt out of some night call responsibilities. Most programs made some accommodations for COVID-19 exposure. Other than financial counseling and academic benefits, most programs did not provide retirement counseling or other supports for retiring physicians.

CONCLUSION

Although limited by a low response rate, we found most programs had older faculty. Substantial variation exists in how programs make accommodations and offer support for older members.

A Novel Online Curriculum and Coaching Strategy to Expand the Addiction Medicine Workforce: The Michigan Collaborative Addiction Resources and Education System

PROBLEM

There is a shortage of addiction medicine (AM) physicians and a 9-year period (2017-2025) in which to build the workforce via a practice pathway enabling physicians to combine experiential hours with passing a board exam to become board-certified AM physicians. Afterward, AM specialists will need to complete the traditional fellowship pathway, requiring additional training.

APPROACH

The Michigan Collaborative Addiction Resources and Education System (MI CARES) was developed from February to June 2019 to support physicians in obtaining AM certification via the practice pathway. This program was originally planned for Michigan physicians but was quickly expanded nationally. This novel, asynchronous, self-directed online curriculum follows the knowledge blueprint for the board exam, including continuing medical education credits. The program also provides 1:1 coaching support to educate physicians on how to properly document their experiential hours on the application for the AM board exam. The first module, which describes the practice pathway, was released in January 2020, and 7 substance-specific content modules were released monthly from February to August 2020.

OUTCOMES

As of October 31, 2020, 231 physicians from 13 American Board of Medical Specialties in 37 U.S. states were enrolled in MI CARES. The longer a module was available, the more participants visited the module. Three early program adopters were approved to sit for the 2019 board exam, and 51 participants passed the board exam in 2020. Of these 51, 5 had previously been denied approval before participating in MI CARES.

NEXT STEPS

It will be important to replicate preliminary evidence of feasibility for this novel model for expanding the workforce in a newly approved and underrepresented specialty to see if it holds promise for replication as other subspecialties are identified. The curriculum is being expanded to include modules on additional topics and adapted for graduate and undergraduate medical education students.

Current Trends and Predictors of Case Outcomes for Malpractice in Colonoscopy in the United States

BACKGROUND

Over 14 million colonoscopies are performed annually, and this procedure remains the largest contributor to malpractice claims against gastroenterologists. The aim of this study was to evaluate reasons for litigation and predictors of case outcomes.

MATERIALS AND METHODS

Cases related to colonoscopy were reviewed within the Westlaw legal database. Patient demographics, reasons for litigation, case payouts, and verdicts were assessed. Multivariate regression was used to determine predictors of defendant verdicts.

RESULTS

A total of 305 cases were included from years 1980 to 2017. Average patient age was 54.9 years (range, 4 to 93) and 52.8% of patients were female. Juries returned defendant and plaintiff verdicts in 51.8% and 25.2% of cases, respectively, and median payout was $995,000. Top reasons for litigation included delay in treatment (65.9%) and diagnosis (65.6%), procedural error (44.3%), and failure to refer (25.6%). Gastroenterologists were defendants in 71% of cases, followed by primary care (32.2%) and surgeons (14.8%). Cases citing informed consent predicted defendant verdict (odds ratio, 4.05; 95% confidence interval, 1.90-9.45) while medication error predicted plaintiff verdict (odds ratio, 0.18; 95% confidence interval, 0.04-0.59). Delay in diagnosis (P=0.060) and failure to refer (P=0.074) trended toward plaintiff verdict but did not reach significance. Most represented states were New York (21.0%), California (13.4%), Pennsylvania (13.1%), Massachusetts (12.5%).

CONCLUSIONS

Malpractice related to colonoscopy remains a significant and has geographic variability. Errors related to sedation predicted plaintiff verdict and may represent a target to reduce litigation. Primary care physicians and surgeons were frequently cited codefendants, underscoring the significance of interdisciplinary care for colonoscopy.

Discontinuity in care: Practice closures among primary care providers and patient health care utilization

We evaluate the consequences for patients of being matched to a new primary care provider due to practice closures. Using an event study and population-level data of patients and providers in Denmark, we find that the transition between providers is smooth; among re-matched patients, there is little change in primary care utilization at the extensive margin. Second, we document a 17% increase in fee-for-service per visit and a large increase in the probability that the patient initiates drug therapy targeting chronic and underdiagnosed diseases (hypertension, hyperlipidemia, and diabetes). Additionally, the re-matched patients are more likely to be admitted to inpatient care for these diseases. The increase in therapeutic initiation is not primarily because the new providers are relatively predisposed to prescribing these drugs. Instead, it appears that when patients match to new providers, there is a consequential reassessment of patients' medical needs which leads to the initiation of new treatment.

Gender disparity in dermatologic society leadership: A global perspective

BACKGROUND

In the last half-century, there has been increased representation of women in medicine. Despite this increase, there continues to be underrepresentation of women in medical leadership positions. The objective of this study was to investigate the phenomenon of gender disparity in the leadership of professional societies of dermatology worldwide.

METHODS

Online databases were used to extract the names of global dermatologic societies. Individual society websites were accessed to obtain information on executive members. Data not available on society websites were obtained through internet searches. Scopus was used to obtain H-indexes and other bibliometric outcomes.

RESULTS

Our data collection spanned 92 countries, with 1733 society leaders identified and information available for 1710. In North America, Europe, Asia, Australia, and the Middle East, women were in a minority in dermatology professional society leadership. In South America, Central America, and Africa, women were in a slight majority. Across all professional societies, the role of president was more frequently held by men (n = 95) as opposed to women (n = 75). Female leaders were less likely to hold concurrent academic positions as deans/chairpersons/directors (83.33%) than their male counterparts (92.06%). The median H-index of female leaders (9) was lower than that of men (14).

CONCLUSION

Gender disparity exists in leadership positions in professional dermatology societies. Cultural/continental specific factors should be explored further. Enhancement of institutional support, mentorship, and sponsorship for female dermatologists should be encouraged.

The Cost of Not Training a Surgical Resident

OBJECTIVE

To quantify surgical trainees' direct financial impact on an academic medical center (AMC) by modeling the cost of replacing them.

DESIGN

The authors developed a model that estimates the financial costs to an AMC if surgical residents were replaced with surgical first assistants (SFAs) and physician assistants (PAs).

SETTING

One AMC providing tertiary level clinical care.

PARTICIPANTS

The model accounts for the training, work hours, and salary differential of residents, as well as other factors that are specific to education and support of residents, SFAs, and PAs.

RESULTS

After accounting for the expenses of surgical residents and the replacement providers in our model, the authors determined that the net cost of replacing 30 surgical residents with PAs and SFAs at one institution is $1,728,628 or $57,621 annually per resident.

