Little has been written about physician stress that may be associated with electronic medical records (EMR).
We assessed relationships between the number of EMR functions, primary care work ...conditions, and physician satisfaction, stress and burnout.
379 primary care physicians and 92 managers at 92 clinics from New York City and the upper Midwest participating in the 2001-5 Minimizing Error, Maximizing Outcome (MEMO) Study. A latent class analysis identified clusters of physicians within clinics with low, medium and high EMR functions.
We assessed physician-reported stress, burnout, satisfaction, and intent to leave the practice, and predictors including time pressure during visits. We used a two-level regression model to estimate the mean response for each physician cluster to each outcome, adjusting for physician age, sex, specialty, work hours and years using the EMR. Effect sizes (ES) of these relationships were considered small (0.14), moderate (0.39), and large (0.61).
Compared to the low EMR cluster, physicians in the moderate EMR cluster reported more stress (ES 0.35, p=0.03) and lower satisfaction (ES -0.45, p=0.006). Physicians in the high EMR cluster indicated lower satisfaction than low EMR cluster physicians (ES -0.39, p=0.01). Time pressure was associated with significantly more burnout, dissatisfaction and intent to leave only within the high EMR cluster.
Stress may rise for physicians with a moderate number of EMR functions. Time pressure was associated with poor physician outcomes mainly in the high EMR cluster. Work redesign may address these stressors.
ABSTRACT
BACKGROUND
General internal medicine (GIM) careers are increasingly viewed as challenging and unsustainable.
OBJECTIVE
We aimed to assess academic GIM worklife and determine remediable ...predictors of stress and burnout.
DESIGN
We conducted an email survey.
PARTICIPANTS
Physicians, nurse practitioners, and physician assistants in 15 GIM divisions participated.
MAIN MEASURES
A ten-item survey queried stress, burnout, and work conditions such as electronic medical record (EMR) challenges. An open-ended question assessed stressors and solutions. Results were categorized into burnout, high stress, high control, chaos, good teamwork, high values alignment, documentation time pressure, and excessive home EMR use. Frequencies were determined for national data, Veterans Affairs (VA) versus civilian populations, and hospitalist versus ambulatory roles. A General Linear Mixed Model (GLMM) evaluated associations with burnout. A formal content analysis was performed for open-ended question responses.
KEY RESULTS
Of 1235 clinicians sampled, 579 responded (47 %). High stress was present in 67 %, with 38 % burned out (burnout range 10–56 % by division). Half of respondents had low work control, 60 % reported high documentation time pressure, half described too much home EMR time, and most reported very busy or chaotic workplaces. Two-thirds felt aligned with departmental leaders’ values, and three-quarters were satisfied with teamwork. Burnout was associated with high stress, low work control, and low values alignment with leaders (all
p
< 0.001). The 45 VA faculty had less burnout than civilian counterparts (17 % vs. 40 %,
p
< 0.05). Hospitalists described better teamwork than ambulatory clinicians and fewer hospitalists noted documentation time pressure (both
p
< 0.001). Key themes from the qualitative analysis were short visits, insufficient support staff, a Relative Value Unit mentality, documentation time pressure, and undervaluing education.
CONCLUSIONS
While GIM divisions overall demonstrate high stress and burnout, division rates vary widely. Sustainability efforts within GIM could focus on visit length, staff support, schedule control, clinic chaos, and EMR stress.
COVID-19 has put extraordinary stress on healthcare workers. Few studies have evaluated stress by worker role, or focused on experiences of women and people of color.
The “Coping with COVID” survey ...assessed US healthcare worker stress. A stress summary score (SSS) incorporated stress, fear of exposure, anxiety/depression and workload (Omega 0.78). Differences from mean were expressed as Cohen's d Effect Sizes (ESs). Regression analyses tested associations with stress and burnout.
Between May 28 and October 1, 2020, 20,947 healthcare workers responded from 42 organizations (median response rate 20%, Interquartile range 7% to 35%). Sixty one percent reported fear of exposure or transmission, 38% reported anxiety/depression, 43% suffered work overload, and 49% had burnout. Stress scores were highest among nursing assistants, medical assistants, and social workers (small to moderate ESs, p < 0.001), inpatient vs outpatient workers (small ES, p < 0.001), women vs men (small ES, p < 0.001), and in Black and Latinx workers vs Whites (small ESs, p < 0.001). Fear of exposure was prevalent among nursing assistants and Black and Latinx workers, while housekeepers and Black and Latinx workers most often experienced enhanced meaning and purpose. In multilevel models, odds of burnout were 40% lower in those feeling valued by their organizations (odds ratio 0.60, 95% CIs 0.58, 0.63, p< 0.001).
Stress is higher among nursing assistants, medical assistants, social workers, inpatient workers, women and persons of color, is related to workload and mental health, and is lower when feeling valued.
ABSTRACT
BACKGROUND
Work conditions in primary care are associated with physician burnout and lower quality of care.
OBJECTIVE
We aimed to assess if improvements in work conditions improve clinician ...stress and burnout.
SUBJECTS
Primary care clinicians at 34 clinics in the upper Midwest and New York City participated in the study.
STUDY DESIGN
This was a cluster randomized controlled trial.
MEASURES
Work conditions, such as time pressure, workplace chaos, and work control, as well as clinician outcomes, were measured at baseline and at 12–18 months. A brief worklife and work conditions summary measure was provided to staff and clinicians at intervention sites.
