Gender Bias in Risk Management Reports Involving Physicians in Training - A Retrospective Qualitative Study

OBJECTIVE

Gender bias, which contributes to burnout and attrition of female medical trainees, may manifest as disparate workplace evaluations. Here, we explore gender-based differences in perceived competence and professionalism as described in an institutional electronic risk management reporting system.

DESIGN

In this retrospective qualitative study, recurring themes were identified from anonymous entries reported to an electronic institutional risk management database from July 2014 to July 2015, and from July 2019 to July 2020 using inductive methods. This electronic system is often used by hospital staff to document complaints against physicians under the pretext of poor patient care, regardless of whether an adverse event occurred. Two individuals independently coded entries. Themes were determined from event indicator codes (EIC) using Delphi methodology and compared between gender and specialty using bivariate statistics.

SETTING

A multi-center integrated healthcare delivery system.

PARTICIPANTS

Risk management entries pertaining to physician trainees by hospital staff as written submissions to the institution's electronic risk management reporting system. Main outcomes included themes defined as: (1) lack of professionalism (i.e., delay in response, attitude, lack of communication), (2) perceived medical error, (3) breach of institutional protocol.

RESULTS

Of the 207 entries included for analysis, 52 entries identified men (25%) and 31 entries identified women (15%). The gender was not available in 124 entries and, therefore, categorized as ambiguous. The most common complaint about men involved a physician-related EIC (n = 12, 23%, EIC TX39) and the most common complaint about women involved a communication-related EIC (n = 7, 23%, EIC TX55). Eighty-eight (43%) entries involved medical trainees; 82 (40%) involved surgical trainees. Women were more often identified by their name only (n = 8, 26% vs. n = 3, 6%; p < 0.001). This finding was consistent in both medical (n = 0, 0% vs. n = 5, 31%; p < 0.001) and surgical (n = 2, 7% vs. n = 3, 25%; p = 0.006) specialties. In entries involving women, a lack of professionalism was most frequently cited (n = 29, 94%). Entries identifying medical errors more frequently involved men (n = 25, 48% vs. n = 7, 23%; p = 0.02).

CONCLUSIONS

Gender-based differences exist in how hospital staff interpret trainees' actions and attitudes. These differences have consequences for training paradigms, perceptions of clinical competence, physician burnout, and ultimately, patient outcomes.

Exploring parenthood in the New Zealand Heart Transplant Program

Heart transplantation is an established treatment for end-stage cardiac disease. This study describes parenthood after heart transplantation in the New Zealand population. An analysis was performed of all heart recipients from the New Zealand program. Exclusion criteria were death within 3 months of transplantation or age <18 years at the time of the survey. Recipients (or next of kin if recipients deceased) were surveyed regarding family status at the time of transplantation and new parenthood after transplantation. A total of 145 of 199 eligible recipients completed the survey ∼12.2 years after transplant (119 male, 26 female). Before transplantation, 81% were in a permanent relationship; 72% had children. After transplantation, 19/45 recipients had 27 children (2 female recipients had 3 children), of whom 15 were planned. Complications occurred in 7/27 pregnancies (including one atrial septal defect requiring surgery). Two recipients died after the birth of their children (children aged 2.6 and 14.1 years). This study provides unique data relevant to both female and male recipients regarding new parenthood after heart transplantation and will promote more informed discussion with transplant recipients.

A cost containment strategy for radical retropubic prostatectomy: Results from implementation of a clinical pathway program

Health care costs from the management of prostate cancer are estimated at $1.5 billion per year. As the number of radical prostatectomies being performed increases, a simultaneous rise in these costs can be expected. However, diminishing resources and the expanding managed care environment necessitate measures to curtail and even reduce these inflationary trends in health care expenditure. With this in mind, we established a collaborative clinical pathway for patients undergoing radical retropubic prostatectomy at our institution. The goals of the pathway were to reduce patient costs and hospital stay and to promote efficient use of resources for the procedure. We studied 71 patients who underwent radical retropubic prostatectomy and were managed according to the pathway during the first year of its implementation (July 1994 through July 1995). Outcome variables for these patients were compared with those of a group of 65 patients who underwent an identical procedure during the previous year (July 1993 through June 1994) before implementation of the pathway. Outcome parameters that were compared included hospital charges, length of stay (LOS), operating room (OR) time, units of packed red cells transfused, morbidity, and mortality. The overall hospital charges since implementation of the pathway decreased by 17.2% when corrected for inflation (p ≤ 0.006). LOS also decreased from a mean of 6.4 days to 5.2 days. There was no significant change in OR time. Overall complications remained unaffected (12.3% vs 12.6%). Based on these results, we conclude that establishment of an individualized, procedure-oriented clinical pathway for patients undergoing radical retropubic prostatectomy can result in significant reduction in patient costs without appreciable effect on morbidity and mortality.