CONCLUSIONS

Without considering other larger and arguably more important issues of educational value or population needs, we provide a reproducible model of financial considerations regarding residents in an AMC. The costs (and foregone benefits) of not training residents may provide additional support for the funding of graduate medical education and finding the optimal balance of graduate medical education and other providers.

Current prescribing practices and guideline concordance for the treatment of uncomplicated urinary tract infections in women

BACKGROUND

Uncomplicated urinary tract infections are one of the most common bacterial infections in the United States. Clinical practice guidelines from the Infectious Diseases Society of America recommend nitrofurantoin, trimethoprim-sulfamethoxazole, and Fosfomycin as first-line antibiotic treatments and discourage the use of fluoroquinolone antibiotic agents. US Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade owing to antibiotic resistance and a high burden of adverse events. Historically, uncomplicated urinary tract infections have high rates of guideline-discordant treatment with past studies noting substantial use of fluoroquinolones, directly contradicting clinical practice guidelines.

OBJECTIVE

This study aimed to assess the current concordance of physician prescribing practices with Infectious Diseases Society of America guidelines for the treatment of uncomplicated urinary tract infections in women and identify patient and physician predictors of guideline concordance.

STUDY DESIGN

A retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, Pennsylvania) National Disease and Therapeutic Index from 2015 to 2019. An estimated 44.9 million women with uncomplicated urinary tract infections at the age of 18 to 75 years were treated as outpatients. This population was selected to lack relevant comorbidities or urological abnormalities so that it matched the Infectious Diseases Society of America guidelines. The proportion of prescriptions for each antibiotic drug class were reported with 95% confidence intervals and compared with the Infectious Diseases Society of America guidelines. Patient and physician characteristics were included in a multivariate logistic regression model to identify independent predictors of antibiotic selection and thereby guideline concordance.

RESULTS

Of the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 million visits of 44.9 million visits) and increased from 48.2% (3.9 million visits of 8.1 million visits) in 2015 to 64.6% (6.3 million visits of 9.8 million visits) in 2019. The most commonly prescribed antibiotic agents were fluoroquinolones (36.4%, 16.3 million visits of 44.9 million visits), nitrofurantoin (31.8%, 14.3 million visits of 44.9 million visits), and trimethoprim-sulfamethoxazole (26.3%, 11.8 million visits of 44.9 million visits). From 2015 to 2019, fluoroquinolone use decreased whereas nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients aged 18 to 29 years (odds ratio, 1.60; 95% confidence interval, 1.36-1.88; P<.001) and 30 to 44 years (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; P=.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment than patients aged 45 to 75 years (reference group). Obstetricians-gynecologists (odds ratio, 3.56; 95% confidence interval, 2.91-4.37; P<.001) and urologists (odds ratio, 3.51; 95% confidence interval, 2.45-5.13; P<.001) had a statistically significantly higher likelihood of concordant treatment than all other specialties combined (reference group).

CONCLUSION

Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotic agents. Although improving, continued misuse of antibiotic agents may contribute to the growing rates of antibiotic resistance. Actions such as educating physicians about antibiotic resistance and clinical practice guidelines and providing feedback on prescription habits are needed to increase guideline concordance and therefore reduce the use of fluoroquinolones, especially for physicians in family and internal medicine.

The age-old question: Thematic analysis of focus groups on physician experiences of aging in emergency medicine

OBJECTIVES

Emergency medicine has a demanding work environment. Characteristics influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) released a policy statement in 2009 suggesting accommodating emergency physicians in preretirement years. We engaged emergency physicians to determine awareness of the ACEP policy and issues faced in preretirement years.

METHODS

We conducted a series of online focus group discussions with a purposive sample of emergency physicians, age ≥ 50 years. The discussion guide was developed from the ACEP policy statement and relevant literature. Groups were audio recorded, transcribed, and analyzed with a thematic coding system developed iteratively by the 4-person team. Emerging themes were identified, organized, and presented with illustrative quotations.

RESULTS

A total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These physicians had between 17 and 35 years of clinical experience (median = 27), 6 were female (21%), and the majority (n = 26, 93%) worked in academic emergency medicine. Only 1 emergency physician was fully aware of the ACEP policy. Three principal content areas were identified: workload demands that change as physicians age, wellness and physician social equity, and senior emergency physician value. Interwoven across all of these was the focus on leadership and solutions to issues. Issues facing emergency physicians in their preretirement years were identified; commitment from emergency medicine site and national leadership and buy-in from junior colleagues was emphasized. Generational conflicts in recognizing the contribution and needs of preretirement emergency physicians was a major barrier to solutions.

CONCLUSIONS

Workload demands, wellness and physician social equity, and concerns about value as a senior physician are major themes confronting preretirement emergency physicians. Generational divides, deficits in local and national leadership, and the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.

Knowledge, attitudes, and practices regarding coccidioidomycosis among healthcare providers in four counties in Washington State, 2017

Coccidioidomycosis is an emerging infection in Washington State. The epidemiology of the disease in Washington is poorly understood at present; underrecognition and underreporting of coccidioidomycosis is suspected based on reports of only severe disease. We sought to characterize healthcare provider knowledge, attitudes, and practices regarding coccidioidomycosis awareness, diagnosis, and treatment in south-central Washington. We conducted a cross-sectional survey of actively practicing healthcare providers in four counties in south-central Washington, an area recently described as endemic for Coccidioides. Survey results were used to assess awareness of reporting requirements, confidence in ability to diagnose and treat, confidence that knowledge is current, calculated knowledge score, and consideration of risk in patient population. The majority of respondents were unaware of the reporting requirement for coccidioidomycosis in Washington and further unaware that the disease had been reported in the state. Less than a third of survey respondents reported confidence in their ability to diagnose coccidioidomycosis and confidence that their knowledge is current. The majority of respondents never or rarely consider a diagnosis of coccidioidomycosis, and <25% of respondents indicated a working knowledge of serologic tests for the infection. The average knowledge score for respondents was 65%. Previous education, training, or practice regarding coccidioidomycosis was the only identified predictor of confidence and consideration of risk. These data indicate the substantial need for education and training among healthcare providers in south-central Washington and support the concern that a small proportion of existing cases of coccidioidomycosis are reported to the health department.

