Navigating Minority and Gender Discrimination, Substance Use Disorder, Financial Distress, and Workplace Politics: Lessons for Work-Life Wellness in Academic Medicine: Part 2 of 3

In this second of three manuscripts addressing a range of complex work and personal issues, the authors explore case scenarios with characters who work in the fields of general surgery, orthopedic surgery, anesthesiology, neurology, radiology, and otolaryngology. The medical specialty identifiers help inform some baseline understanding of the demands of that particular profession but are less pertinent than the specifics of each case. In this manuscript, the authors dive into the topics of navigating a lawsuit and professional burnout, personal finances, substance use disorder, demands of clinical work and workplace politics, diversity and inclusion, and dealing with major personal illness. The authors provide practical steps to help the readers deal with similar situations and provide insight to support persons on how to improve support structures.

Lessons From the Northeast COVID-19 Surge: Well-Being of the Health Care Workforce

The COVID-19 pandemic has had an unprecedented impact on the US health care system which was already experiencing higher levels of personal burnout among health care workers than the average US worker. Well-being efforts to support the workforce have become a critical countermeasure during the pandemic. This work was presented at the Thomas Jefferson University, College of Population Health Seminar Series: Clinical Lessons from the Northeast Surge, COVID-19: Spread the Science, not the Virus, held August 18, 2020. The entire series was held virtually from July 21 to September 29, 2020. The authors describe issues impacting health care workers during this early period of the pandemic with two examples of concrete strategies to approach well-being at the organizational level and lessons learned.

Innovative Wellness Models to Support Advancement and Retention Among Women Physicians

Despite improvements in representation of women in academic medicine, the rate of promotion and career advancement remains unequal. Compared with their male colleagues, women report lower rates of personal-organizational value alignment and higher rates of burnout. Particular challenges further exist for Black women, Indigenous women, women of color, and third gender or gender nonbinary faculty. Promoting the well-being of women physicians requires innovative approaches beyond the traditional scope of physician well-being efforts and careful attention to the unique barriers women face. Three wellness-oriented models are presented to promote the professional fulfillment and well-being of women physicians: (1) redefine productivity and create innovative work models, (2) promote equity through workplace redesign and burnout reduction, and (3) promote, measure, and improve diversity, equity, and inclusion. By engaging in innovative models for equitable advancement and retention, it is anticipated that diverse groups of women faculty will be better represented at higher levels of leadership and thus contribute to the creation of more equitable work climates, fostering well-being for women physicians.

The Evolving Role of the Chief Wellness Officer in the Management of Crises by Health Care Systems: Lessons from the Covid-19 Pandemic

Even before the onset of the Covid-19 pandemic, clinician burnout was a recognized occupational syndrome and a driver of suboptimal patient care. National calls for system-level interventions to improve clinician well-being led some health care organizations (HCOs) to appoint a Chief Wellness Officer (CWO). By incorporating CWOs into the emergency command structure, these HCOs were equipped to identify and address health care worker needs throughout the pandemic. CWOs learned important lessons regarding how HCOs can best address workforce well-being in the midst of a crisis. Key CWO contributions include identifying evolving sources of worker anxiety, deploying support resources, participating in operational decision-making, and assessing the impact of fluid pandemic protocols on clinician well-being. As HCOs seek to promote posttraumatic growth, attention to the well-being of the workforce should be incorporated into emergency management protocols with the goal of sustaining a resilient health care workforce.

Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors

IMPORTANCE

Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error.

OBJECTIVE

To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study.

EXPOSURES

Sleep-related impairment.

MAIN OUTCOMES AND MEASURES

Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection.

RESULTS

Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r = 0.51; P < .001), work exhaustion (r = 0.58; P < .001), and overall burnout (r = 0.59; P < .001) were large. Sleep-related impairment correlation with professional fulfillment (r = -0.40; P < .001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively.

CONCLUSIONS AND RELEVANCE

In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.

Organizational strategies to reduce physician burnout and improve professional fulfillment

Burnout is highly prevalent among physicians and has been associated with negative outcomes for physicians, patients, staff, and health-care organizations. Reducing physician burnout and increasing physician well-being is a priority. Systematic reviews suggest that organization-based interventions are more effective in reducing physician burnout than interventions targeted at individual physicians. This consensus review by leaders in the field across multiple institutions presents emerging trends and exemplary evidence-based strategies to improve professional fulfillment and reduce physician burnout using Stanford's tripartite model of physician professional fulfillment as an organizing framework: practice efficiency, culture, and personal resilience to support physician well-being. These strategies include leadership traits, latitude of control and autonomy, collegiality, diversity, teamwork, top-of-license workflows, electronic health record (EHR) usability, peer support, confidential mental health services, work-life integration and reducing barriers to practicing a healthy lifestyle. The review concludes with evidence-based recommendations on establishing an effective physician wellness program.