Prevalence of BRCA mutations in an unselected population of triple-negative breast cancer

BACKGROUND

This study assessed BRCA1 and BRCA2 mutation prevalence in an unselected cohort of patients with triple-negative breast cancer (BC).

METHODS

One hundred ninety-nine patients were enrolled. Triple negativity was defined as <1% estrogen and progesterone staining by immunohistochemistry and HER-2/neu not overexpressed by fluorescence in situ hybridization. Having given consent, patients had BRCA1 and BRCA2 full sequencing and large rearrangement analysis. Mutation prevalence was assessed among the triple-negative BC patients and the subset of patients without a family history of breast/ovarian cancer. Independent pathological review was completed on 50 patients.

RESULTS

Twenty-one deleterious BRCA mutations were identified--13 in BRCA1 and 8 in BRCA2 (prevalence, 10.6%). In 153 patients (76.9%) without significant family history (first-degree or second-degree relatives with BC aged <50 years or ovarian cancer at any age), 8 (5.2%) mutations were found. By using prior National Comprehensive Cancer Network (NCCN) guidelines recommending testing for triple-negative BC patients aged <45 years, 4 of 21 mutations (19%) would have been missed. Two of 21 mutations (10%) would have been missed using updated NCCN guidelines recommending testing for triple-negative BC patients aged <60 years.

CONCLUSIONS

The observed mutation rate was significantly higher (P = .0005) than expected based on previously established prevalence tables among patients unselected for pathology. BRCA1 mutation prevalence was lower, and BRCA2 mutation prevalence was higher, than previously described. Additional mutation carriers would have met new NCCN testing guidelines, underscoring the value of the updated criteria. Study data suggest that by increasing the age limit to 65 years, all carriers would have been identified.

Factors that influence adherence to HIV medications: perceptions of women and health care providers

The purpose of this pilot study was to explore factors that influence adherence to antiretroviral therapy (ART) in women with human immunodeficiency virus (HIV) disease. Antiretroviral medications that reduce viral count and prolong the time between a diagnosis of HIV disease and acquired immunodeficiency syndrome (AIDS) are expensive, numerous, and have multiple side effects. Common reasons for not adhering to the medication regimen include ART side effects and a dosage schedule that disrupts daily activities. Failure to take or errors in taking ART can result in an exacerbation of symptoms and disease progression or the development of drug-resistant strains of HIV. Women and providers in separate focus groups identified factors that facilitated and hindered adherence to ART. Knowledge of factors that influence adherence to ART will facilitate the development of interventions. Patient-provider relationships and side effects of weight gain are discussed as factors that influence adherence to ART.

Synthesis of functionalized chiral carbocyclic cleft molecules complementary to Tröger's base derivatives

The synthesis of optically pure functionalized cleft molecules derived from dibenzobicyclo[b,f][3.3.1]nona-5a,6a-diene-6,12-dione is reported. These clefts are reminiscent of Tröger's base but contain clefts with different dimensions and additional carbonyl (or alcohol) groups that may be utilized in molecular recognition studies. The 2,8-dimethyl and 2,8-dibromo derivatives were synthesized via an intramolecular Friedel-Crafts acylation and were resolved by chiral HPLC. The 2,8-dinitro derivative was prepared by regiospecific nitration of dibenzobicyclo[b,f][3.3.1]nona-5a, 6a-diene-6,12-dione. The dibromo and dinitro derivatives allow direct access to a range of functionalized molecular clefts. Palladium-catalyzed coupling of the dibromo derivative afforded the disubstituted phenyl, anisole, and acetylene derivatives, while reduction of the dinitro derivative and acetylation provided amino-dione and amide-hydroxyl derivatives. X-ray crystal structures of the dimethyl 12, dibromo 13, di(p-methoxyphenyl) 16, dinitro 18, and dimethyl dinitro 22 derivatives show cleft angles between the planes between the aromatic rings of 84-104 degrees. The synthetic route, structural features, and potential for molecular recognition studies of this class of clefts are compared with those of the more widely studied Tröger's base cleft molecules.

Reducing the length of stay after kidney transplantation--the intensive outpatient unit

The need to reduce the costs associated with the initial hospitalization for kidney transplantation has led to the development of outpatient facilities in which patients can be seen on a daily basis. The implementation of a kidney transplant intensive outpatient unit (IOPU) is described. Prior to the opening of the IOPU, the median and mean lengths of stay after kidney transplantation in our program were 14.0 and 18.9 d, respectively. Subsequent to the opening of the IOPU, the median and mean lengths of stay after kidney transplantation have gradually decreased and are currently 5.0 and 7.5 d, respectively. The median inpatient cost of transplantation, excluding organ acquisition charges, has decreased by 54%, from $25516 to $11616. Patient satisfaction has exceeded 80%. The IOPU represents an effective means of reducing the cost associated with transplantation, without sacrificing the quality of care.