Interested constituents: identifying groups to mobilize in community organizing efforts to strengthen alcohol control policies

Background: Policy support research identifies demographic profiles of those who support policies, but community organizers aim to mobilize groups with an existing structure. Thus, identifying established groups that support alcohol policies may aid organizing efforts.Objective: This paper calculates prevalence and odds of policy support among three potential constituency groups (i.e., religious affiliation, persons harmed by others' drinking, and persons in recovery from alcohol) for three policies: alcohol tax increases, banning alcohol in corner stores, and universal coverage for alcohol treatment.Methods: Using the 2014-15 National Alcohol Survey (n = 3,444; 1,457 male, 1,987 female) and logistic regression, this study explores associations between constituency groups and policy support.Results: Support was higher for the individual-level strategy of alcohol treatment (80.8%) than raising taxes (27.5%) and banning sales in corner stores (52.2%). Support for taxes was higher among persons who valued religion highly (vs not; aOR = 1.46, p < .01), persons harmed by others' drinking (vs not; aOR = 1.71, p < .001), and persons in recovery (vs. not; aOR = 1.76, p = .02); Catholics had lower odds of support for taxes (vs no denomination; aOR = 0.63, p = .01). Persons who valued religion highly (aOR = 1.53, p < .001), Protestants (aOR = 1.63, p < .01), Catholics (aOR = 1.46, p = .03), and persons with other religious denominations (aOR = 2.17, p = .02) had higher odds of supporting bans in corner stores. Only those in recovery showed greater support for treatment (aOR = 3.20, p < .001).Conclusion: Overall, support was lower for population-wide approaches, but results revealed constituency groups that supported these policies. These groups may be allies to organizers who seek to reduce population-level alcohol consumption and harms.

Methods to Mitigate Industry Influence in Industry Sponsored Research

Medical and surgical research has always had a long-standing relationship with industry-based funding from sources, such as drug and device companies. Concerns exist surrounding the association between funding sources, outcome from studies and publication bias. Studies demonstrating increased odds ratios associated with positive results in industry sponsored studies across medicine have stimulated Cochrane reviews, literature reviews and other articles to examine this relationship further. In spine surgery in particular, studies with positive results have an odds ratio of 3.3 of being published. This article discusses the biases associated with industry sponsorship, possible ways to reduce such biases and ways to improve transparency in research relationships. This article explores the types of bias that can be encountered at different stages of research including previous trials in spine surgery. The means of improving transparency including the Physician Payment Sunshine Act of 2010 and International Committee of Medical Journal Editors (ICJME) accreditation are discussed. We recognize that physicians undertaking industry sponsored research should be protected and not be liable to perverse incentives. We conclude that mitigating bias in industry sponsored research is a multistep process and needs a multifaceted approach. The main beneficiary of research should be patients and as such a collective effort from medical professionals, health care institutions, journals and industry should approach research, and publications with that in mind.

Impact of a 50-Year Premedical Postbaccalaureate Program in Graduating Physicians for Practice in Primary Care and Underserved Areas

PURPOSE

To evaluate the effectiveness of Wayne State University School of Medicine's (WSUSOM's) 50-year premedical postbaccalaureate program (PBP)-the first and oldest in the United States-in achieving its goals, as measured by medical school matriculation and graduation, primary care specialization, and current practice location.

METHOD

A retrospective study of a complete comparative dataset of 9,856 WSUSOM MD graduates (1979-2017) was performed in July-August 2018. This included 539 graduates who were admitted to the PBP between 1969 and 2012. Data collected included PBP students' sociodemographics, postgraduate specialization, residence location at time of admission to the PBP, and current medicine practice location. Health professional shortage areas (HPSAs) and medically underserved areas/populations (MUA/Ps) were determined for residence at admission to the PBP and current medicine practice location.

RESULTS

Of the 539 PBP students, 463/539 (85.9%) successfully completed the PBP and matriculated to WSUSOM. Of those, 401/463 (86.6%) obtained an MD, and of those, 233/401 (58.1%) were female and 277/401 (69.1%) were African American. Average investment per PBP student was approximately $52,000 and for an MD graduate was approximately $77,000. The majority of PBP MD graduates with current practice information resided in HPSAs or MUA/Ps at admission to PBP (204/283, 72.1%) and were currently practicing in HPSAs or MUA/Ps (232/283, 82.0%), and 139/283 (49.1%) became primary care physicians (PCPs). Comparison of WSUSOM PBP and non-PBP MD graduates showed PBP physicians become PCPs and practice in HPSAs or MUA/Ps at higher rates than non-PBP physicians (P < .001).

CONCLUSIONS

The PBP was successful in graduating a large proportion of physicians from socioeconomically disadvantaged and diverse backgrounds, who practice as PCPs and who practice in HPSAs and MUA/Ps, thereby accomplishing the PBP's goals of helping to address the broad health care needs of all people in the United States.

Increasing access to medications for opioid use disorder: Policy analysis and proposals

Opioid overdose continues to be the leading cause of accidental death in the United States, and the prevalence of OUD continues to increase. Increased access to health insurance-specifically in regard to state-funded Medicaid programs-as well as robust formularies and limited prior authorization have been demonstrated to be effective both in treating patients with OUD, as well as producing cost savings for government and commercial payors.

Understanding the Impact of COVID-19 on Physician Moms

Objective:

This study evaluates the personal and professional experiences of physician mothers during the coronavirus disease 2019 (COVID-19) pandemic and the impact of the pandemic on the lives of physician mothers.

Methods:

Using social media to reach a broad range of physicians, a convenience sample of physician mothers completed an on-line survey posted between April 27 and May 11. Members were encouraged to repost on social media and share with personal contacts resulting in a passive snowball sampling effect.

Results:

A total of 2709 physician mothers from 48 states, Puerto Rico, and 19 countries representing more than 25 medical specialties completed the survey. Most were between 30 and 39 y of age, 67% self-identified as white, 17% as Asian, 4% as African American. Most had been working for 11-16 y. A total of 91% had a spouse/partner of the opposite sex. Over half were practicing in an area they identified as high COVID-19 density, while 50% had personally cared for a person with COVID-19. Physician mothers were most concerned about exposing their children to COVID-19 and about the morale and safety of their staff.

Conclusions:

This is one of the first studies to explore the personal and professional challenges facing physician mothers during a pandemic. Physician mothers were most concerned about exposing their families to COVID-19. Mothers continued to work and at times increased their work, despite having domestic, childcare, and schooling responsibilities.

Education, Knowledge, and Practice Characteristics of Cannabis Physicians: A Survey of the Society of Cannabis Clinicians

Context: Medical cannabis use has increased in recent years despite being a federally illegal drug in the United States. States with medical cannabis use laws require patients to be certified by physicians. However, little is known about the education, knowledge, and practice characteristics of physicians who recommend and supervise patients' use of medical cannabis. Objective: This study assessed how U.S. physicians who practice cannabis medicine are educated, self-assess their knowledge, and describe their practice. Methods: In fall 2017, a 57-item, electronic survey was sent to all members of the Society of Cannabis Clinicians. Because California has had legalized medical cannabis for longer than any other state, we analyzed responses for 14 items between California and non-California physicians. Results: Of 282 surveyed, 133 were eligible and 45 completed the survey. Of those, multiple medical specialties were represented. Only one physician received education during medical school about cannabis medicine, but physicians gained knowledge through conferences (71%, 32/45), the medical literature (64%, 29/45), and websites (62%, 28/45). Just over half (56%, 20/45) felt that there was sufficient information available to practice cannabis medicine. Of the 37 who answered the knowledge question, most felt knowledgable about cannabinoids (78%, 29/37) and the endocannabinoid system (76%, 28/37). There was a wide variation in the number of cannabis recommendations provided by physicians over the course of their practice career (median 1200; interquartile range, 100-5000), and most provided condition-specific treatment (69%, 31/45) and dosing recommendations (62%, 28/45). The majority (81%, 30/37) of physicians received referrals from mainstream medical providers. No differences were found between California and non-California physicians, except more women were from California (p=0.02). Conclusions: The use of medical cannabis continues to increase in the United States and globally. All states that allow medical cannabis require a physician's recommendation, yet few states require specific clinical training. Findings of this study suggest the need for more formal education and training of physicians in medical school and residency, more opportunities for cannabis-related continuing medical education for practicing physicians, and clinical and basic science research that will inform best practices in cannabis medicine.