Climate research priorities for policy-makers, practitioners, and scientists in Georgia, USA

Climate change has far-reaching effects on human and ecological systems, requiring collaboration across sectors and disciplines to determine effective responses. To inform regional responses to climate change, decision-makers need credible and relevant information representing a wide swath of knowledge and perspectives. The southeastern U. S. State of Georgia is a valuable focal area for study because it contains multiple ecological zones that vary greatly in land use and economic activities, and it is vulnerable to diverse climate change impacts. We identified 40 important research questions that, if answered, could lay the groundwork for effective, science-based climate action in Georgia. Top research priorities were identified through a broad solicitation of candidate research questions (180 were received). A group of experts across sectors and disciplines gathered for a workshop to categorize, prioritize, and filter the candidate questions, identify missing topics, and rewrite questions. Participants then collectively chose the 40 most important questions. This cross-sectoral effort ensured the inclusion of a diversity of topics and questions (e.g., coastal hazards, agricultural production, ecosystem functioning, urban infrastructure, and human health) likely to be important to Georgia policy-makers, practitioners, and scientists. Several cross-cutting themes emerged, including the need for long-term data collection and consideration of at-risk Georgia citizens and communities. Workshop participants defined effective responses as those that take economic cost, environmental impacts, and social justice into consideration. Our research highlights the importance of collaborators across disciplines and sectors, and discussing challenges and opportunities that will require transdisciplinary solutions.

Emergency Physicians Who Produce Higher Relative Value Units Per Hour Spend Similar Amounts of Time at Patient Bedsides as Their Colleagues

BACKGROUND

Emergency physicians (EPs) are expected to deliver quality care while maintaining high levels of efficiency and productivity as measured by the relative value unit (RVU).

OBJECTIVES

We sought to determine whether academic EPs with higher RVUs spend less time at the bedside than their colleagues.

METHODS

This was a prospective, observational, cohort study. A 13-item task list was generated, pilot-tested, and placed onto a computerized tablet.

RESULTS

There was no difference among EPs in terms of time spent at bedside, 26.7% of total time, 17.31 min (95% confidence interval [CI] 14.43-20.19), p = 0.052; resident interaction 13.1%, 8.46 min (95% CI 4.68-12.25), p = 0.959; charting, 11.1%, 7.17 min (95% CI .746-5.65), p = 0.055; information search, 10.5%, 6.80 min (95% CI 0.84-8.52), p = 0.320; walking, 9.0%, 5.86 min (95% CI 5.17-6.54), p = 0.112; consultant interaction, 8.2%, 5.28 min (95% CI 3.18-7.40), p = 0.404; writing orders, 6.5%, 4.19 min (95% CI 3.22-5.15), p = 0.109; nursing interaction, 5.6%, 3.65 min (95% CI 2.54-4.76), p = 0.260; other, 5.2%, 3.65 min (95% CI 1.76-5.02), p = 0.785; medical student interaction, 4.2%, 2.75 min (95% CI 0.53-4.97), p = 0.102; physician assistant interaction, 2.8%, 1.79 min (95% CI 1.08-2.50), p = 0.959; clerical interaction, 1.7%, 1.13 min (95% CI .69-1.57), p = 0.335; and electrocardiogram interpretation, 0.7%, 0.45 min (95% CI .32-.58), p = 0.793.

CONCLUSIONS

Despite differences in RVU-based productivity data, academic EPs spend similar amounts of time involved in the daily tasks of taking care of patients, underscoring that direct physician-patient interaction is one practice parameter that is not compromised among these EPs.

Patient satisfaction surveys and quality of care: an information paper

With passage of the Patient Protection and Affordable Care Act of 2010, payment incentives were created to improve the "value" of health care delivery. Because physicians and physician practices aim to deliver care that is both clinically effective and patient centered, it is important to understand the association between the patient experience and quality health outcomes. Surveys have become a tool with which to quantify the consumer experience. In addition, results of these surveys are playing an increasingly important role in determining hospital payment. Given that the patient experience is being used as a surrogate marker for quality and value of health care delivery, we will review the patient experience-related pay-for-performance programs and effect on emergency medicine, discuss the literature describing the association between quality and the patient-reported experience, and discuss future opportunities for emergency medicine.

Benign nuchal rigidity: the emergency department evaluation of acute prevertebral calcific tendonitis

Acute prevertebral calcific tendonitis (APCT) is a rare condition, the exact incidence of which is unknown. It is of particular interest to the emergency physician owing to the other potentially devastating conditions in the differential diagnosis of neck stiffness and/or odynophagia (including retropharyngeal abscess, infectious spondylitis, and meningitis.) In contrast, APCT has a benign clinical course and can be easily managed in the emergency department. We will present a case of APCT, followed by a brief discussion of the disease and current literature.