Utility of clinical pathway and prospective case management to achieve cost and hospital stay reduction for aortic aneurysm surgery at a tertiary care hospital

PURPOSE

We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery.

METHODS

We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed.

RESULTS

Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% (p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate (p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS (p < 0.01) and charges (p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure (p < 0.01) and fluid overload (p < 0.01).

CONCLUSIONS

Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% (p < 0.05) and overall LOS reduction of 3.5 days (p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care.

Cortisol secretion and growth in ewe lambs chronically exposed to electric and magnetic fields of a 60-Hertz 500-kilovolt AC transmission line

A study was conducted to determine whether chronic exposure of ewe lambs to the electric and magnetic fields (EMF) of a high-voltage ac transmission line affected cortisol secretion and growth. Twenty Suffolk ewe lambs were assigned randomly in equal numbers to a control and treatment group. Treatment from 2 to 10 mo of age consisted of continuous exposure within the electrical environment of a 60-Hz, 500-kV transmission line (mean electric field 6 kV/m, mean magnetic field 40 mG). Treated lambs were confined directly beneath the transmission line; control lambs were maintained in a pen of similar construction 229 m from the line where the EMF were at ambient levels (mean electric field < 10 V/m, mean magnetic field < .3 mG). Cortisol was analyzed by RIA in serum of blood samples collected at .5- to 3-h intervals over eight 48-h periods. All ewe lambs were weighed weekly and side-patch wool growth was measured biweekly. Cortisol secretion occurred in a circadian rhythm; daytime serum concentrations were greater (P < .05) than nighttime concentrations for both groups. Concentrations of cortisol did not differ between the control and exposed ewe lambs. Weight gain and wool fiber length and diameter also were not affected by treatment. These data suggest that chronic exposure of developing ewe lambs to 60-Hz environmental EMF does not affect concentrations of cortisol secretion, body weight gain, and wool growth.

Stressors and rewards of being an AIDS emotional-support volunteer: a scale for use by care-givers for people with AIDS

This study describes scales which can be used to identify the levels of stress and reward associated with being a AIDS emotional-support volunteer. Four categories of stressors were identified. These were 'emotional overload', 'client problems', 'lack of support' and 'lack of training'. The reward categories were 'personal effectiveness', 'emotional support', 'social support' and 'empathy/self-knowing'. There were low, but positive correlations between these stressor scales and other measures of psychological morbidity, the 28-item General Health Questionnaire (GHQ) and the Maslach Burnout Inventory (MBI). Levels of stress and reward were positively correlated and, taken together, the scales may be of use as a measure of the degree of involvement of volunteers in the AIDS care-giving process. Although these scales were derived from items provided from AIDS emotional-support volunteers many of the items may also be relevant to other health workers providing care for people with AIDS.

The Ankali project: a model for the use of volunteers to provide emotional support in terminal illness

The Ankali project has provided emotional support to about 250 persons with the acquired immunodeficiency syndrome, their partners, family members and friends. Volunteers act as a "supportive friend" and allow subjects the opportunity to express their feelings. The project's model easily could be adapted to meet the needs of persons with other terminal illnesses. One of the most important features of the model is the compulsory support-group structure for volunteers.

Changes in left ventricular ejection fraction after intracoronary thrombolytic therapy. Results of the Registry of the European Society of Cardiology

Changes of left ventricular ejection fraction (delta EF) determined by monoplane contrast angiography before intracoronary streptokinase infusion and in the chronic stage of infarction before hospital discharge were assessed in 125 patients. Preintervention EF was .49 +/- .136 and chronic EF was .025 +/- .118 higher (p = .02) in the total group. Some subgroups had an improved EF: patients with collaterals (delta EF = .046 +/- .106, p less than .01, n = 42), patients with incomplete obstruction before intervention (delta EF = + .076 +/- .141, p = .03, n = 19) and patients in whom complete obstruction was permanently recanalized (delta EF = .024 +/- .113, p = .04, n = 89). A continuous model relating delta EF to both duration of infarct symptoms before hospital admission and to preintervention EF showed a decline in EF improvement over time in the subgroup that was admitted within less than 6 hours after the onset of chest pain and successfully recanalized (n = 72).

Independent regulation of atrial coronary blood flow by atrial contraction rate in conscious dogs

The effects of separate increases in atrial and ventricular contraction rates on the distribution of coronary flow within the heart were determined in conscious dogs with chronic heart block. Atrial tachycardia increased atrial blood flow and did not change ventricular blood flow. Ventricular tachycardia increased ventricular blood flow but not atrial blood flow. The results are consistent with the concept of local regulation of coronary perfusion by local myocardial energy turnover. The results also call attention to a potential adverse impact of atrial tachyarrhythmia in patients with underlying coronary ischemia.