Physician death by suicide in the United States: 2012-2016

Reports of incidence of physician suicide in the United States (US) are outdated. The aims of this research were to assess incidence, methods, and associated risk factors of physicians compared to non-physicians in the general US population. Retrospective suicide data (victim age 25 and over) from the 2012-2016 National Violent Death Reporting System were analyzed to test for differences in rates, methods, and risk factors of male and female physicians to non-physicians. The dataset included 498 physician suicides (403 males and 95 females) and 74,420 non-physicians (57,188 males and 17,232 females). No significant difference was found in suicide incidence between gender and age-adjusted physicians vs. non-physicians, though the female physician rate of suicide appeared higher than female non-physicians. The male to female physician ratio of suicide was about 2:1, whereas the ratio in non-physicians was closer to 4:1. Female physicians used poisoning and hanging most often as a method of suicide, where males used firearms. Depressed mood (as perceived by self or others), mental health problems (defined by a diagnosis of depression, a prescribed antidepressants or toxicology report of antidepressants), poor general medical health, and work-related stressors were more frequently associated with physician than with non-physician suicides. In conclusion, results suggest a possible heightened risk to female physicians, which warrants further investigation. Several physician-specific modifiable suicide risk factors present opportunities for prevention.

Characterizing the use of osteopathic manipulative medicine in the obstetric population by trimester and indications for use

Context

Osteopathic manipulative medicine (OMM) has been shown to successfully alleviate some pregnancy-related pain. However, most of the published data focuses on the third trimester and postpartum period or musculoskeletal indications.

Objective

To explore OMM use among obstetrical providers and determine the frequency of use by trimester and by clinical indications across multiple types of women's healthcare practices in Southern and Central Maine.

Methods

An anonymous, 43-item survey, presented in English, was emailed to 172 eligible providers (physicians, nurse practitioners, and certified nurse midwives with obstetrics privileges at one of two main delivery centers in southern and central Maine) via an encrypted database system in January 2018. Follow-up email reminders were sent weekly for three weeks. Questions addressed use of OMM for specific indications, knowledge of OMM, and perceived barriers use of OMM.

Results

The survey response rate was 73 of 172 (42%); 95% of respondents were physicians (n=69). Due to the low response rate of non-physicians, only data from physicians was included in the study. Data were summarized descriptively as frequencies (n [%]). The highest rates of OMM utilization were during the third trimester (35 [51.5%]) and postpartum (41 [60.3%]) periods, while the lowest rates of utilization were in the intrapartum (eight [11.9%]) and first trimester periods (26 [38.3%]). Osteopathic physicians (n=19) used OMM more frequently in the first, second, and third trimesters, as well as the intrapartum period (10 [52.6%]; 11 [57.9%]; 14 [73.7%]; and six [31.6%], respectively) compared with their allopathic physician (n=50) counterparts (nine [8%]; 15 [30%]; 21 [42%]; and two [4%], respectively). While osteopathic physicians reported higher frequencies of OMM use and referral for non-musculoskeletal indications such as constipation, edema, and nasal congestion (13 [68.4%]; 11 [57.9%]; 10 [52.6%], respectively), musculoskeletal complaints were the most frequently cited indication for OMM use among both osteopathic and allopathic physicians (low back, 67 [97.1%]; pelvis, 65 [94.2%]; coccyx, 50 [72.5%]; and head, 49 [71%]).

Conclusion

These results suggest that more education is needed about OMM use in the obstetric population, particularly during early trimesters and the intrapartum period, as well as for visceral and lymphatic complaints of pregnancy.

Feminization of the Rheumatology Workforce: A Longitudinal Evaluation of Patient Volumes, Practice Sizes, and Physician Remuneration

OBJECTIVE

To compare differences in clinical activity and remuneration between male and female rheumatologists and to evaluate associations between physician gender and practice sizes and patient volume, accounting for rheumatologists' age, and calendar year effects.

METHODS

We conducted a population-based study in Ontario, Canada, between 2000 to 2015 identifying all rheumatologists practicing as full-time equivalents (FTEs) or above and assessed differences in practice sizes (number of unique patients), practice volumes (number of patient visits), and remuneration (total fee-for-service billings) between male and female rheumatologists. Multivariable linear regression was used to evaluate the effects of gender on practice size and volume separately, accounting for age and year.

RESULTS

The number of rheumatologists practicing at ≥ 1 FTE increased from 89 to 120 from 2000 to 2015, with the percentage of females increasing from 27.0% to 41.7%. Males had larger practice sizes and practice volumes. Remuneration was consistently higher for males (median difference of CAD $46,000-102,000 annually). Our adjusted analyses estimated that in a given year, males saw a mean of 606 (95% CI 107-1105) more patients than females did, and had 1059 (95% CI 345-1773) more patient visits. Among males and females combined, there was a small but statistically significant reduction in mean annual number of patient visits, and middle-aged rheumatologists had greater practice sizes and volumes than their younger/older counterparts.

CONCLUSION

On average, female rheumatologists saw fewer patients and had fewer patient visits annually relative to males, resulting in lower earnings. Increasing feminization necessitates workforce planning to ensure that populations' needs are met.

Advanced Practice Providers Utilization Trends in Otolaryngology From 2012 to 2017 in the Medicare Population

Objective

Nurse practitioners and physician assistants form a growing advanced practice provider (APP) group. We aim to analyze the trends and types of services provided by APPs in otolaryngology.

Study Design

Cross-sectional study.

Setting

Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use Files, 2012-2017.

Methods

The Medicare database was searched for 13 commonly used otolaryngology-specific Current Procedural Terminology ( CPT) codes, and 10 evaluation and management (E/M) codes were evaluated by provider type. Changes in code utilization were compared between physicians and APPs over time.

Results

From 2012 to 2017, there was a 51% increase in the number of otolaryngology APPs, compared to a 2.2% increase in physician providers. APPs increased their share of new and established patient visits from 4% to 7%d 11% to 15%, respectively. There was not a significant difference over time in number of patient visits performed annually per provider according to provider type. The increase in number of APP vs physician providers was significantly greater for every procedure except for balloon sinus dilation and tympanostomy tube placement.