Achieving efficiency in crowded emergency departments: a research agenda

In 2011, Academic Emergency Medicine convened a consensus conference entitled "Interventions to Assure Quality in the Crowded Emergency Department." This article, a product of the breakout session on "interventions to safeguard efficiency of care," explores various elements of the research agenda on efficiency and quality in crowded emergency departments (EDs). The authors discuss four areas identified as critical to achieving progress in the research agenda for improving ED efficiency: 1) What measures can be used to understand and improve the efficiency and quality of interventions in the ED? 2) Which factors outside of the ED's control affect ED efficiency? 3) How do workforce factors affect ED efficiency? 4) How do ED design, patient flow structures, and use of technology affect efficiency? Filling these knowledge gaps is vital to identifying interventions that improve the delivery of emergency care in all EDs.

Emergency severity index triage system correlation with emergency department evaluation and management billing codes and total professional charges

OBJECTIVES

All services provided by physicians to patients during an emergency department (ED) visit, including procedures and "cognitive work," are described by common procedural terminology (CPT) codes that are translated by coders into total professional (physician) charges for the visit. These charges do not include the technical (facility) charges. The objectives of this study were to characterize associations between Emergency Severity Index (ESI) acuity level, ED Evaluation and Management (E&M) billing codes 99281-99285 and 99291, and total ED provider charges (sum of total procedure and E&M professional charges). Secondary objectives were to identify factors that might affect these associations and to evaluate the performance of ESI and identified variables to predict E&M code and average total professional charges.

METHODS

The authors reviewed 276,824 patient records for calendar year 2007, of which 193,952 adult ED visits from three different ED types (community, university-based academic, and non-university-based academic) met inclusion criteria. Correlations between 1) ESI level and E&M billing code per visit by institution and 2) ESI and total professional charges were analyzed using Spearman rank correlation. Linear regression analysis was performed to identify variables that significantly affected these correlations.

RESULTS

ESI level and E&M codes were moderately correlated (Spearman r = 0.51). ESI levels corresponded proportionately to higher E&M codes. ESI 1, 2, and 3 most frequently corresponded with E&M level 5 (50, 62, and 45%, respectively), and ESI 4 and 5 most frequently corresponded with E&M level 3 (56 and 67%, respectively). Only age by decade significantly affected the association between ESI level and E&M billing code. The mean total professional charge for all patient encounters was $421 (SD ± $204) with increasing mean charges per patient by increasing ESI acuity. Race and E&M code significantly affected the relationship between ESI level and total ED professional charges per patient (adjusted r(2) = 0.66).

CONCLUSIONS

A moderate, nonlinear correlation exists between ESI acuity levels and ED E&M billing codes. Increasing age affects this correlation. Race and E&M code affect the correlation between ESI level and total professional charges. As such, basic triage data can be used to estimate E&M code and total professional charges. Future studies are needed to validate these findings across other institutional settings.

Emergency department tachypnea predicts transfer to a higher level of care in the first 24 hours after ED admission

OBJECTIVES

The authors hypothesized that vital sign abnormalities detected in the emergency department (ED) can be used to forecast clinical deterioration occurring within 24 hours of hospital admission.

METHODS

This was a retrospective case-control study performed after implementation of a hospitalwide rapid response team (RRT) system. Inclusion criteria for study patients consisted of age > or = 18 years, admission to the general floor though the ED, and RRT activation and subsequent transfer to a higher level of care in the first 24 hours. Control patients were > or =18 years, were admitted to the floor though the ED, never required RRT or transfer to a higher level of care, and were matched to cases by risk of mortality. Multilevel logistic regression was used to model the odds of an adverse outcome as a function of race and sex, respiratory rate (RR), heart rate (HR), and systolic (sBP) and diastolic blood pressure (dBP) at time of transfer from the ED.

RESULTS

A total of 74 cases and 246 controls were used. RR (odds ratio [OR] = 2.79 per 10-point change, 95% confidence interval [CI] = 1.41 to 5.51) and to a lesser extent dBP (OR = 0.81, 95% CI = 0.67 to 0.97) contributed significantly to the odds of intensive care unit (ICU) or intermediate care transfer within 24 hours of admission; HR (OR = 1.15, 95% CI = 0.98 to 1.37) did not.

CONCLUSIONS

Emergency department RR preceding floor transfer appears to have a significant relationship to the need for ICU or intermediate care transfer in the first 24 hours of hospital admission.

Emergency department patient flow: the influence of hospital census variables on emergency department length of stay

OBJECTIVES

The objective was to evaluate the association between hospital census variables and emergency department (ED) length of stay (LOS). This may give insights into future strategies to relieve ED crowding.