INTERVENTIONS
Diverse interventions were grouped into three categories: 1) improved communication; 2) changes in workflow, and 3) targeted quality improvement (QI) projects.
ANALYSIS
Multilevel regressions assessed impact of worklife data and interventions on clinician outcomes. A multilevel analysis then looked at clinicians whose outcome scores improved and determined types of interventions associated with improvement.
RESULTS
Of 166 clinicians, 135 (81.3 %) completed the study. While there was no group treatment effect of baseline data on clinician outcomes, more intervention clinicians showed improvements in burnout (21.8 % vs 7.1 % less burned out,
p
= 0.01) and satisfaction (23.1 % vs 10.0 % more satisfied,
p
= 0.04). Burnout was more likely to improve with workflow interventions Odds Ratio (OR) of improvement in burnout 5.9,
p
= 0.02, and with targeted QI projects than in controls (OR 4.8,
p
= 0.02). Interventions in communication or workflow led to greater improvements in clinician satisfaction (OR 3.1,
p
= 0.04), and showed a trend toward greater improvement in intention to leave (OR 4.2,
p
= 0.06).
LIMITATIONS
We used heterogeneous intervention types, and were uncertain how well interventions were instituted.
CONCLUSIONS
Organizations may be able to improve burnout, dissatisfaction and retention by addressing communication and workflow, and initiating QI projects targeting clinician concerns.
Background
Physician burnout is often assessed by healthcare organizations. Yet, scores from different burnout measures cannot currently be directly compared, limiting the interpretation of results ...across organizations or studies.
Objective
To link common measures of burnout to a single metric in psychometric analyses such that group-level scores from different assessments can be compared.
Design
Cross-sectional survey.
Setting
US practices.
Participants
A total of 1355 physicians sampled from the American Medical Association Physician Masterfile.
Main Measures
We linked the Stanford Professional Fulfillment Index (PFI) and Mini-Z Single-Item Burnout (MZSIB) scale to the Maslach Burnout Inventory (MBI) in item response theory (IRT) fixed-calibration and equipercentile analyses and created crosswalks mapping PFI and MZSIB scores to corresponding MBI scores. We evaluated the accuracy of the results by comparing physicians’ actual MBI scores to those predicted by linking and described the closest cut-point equivalencies across scales linked to the same MBI subscale using the resulting crosswalks.
Key Results
IRT linking produced the most accurate results and was used to create crosswalks mapping (1) PFI Work Exhaustion (PFI-WE) and MZSIB scores to MBI Emotional Exhaustion (MBI-EE) scores and (2) PFI Interpersonal Disengagement (PFI-ID) scores to MBI Depersonalization (MBI-DP) scores. The commonly used MBI-EE raw score cut-point of ≥27 corresponded most closely with respective PFI-WE and MZSIB raw score cut-points of ≥7 and ≥3. The commonly used MBI-DP raw score cut-point of ≥10 corresponded most closely with a PFI-ID raw score cut-point of ≥9.
Conclusions
Our findings allow healthcare organizations using the PFI or MZSIB to compare group-level scores to historical, regional, or national MBI scores (and vice-versa).
Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care.
To assess the relationship among adverse primary care work conditions, ...adverse physician reactions (stress, burnout, and intent to leave), and patient care.
Cross-sectional analysis.
119 ambulatory clinics in New York, New York, and in the upper Midwest.
422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure.
Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits).
More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors.
The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician.
Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.
Patients have differing expectations of female versus male physicians. Female patients tend to seek more empathic listening and longer visits, especially with female physicians; however, female ...doctors are not provided more time for this. Female doctors have more female patients than male doctors, and more patients with psychosocial complexity. We propose that gender differences in patient panels and gendered expectations of female physicians may contribute to the high rate of burnout among female clinicians, as well as to the many female physicians working part-time to reduce stress in their work lives. We propose several mechanisms for addressing this, including brief increments in visit time (20, 30 and 40 min), staff awareness, training in patient expectations during medical school, adjusting for patient gender in compensation plans, and co-locating behavioral medicine specialists in primary care settings. Beneficial outcomes could include fewer malpractice suits, greater patient satisfaction, higher quality care, and lower burnout among female physicians.
Background
Recruiting participants to clinical research studies is challenging, especially when conducted in safety net settings. We sought to compare the efficacy of different recruitment strategies ...in an NIH-funded study assessing treatment burden in patients with multiple chronic conditions (MCCs).
Methods
Targeted mailing, in-person table-based recruitment (“tabling”) in the waiting room, and telephone calling were used to enroll subjects into one of two studies of treatment burden: a survey study to validate a brief measure of treatment burden for quality assessment (study 1) or a qualitative study to develop a treatment burden clinical communication tool (study 2).
Results
Over 50% of subjects in each study were African American or African immigrants. In study 1, the enrollment goal of 200 was reached within 4 months. Tabling enrolled 78.5% of patients, while the remainder (21.5%) were enrolled from phone calls to eligible patients identified through the electronic medical record (EMR). In study 2, 340 eligible patients were identified through the EMR, and 7 (2.1%) were successfully enrolled via mailed invitations and responses. Retention rates (66% in study 1 and 71% in study 2) were reasonable in all groups.
Conclusions
Study recruiting goals in our safety net population were rapidly reached using the tabling method, which had substantively higher enrollment rates than mailings or telephone calls based on EMR reports. Future trials could compare recruitment strategies across settings and clinical populations.
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