Conclusion

Due to increasing numbers, APPs are accounting for more patient visits and procedures over time. The physician workforce and the numbers of procedures performed per physician have remained relatively stable from 2012 to 2017. Increasing complexity of patients seen and a broader range of procedures offered by work-experienced or postgraduate-trained APPs may further improve access to health care in the face of possible physician shortages.

Strategies to improve patient care for obstructive sleep apnea: a report from the American Academy of Sleep Medicine Sleep-Disordered Breathing Collaboration Summit

NONE

In Chicago, Illinois, on Saturday, November 10, 2018, the American Academy of Sleep Medicine hosted 35 representatives from 14 medical societies, nurse practitioner associations and patient advocacy groups for a one-day Sleep-Disordered Breathing Collaboration Summit to discuss strategies to improve the diagnosis and treatment of obstructive sleep apnea. This report provides a brief synopsis of the meeting, identifies current challenges, and highlights potential opportunities for ongoing collaboration.

Patterns, contexts, and motivations for polysubstance use among people who inject drugs in non-urban settings in the U.S. Northeast

BACKGROUND

Polysubstance use (i.e., using ≥2 psychoactive substances concomitantly) is associated with increased morbidity and mortality and complicates drug treatment needs among people who inject drugs (PWID). We explored patterns, contexts, motivations, and perceived consequences of polysubstance use among PWID in small cities and towns in the U.S. Northeast.

METHODS

Between October 2018 and March 2019, we conducted semi-structured interviews with 45 PWID living outside of the capital cities of Rhode Island and Massachusetts recruited online and through community-based organizations. Written transcripts were coded inductively and deductively using a team-based approach and analyzed thematically.

RESULTS

All participants reported recent polysubstance use, with most using five or more classes of substances in the past three months. Polysubstance use often followed long personal drug use histories (i.e., years or decades of occasional drug use). Reasons for polysubstance use included obtaining synergistic psychoactive effects as a result of mixing drugs (i.e., using drugs to potentiate effects of other drugs) and managing undesirable effects of particular drugs (e.g., offsetting the depressant effects of opioids with stimulants or vice-versa). Polysubstance use to self-medicate poorly managed physical and mental health conditions (e.g., chronic pain, anxiety, and depression) was also reported. Inadequately managed cravings and withdrawal symptoms prompted concomitant use of heroin and medications for opioid use disorder, including among individuals reporting cocaine or crack as their primary "issue" drugs. Polysubstance use was perceived to increase overdose risks and to be a barrier to accessing healthcare and drug treatment services.

CONCLUSION

Healthcare services and clinicians should acknowledge, assess, and account for polysubstance use among patients and promote harm reduction approaches for individuals who may be using multiple drugs. Comprehensive healthcare that meets the social, physical, mental health, and drug treatment needs of PWID may decrease the perceived need for polysubstance use to self-medicate poorly managed health conditions and symptoms.

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic.

Comparison of Number and Geographic Distribution of Pediatric Subspecialists and Patient Proximity to Specialized Care in the US Between 2003 and 2019

IMPORTANCE

Geographic proximity to a pediatric subspecialist is a key factor in obtaining specialized care. However, comparative data regarding the number of pediatric subspecialists, distribution of subspecialists, and patient proximity to subspecialists in the United States between 2003 and 2019 have not been explored; the last known national analysis was published in 2006 and used data from 2003.

OBJECTIVE

To compare the number and distribution of pediatric subspecialists and patient proximity to pediatric subspecialists in the United States between 2003 and 2019 and to assess whether the increase in the number of pediatric subspecialists is associated with improvements in patient proximity to specialized care and the geographic distribution of pediatric subspecialists.

DESIGN, SETTING, AND PARTICIPANTS

This national repeated cross-sectional study used data from the American Board of Pediatrics to examine the overall change in the number of subspecialists for 20 pediatric subspecialties between 2003 and 2019. The study included 24 375 pediatric subspecialists who were 70 years or younger, had active certification from the American Board of Pediatrics as of June 2019, and had addresses in the United States. Subspecialists' addresses were linked by zip code to child population data to evaluate the geographic distribution of subspecialists, the population-weighted averages for service areas, and the straight-line distances to subspecialists. Descriptive statistics and maps were used to examine patient proximity to subspecialists and regional subspecialist distribution and dispersion by hospital referral region. Subspecialist-to-child population ratios per 100 000 children, changes over time, and coefficients of variation were calculated to further elucidate subspecialist distribution. Data were collected in June 2019 and analyzed from July 8, 2019, to December 17, 2019.

MAIN OUTCOMES AND MEASURES

Values from 2019 were compared with data from 2003 for mean straight-line distance in miles from patients to subspecialists, by subspecialty; percentage of children younger than 18 years living at specific distance ranges; subspecialist-to-child population ratios across hospital referral regions; and coefficients of variation for population ratios.

RESULTS

Among 24 375 pediatric subspecialists 70 years and younger, 23 436 subspecialists were certified in 1 subspecialty, and 939 subspecialists were certified in more than 1 subspecialty. The number of certified pediatric subspecialists in the United States increased by 76.8% between 2003 and 2019, with increases varying across subspecialties. The estimated means for travel distances decreased among all subspecialties; however, depending on the subspecialty, an estimated 1 million to 39 million children (2%-53%) resided 80 miles or more from a subspecialist. An analysis across hospital referral regions indicated increased subspecialist-to-child ratios and an increased number of regions with a subspecialist but continued wide variation across regions for most subspecialties. Eleven subspecialties had 1 or fewer subspecialists per 100 000 children across hospital referral regions.

CONCLUSIONS AND RELEVANCE

Although patient proximity to pediatric subspecialty care has improved nationally, substantial distribution gaps among specific subspecialties remain. Long-term solutions that encourage movement of subspecialists to underserved locations or that extend the practice of current subspecialties may warrant consideration, particularly among subspecialties with a limited number of practitioners.

An Investigation of the Relationship Between COMLEX-USA Licensure Examination Performance and State Licensing Board Disciplinary Actions

PURPOSE

Passing the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) serves as a licensing requirement, yet there is limited understanding between this high-stakes exam and performance outcomes. This study examined the relationship between COMLEX-USA scores and disciplinary actions received by osteopathic physicians.

METHOD

Data for osteopathic physicians (N = 26,383) who graduated from medical school between 2004 and 2013 were analyzed using multinomial logistic regression to assess the relationship between COMLEX-USA scores and placement into one of 3 disciplinary action categories relative to no action received, controlling for years in practice and gender.