METHODS

This multicenter cohort study captured ED LOS and disposition for all ED patients in five hospitals during five 1-week study periods. A stepwise multiple regression analysis was used to examine associations between ED LOS and various hospital census parameters.

RESULTS

Data were analyzed on 27,325 patients on 161 study days. A significant positive relationship was demonstrated between median ED LOS and intensive care unit (ICU) census, cardiac telemetry census, and the percentage of ED patients admitted each day. There was no relationship in this cohort between ED LOS and ED volume, total hospital occupancy rate, or the number of scheduled cardiac or surgical procedures.

CONCLUSIONS

In multiple hospital settings, ED LOS is correlated with the number of admissions and census of the higher acuity nursing units, more so than the number of ED patients each day, particularly in larger hospitals with busier EDs. Streamlining ED admissions and improving availability of inpatient critical care beds may reduce ED LOS.

Measuring the opportunity loss of time spent boarding admitted patients in the emergency department: a multihospital analysis

Emergency department (ED) crowding is an international crisis affecting the timeliness and quality of patient care. Boarding of admitted patients in the ED is recognized as a major contributor to ED crowding. The opportunity loss of this time is the benefit or value it could produce if it were used for something else. In crowded EDs, the typical alternative use of this time is to treat patients waiting to be seen. Various ED performance benchmarks related to inpatient boarding have been proposed, but they are not commonly reported and have yet to be evaluated to determine whether they correlate with the opportunity loss of time used for boarding. This study quantified several measures of ED boarding in a variety of hospital settings and looked for correlations between them and the opportunity loss of the time spent on boarding. In particular, average boarding time per admission was found to be easy to measure. Results revealed that it had a near-perfect linear correlation with opportunity loss. The opportunity loss of every 30 minutes of average boarding time equaled the time required to see 3.5 percent of the ED's daily census. For busy hospitals, the opportunity loss allowed sufficient time for staff to be able to see up to 36 additional patients per day. This correlation suggests that average boarding time per admission may be useful in evaluating efforts to reduce ED crowding and improve patient care.

A qualitative investigation into the opinions of adolescent females regarding their body image concerns and dieting practices in the Republic of Ireland (ROI)

The aim of this study was to investigate the opinions of female adolescents living in the ROI on issues relating to body image and dietary practice. A qualitative study was selected to enable the issues to be explored in depth. Sixteen focus groups were executed with adolescent females (n=124) aged 15-16 years. Data collection took place during class time in both rural and urban schools in the ROI. Data were analysed using a qualitative thematic methodology, namely framework analysis. High levels of body dissatisfaction existed and dieting was found to be prevalent. The influence of media celebrities was significant. The girls not only aspired to be like them in terms of physique but also followed their alleged dieting regimes in detail. Peers also influenced body dissatisfaction and dieting practices. Consequently, eating habits were altered to accommodate this quest for thinness with a tendency to skip main meals as part of the dieting practice while maintaining an unhealthy snacking pattern. The results are of concern as the adolescent females were utilising unhealthy methods of weight control such as skipping meals and fasting in their quest to obtain a thin physique. A slim body image was deemed important for peer acceptance; hence 'crash' dieting was in existence. This mindset and the resultant dietary practices may have negative health consequences during both adolescence and later life. School interventions targeting adolescent females and focusing on healthy eating and body image are therefore urgently required.

An assessment of the faculty development needs of junior clinical faculty in emergency medicine

OBJECTIVES

Academic physicians must be able to access the resources necessary to support their ongoing professional development and meet requirements for continued academic advancement. The authors sought to determine the self-perceived career development needs of junior clinical faculty in emergency medicine (EM) and the availability of educational resources to meet those needs.

METHODS

An educational "needs assessment" survey was distributed to 954 American College of Emergency Physicians (ACEP) members listed in the ACEP database as being faculty at EM residency programs in the United States and having graduated from an EM residency within the past 7 years. Respondents were asked to rank the importance of 22 areas of faculty development to their own professional growth and then to indicate whether educational resources in each area were available to them. Respondents were also asked to note the educational formats they prefer. A search for currently available resources in each topic area was undertaken and compared to the survey results.

RESULTS

A total of 240 responses were received. Self-perceived career development needs were identified in the following areas: bedside teaching, lecture development, business skills, managerial skills, educational research, mentorship and career counseling, interpersonal skills, leadership skills, scholarly writing skills, physician wellness, and knowledge of the faculty development process. While a review of currently available educational resources revealed lectures, conferences, and online materials pertinent to most of these topics, a relative lack of resources in the areas of mentorship and physician wellness was identified.

CONCLUSIONS

Junior clinical faculty in EM perceive a lack of educational resources in a number of areas of faculty development. The academic community of EM should strive to improve awareness of and access to currently existing resources and to develop additional resources to address the area of physician wellness. The lack of mentorship in academic EM continues to be a problem in search of a solution.