RESULTS

Less than 1% of physicians in this study (n = 187) had a disciplinary action(s). Controlling for all COMLEX-USA levels, years in practice, and gender, higher Level 3 scores were associated with significant decreased odds for all action categories: revoked licensed (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.36, 0.72; P < .001), imposed limitations to practice (OR = 0.59, 95% CI 0.41, 0.84; P < .01), and other action imposed (OR = 0.48, 95% CI 0.33, 0.69; P < .001), relative to not receiving an action. In these same models, higher Level 2 Performance Evaluation Biomedical/Biomechanical Domain scores decreased the odds for an action that revoked a license (OR = 0.75, 95% CI 0.58, 0.98; P < .05) and imposed limitations to practice (OR = 0.64, 95% CI 0.49, 0.84; P < .001).

CONCLUSIONS

These findings provide evidence that the COMLEX-USA delivers useful information regarding the likelihood of a practitioner receiving state board disciplinary actions.

Gender Differences Among Academic Pediatric Radiology Faculty in the United States and Canada

OBJECTIVE

It is currently unknown whether efforts in recent years to create equal opportunities for female faculty in academic medicine have succeeded. We looked at faculty members in academic pediatric radiology departments across the United States and Canada to assess for evidence of gender disparities and differences in academic performance between males and females.

METHODS

The analysis included diagnostic radiology programs across the United States and Canada, as specified by the American Medical Association's Fellowship and Residency Electronic Interactive Database (FREIDA Online) and the Canadian Resident Matching Service website. The Scopus database was used to retrieve the H-index, number of publications, and number of citations for each faculty member. We examined the distribution of male and female faculty members across geographical regions, academic ranks, and leadership roles. Academic performance was also compared.

RESULTS

Across all regions and academic ranks, disparities exist between the number of male and female faculty members. The greatest disparity was found amongst the professor rank, where more than 70% of positions were occupied by males. Female professors were found to demonstrate similar levels of academic performance compared to their male counterparts, although this parity was not observed amongst assistant and associate professors.

CONCLUSION

Women occupied almost half (46.6%) of the total academic pediatric radiology workforce, despite having been previously shown to make up only 21% of radiologists. However, gender disparities currently exist among academic pediatric radiology faculty, with a significantly higher percentage of men in pediatric radiology faculty positions. Women, however, currently occupy a greater percentage of leadership positions compared to men, even though the majority of senior academic ranks are held by men.

Issues Faced by Senior Women Physicians: A National Survey

Background: As the first large numbers of female physicians complete their careers, information is needed to enable institutions and individuals to optimize the final career phase and transition to retirement of these women, as well as to help younger women physicians prepare for later phases of their careers. Materials and Methods: To identify the leading issues for older female physicians, a 34-item electronic questionnaire covering heath, finances, preparation for and attitudes about retirement, caretaking responsibilities, life-work integration, various aspects of discrimination and harassment, professional isolation, and work-related stress and burnout-incorporating standardized measures of career satisfaction was distributed through the Kansas Medical Society and nationally through the American Medical Association Senior Physicians Section newsletter to female physicians older than 60 years in 2018. A total of 155 physicians self-identified as eligible and completed at least half of the survey. Results: Respondents were 60-87 years of age, mean 70.4 (±6.4) years. The majority reported good health and being financially well prepared for retirement. Twenty percent were caretakers for grandchildren, parents, or spouses. Measures of career and job satisfaction were reasonably high, despite negative work environment and burnout scores. Problems with family/career balance, age- and gender-based discrimination and harassment, salary inequity, and professional isolation persisted throughout their careers, but diminished in frequency for senior women. Conclusions: Issues faced by younger women physicians do not disappear with age or seniority. To recruit and support female physicians, issues such as balancing family/work responsibilities, combating harassment and bias, and promoting healthy work environments must be addressed throughout their entire careers.

Changes in Working Conditions and Mental Health Among Intensive Care Physicians Across a Decade

Background: International studies have shown that among physicians working in intensive care, a relatively high level of work load, an elevated risk of developing burnout and reduced mental health are frequent. The implementation of a legislative intervention in Germany with the goal to reduce the working hours of physicians, offered an opportunity to investigate the potential influence of occupational conditions on stress and mental health. The present study investigates working conditions, occupational stress and burnout risk in two samples of German Intensive Care Physicians in 2006 and 2016. The aim was to assess how occupational and private stress factors influenced burnout and Effort-Reward-Imbalance indices over this time-period. Methods: Intensive care physicians were surveyed during the annual conference of their profession in two cross-sectional studies (10-year gap). Data on demographic (occupational, family), medical history, and mental health (burnout and Effort-Reward-Imbalance) were assessed by paper pencil questionnaires. Results: In total, N = 2,085 physicians participated (2006: N = 1,403, 2016: N = 695), with N = 1,840 (2006 = 1,248; 2016 = 592) eligible for propensity score matching comparison. In general, more working hours per week and working days on weekends were associated with an increased effort/reward imbalance and higher burnout scores. From 2006 to 2016, reductions in working hours per week and days worked on weekends were accompanied by improvements in occupational stress (Effort-Reward-Imbalance) and by trend in mental health indices (burnout) after matching for differences in working conditions. Conclusions: The study presents the changes concerning occupational stress factors and mental wellbeing in physicians working in intensive care in 2016 as compared to 2006. These findings may promote the implementation of preventive strategies in the vocational context to protect health and productivity of physicians, especially intensive care physicians.

Differences between Licensed Healthcare Professionals with Substance Use-Related Licensure Discipline

Substance Use Disorder (SUD) is a significant public health concern in the United States and healthcare providers are not immune to this disease. The potential for patient harm presented by an impaired provider is the reason SUD in licensed healthcare professionals is a regulatory issue. Aim: This research study seeks to identify the differences in the disciplinary action taken among pharmacists, physicians, and nurses (LPN & RN) in 24 states. Methods: A retrospective secondary data analysis was performed using the public use data file of the National Practitioner Data Bank (NPDB). Inclusion data were grouped and recoded to analyze using Chi-square to compare differences between groups. Results: Nurses are revoked and fined at much higher rates than medicine. Nurses and pharmacists are placed on probation at higher rates than medicine, and medicine was censured more than their nursing and pharmacy colleagues. Conclusions: Licensed healthcare professionals are punished differently for similar SUD-related offenses. Further research should explore these differences to identify evidenced based ways to protect the public while assisting this special at-risk population to recover from SUD.

Teaching Millennials and Generation Z

Each generation is defined not solely by the date of their birth, but also for their beliefs, their priorities, and their motivations. Many factors play heavily into the development of each generation's collective identify, including parenting styles, significant political and current events, changing gender roles, and other formative experiences. These factors significantly and uniquely influence how each generation lives, learns, and interacts with others (Gerhardt, 2016). While most medical educators today are baby boomers, the majority of medical students are millennial and generation Z individuals, who communicate, learn, and interact very differently than their instructors. As a result, effective medical educators are challenged to update their methods of instruction to best suit these newer generations of learners for better assimilation, clinical application, and long-term retention of material, to maintain delivery of high-quality healthcare in the country for future generations (Desy et al., 2017; Waljee, 2018).

Language of written medical educational materials for non-English speaking populations: an evaluation of a simplified bi-lingual approach

BACKGROUND

Debates have arisen in various non-English speaking countries over the chosen language of instruction in medical education, whether it has to be the English language or the mother tongue. English-based education supporters argue that English is the leading international language of medicine and research, and a crucial tool for Continuing Medical Education (CME), as well as for students who seek practice abroad. On the other hand, mother-tongue-based medical education supporters present it as a way to endorse communication and comprehension between medical practitioners and health care system users, to bridge the gap between practitioners and the paramedical staff, and to overcome linguistic dualism and the language thinking disparity while studying in another. This study aimed to evaluate one of the simplified bi-lingual approaches in terms of medical-educational-written texts for a non-English speaking population: Arabic speaking medical students in specific.

METHODS

1546 Arabic-speaking-medical students from different countries participated in a one-step-interactive-experimental-online test. The test assessed participants' scientific comprehension of three distinct written paragraphs: The first paragraph used conventional mother tongue (Arabic), the second combined English terminology and simplified mother tongue (hybrid), and the third used an English excerpt (English). Two multiple-choice questions (First question in Arabic, second in English) followed each paragraph. Response time was communicated for each paragraph. Participants were asked to select their favorable method. Repeated Measures ANOVA models and Paired Samples t-Test were used for statistical analysis.

RESULTS

Participants scored a mean of [0.10] for the Arabic paragraph, [0.72] for the hybrid paragraph, and [0.24] for the English paragraph (P <  0.001). Results showed a significantly higher mean of points and correct answers within the fastest time for the hybrid paragraph [0.68] compared to the Arabic [0.08] and English [0.18] paragraphs (P <  0.001). Moreover, 50% of participants preferred the hybrid paragraph over the other two paragraphs.

CONCLUSIONS

Taking into consideration the large number of participants and the statistically significant results, authors propose that simplified Arabic combined with English terminology may present a viable alternative method for medical-educational-written texts in Arabic-speaking population.

Navigating Tumultuous Change in the Medical Profession: The Coalition for Physician Accountability

Collaboration among the national organizations responsible for self-regulation in medicine in the United States is critical, as achieving the quadruple aim of enhancing the patient experience and improving population health while lowering costs and improving the work life of clinicians and staff is becoming more challenging. The leaders of the national organizations responsible for accreditation, assessment, licensure, and certification recognize this and have come together as the Coalition for Physician Accountability. The coalition, which meets twice per year, was created in 2011 as a discursive space for group discussion and action related to advancing health care, promoting professional accountability, and improving the education, training, and assessment of physicians. The coalition offers a useful avenue for members to seek common ground and develop constructive, thoughtful solutions to common challenges. Its members have endorsed consensus statements about current topics relevant to health care regulation, advanced innovation in medical school curricula, encouraged a plan for single graduate medical education accreditation for physicians holding MD and DO degrees, supported interprofessional education, championed opioid epidemic mitigation strategies, and supported initiatives responsive to physician workforce shortages, including the Interstate Medical Licensure Compact, an expedited pathway by which eligible physicians may be licensed to practice in multiple jurisdictions.

FSMB Census of Licensed Physicians in the United States, 2018

There are 985,026 physicians with Doctor of Medicine (MD) and Doctor of Osteopathic Medicine (DO) degrees licensed to practice medicine in the United States and the District of Columbia, according to physician census data compiled by the Federation of State Medical Boards (FSMB). These qualified physicians graduated from 2,089 medical schools in 167 countries and are available to serve a U.S. national population of 327,167,434. While the percentage of physicians who are international medical graduates have remained relatively stable over the last eight years, the percentage of physicians who are women, possess a DO degree, have three or more licenses, or are graduates of a medical school in the Caribbean have increased by varying degrees during that same period.

This report marks the fifth biennial physician census that the FSMB has published, highlighting key characteristics of the nation's available physician workforce, including numbers of licensees by geographic region and state, type of medical degree, location of medical school, age, gender, specialty certification and number of active licenses per physician. The number of licensed physicians in the United States has been growing steadily, due in part to an expansion in the number of medical schools and students during the past two decades, even as concerns of a physician shortage to meet health care demands persist. The average age of licensed physicians continues to increase, and more licensed physicians appear to be specialty certified, though the latter finding may reflect more comprehensive reporting. This census was compiled using the FSMB's Physician Data Center (PDC), which collects, collates and analyzes physician data directly from the nation's state medical and osteopathic boards and is uniquely positioned to provide a comprehensive snapshot of information about licensed physicians. A periodic national census of this type offers useful demographic and licensure information about the available physician workforce that may be useful to policy makers, researchers and related health care organizations to better understand and address the nation's health care needs.

Consolidation Trends In California's Health Care System: Impacts On ACA Premiums And Outpatient Visit Prices

California has heavily concentrated hospital, physician, and health insurance markets, but their current structure and functioning is not well understood. We assessed consolidation trends and performed an analysis of "hot spots"-markets that potentially warrant concern and scrutiny by regulators in terms of both horizontal concentration (such as hospital-hospital mergers) and vertical integration (hospitals' acquisition of physician practices). In 2016, seven counties were high on all six measures used in our hot-spot analysis (four horizontal concentration and two vertical integration measures), and five counties were high on five. The percentage of physicians in practices owned by a hospital increased from about 25 percent in 2010 to more than 40 percent in 2016. The estimated impact of the increase in vertical integration from 2013 to 2016 in highly concentrated hospital markets was found to be associated with a 12 percent increase in Marketplace premiums. For physician outpatient services, the increase in vertical integration was also associated with a 9 percent increase in specialist prices and a 5 percent increase in primary care prices. Legislative proposals, actions by the state's attorney general, and other regulatory changes are suggested.

From helices to health: undergraduate medical education in genetics and genomics

Rapid advances in genomic technologies combined with drastic reductions in cost and a growing number of clinical genomic tests are transforming medical practice. While enthusiasm about applications of precision medicine is high, the existing clinical genetics workforce is insufficient to meet present demands and will fall increasingly short as the use of genetic and genomic testing becomes more routine. To address this shortage, physicians in all areas of medicine will require genomic literacy. Undergraduate medical students, therefore, need a solid foundation in genetics and genomics so they can apply genomic medicine across a range of specialties. Here, we review the current trends and challenges in undergraduate medical genetics education in North America, highlight innovations and offer recommendations.

The Role and Value of Public Members in Health Care Regulatory Governance

American medicine has progressively embraced transparency and accountability in professional self-regulation. While public members serving on health care regulatory boards involved with the accreditation, assessment, certification, education, and licensing of physicians provide formal opportunities for voicing public interests, their presence has not been deeply explored. Using 2016 survey and interview data from health care organizations and public members, the authors explore the value and challenges of public members. Public members were often defined as individuals who did not have a background in health care and provided a patient perspective, but in some instances prior health care experience did not automatically exclude these individuals from serving as public members. Public members served on the majority of national health care regulatory boards and constituted an average 9% to 15% of board composition, depending on how rigidly the organizations defined "public member." Public members were valued for their commitment to the priorities and interests of the public, ability to help boards maintain that public focus, and various professional skills they offer to boards. A main challenge that public members faced was their lack of familiarity with and knowledge of the health care field. The authors suggest several considerations for improved public member integration into health care regulatory organizations: clearly defined roles of public members, including evaluating whether or not previous health care experience either contributes or hinders their role within the organization; greater visibility of opportunities for the public to serve on these boards; and potentially a more intensive orientation for public members.

United States Physician Preferences Regarding Healthcare Financing Options: A Multistate Survey

Background: Not much is currently known about United States (US) physicians’ opinions about healthcare financing, specifically subsequent to the creation and implementation of the Affordable Care Act (ACA). Objectives: A four state survey of practicing US based physicians’ opinions about healthcare financing following ACA passage and implementation. Methods: Physician leaders practicing in the state of New York, Texas, Colorado and Mississippi were surveyed. Two factor analyses (FA) were conducted to understand the underlying constructs. Results: We determined the final response rate to be 26.7% after adjusting it for a variety of factors. Most physicians favored either a single payer system (43.8%) or individualized insurance coverage using health savings accounts (33.2%). For the single-payer system, FA revealed two underlying constructs: System orientation (how the physicians perceived the impact on the healthcare system or patients) and individual orientation (how the physicians perceived the impact on individual physicians). Subsequently, we found that physicians who were perceived neutral in their attitudes towards physician-patient relationship and patient conflict were also neutral in reference to system orientation and individual orientation. Physicians who were perceived as stronger on the physician-patient relationship were more supportive of a single-payer system. Conclusion: This study brings attention to the paradox of social responsibility (to provide quality healthcare) and professional autonomy (the potential impact of a healthcare financing structure to negatively affect income and workload). Efforts to further reform healthcare financing and delivery in the US may encounter resistance from healthcare providers (physicians, mid-level prescribers, pharmacists, or nurses) if the proposed reform interferes with their professional autonomy.

Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2018

This study was conducted to identify the approximate number and density of actively licensed acupuncturists, as well as the number of schools in acupuncture and oriental medicine (AOM) by January 1, 2018 in the United States (U.S.). We contacted the appropriate department governing acupuncturists, such as the Board of Acupuncture or Board of Medicine, etc. in each state and U.S. territories, to collect the data. We also conducted online license information searches in order to collect the most accurate numbers of licensed acupuncturists, especially for those states in which a board could not be reached. We found that the number of actively licensed acupuncturists as of January 1, 2018 in the U.S. was 37,886. The ten states with the largest number of acupuncturists (28,452 or 75.09% of the U.S. total), in order by total, included California, New York, Florida, Colorado, Washington, Oregon, Texas, New Jersey, Maryland and Massachusetts. The number of practitioners was greater than 1000 for each of these states. Among them, the largest three were California (12,135; 32.03%), New York (4438; 11.71%) and Florida (2705; 7.13%). These three states accounted for more than half of the overall total. The number of total licensed acupuncturists has increased 257% since 1998. The overall acupuncturist density in the U.S. - measured as number of acupuncturists per 100,000 - was 11.63 (total number of licensed acupuncturists: 37,886, divided by the total population: 325,719,178 at the start of 2018). There were 20 states with an acupuncturist density of more than 10 per 100,000 population. Hawaii (52.82) was the highest, followed by Oregon (34.88), Vermont (30.79), California (30.69) and then New Mexico (30.27). There were 62 active, accredited AOM schools which altogether offered 100 programs: 32 master degrees in Acupuncture, 53 master degrees in Oriental medicine, 13 postgraduate doctorate degrees and 2 entry-level doctorate degrees. Among these active accredited schools, institutions in the West and East Coast states comprised 77.42% of the national total. California, Florida, and New York represented 41.94%. There were 48 jurisdictions (47 States and the District of Columbia) with acupuncture practice laws in place. States without acupuncture laws included Alabama, Oklahoma and South Dakota. The data suggests that acupuncture profession has steadily grown in the United States.

Graphicle: Exploring Units, Networks, and Context in a Blended Visualization Approach

Many real-world datasets are large, multivariate, and relational in nature and relevant associated decisions frequently require a simultaneous consideration of both attributes and connections. Existing visualization systems and approaches, however, often make an explicit trade-off between either affording rich exploration of individual data units and their attributes or exploration of the underlying network structure. In doing so, important analysis opportunities and insights are potentially missed. In this study, we aim to address this gap by (1) considering visualizations and interaction techniques that blend the spectrum between unit and network visualizations, (2) discussing the nature of different forms of contexts and the challenges in implementing them, and (3) demonstrating the value of our approach for visual exploration of multivariate, relational data for a real-world use case. Specifically, we demonstrate through a system called Graphicle how network structure can be layered on top of unit visualization techniques to create new opportunities for visual exploration of physician characteristics and referral data. We report on the design, implementation, and evaluation of the system and effectiveness of our blended approach.

Geographic Variation in the Supply of Selected Behavioral Health Providers

INTRODUCTION

In 2015, an estimated 43.4 million Americans aged 18 and older suffered from a behavioral health issue. Accurate estimates of the number of psychiatrists, psychologists, and psychiatric nurse practitioners are needed as demand for behavioral health care grows.

METHODS

The National Plan and Provider Enumeration System National Provider Identifier data (October 2015) was used to examine the supply of psychiatrists, psychologists, and psychiatric nurse practitioners. Providers were classified into three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). Claritas 2014 U.S. population data were used to calculate provider-to-population ratios for each provider type. Analysis was completed in 2016.

RESULTS

Substantial variation exists across Census Divisions in the per capita supply of psychiatrists, psychologists, and psychiatric nurse practitioners. The New England Census Division had the highest per capita supply and the West South Central Census Division had among the lowest supply of all three provider types. Nationally, the per capita supply of these providers was substantially lower in non-metropolitan counties than in metropolitan counties, but Census Division disparities persisted across geographic categories. There was a more than tenfold difference in the percentage of counties lacking a psychiatrist between the New England Census Division (6%) and the West North Central Census Division (69%). Higher percentages of non-metropolitan counties lacked a psychiatrist.

CONCLUSIONS

Psychiatrists, psychologists, and psychiatric nurse practitioners are unequally distributed throughout the U.S. Disparities exist across Census Divisions and geographic categories. Understanding this unequal distribution is necessary for developing approaches to improving access to behavioral health services for underserved populations.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.