Faculty Bibliography

BACKGROUND:Physicians' interest in the health and well-being of their patients is a tenet of medical practice. Physicians' ability to act upon this interest by caring for and about their patients is central to high-quality clinical medicine and may affect burnout. To date, a strong theoretical and empirical understanding of physician caring does not exist. To establish a practical, evidence-based approach to improve health care delivery and potentially address physician burnout, we sought to identify and synthesize existing conceptual models, frameworks, and definitions of physician caring. METHODS:We performed a scoping review on physician caring. In November 2019 and September 2020, we searched PubMed MEDLINE, Embase, PsycINFO, CINAHL, and CENTRAL Register of Controlled Trials to identify conceptual models, frameworks, and definitions of physician caring. Eligible articles involved discussion or study of care or caring among medical practitioners. We created a content summary and performed thematic analysis of extracted data. RESULTS:Of 11,776 articles, we reviewed the full text of 297 articles; 61 articles met inclusion criteria. Commonly identified concepts referenced Peabody's "secret of care" and the ethics of care. In bioethics, caring is described as a virtue. Contradictions exist among concepts of caring, such as whether caring is an attitude, emotion, or behavior, and the role of relationship development. Thematic analysis of all concepts and definitions identified six aspects of physician caring: (1) relational aspects, (2) technical aspects, (3) physician attitudes and characteristics, (4) agency, (5) reciprocity, and (6) physician self-care. DISCUSSION:Caring is instrumental to clinical medicine. However, scientific understanding of what constitutes caring from physicians is limited by contradictions across concepts. A unifying concept of physician caring does not yet exist. This review proposes six aspects of physician caring which can be used to develop evidence-based approaches to improve health care delivery and potentially mitigate physician burnout.

BACKGROUND:Trial recruitment of Black, indigenous, and people of color (BIPOC) is key for interventions that interact with socioeconomic factors and cultural norms, preferences, and values. We report on our experience enrolling BIPOC participants into a multicenter trial of a shared decision-making intervention about anticoagulation to prevent strokes, in patients with atrial fibrillation (AF). METHODS:We enrolled patients with AF and their clinicians in 5 healthcare systems (three academic medical centers, an urban/suburban community medical center, and a safety-net inner-city medical center) located in three states (Minnesota, Alabama, and Mississippi) in the United States. Clinical encounters were randomized to usual care with or without a shared decision-making tool about anticoagulation. ANALYSIS/METHODS:We analyzed BIPOC patient enrollment by site, categorized reasons for non-enrollment, and examined how enrollment of BIPOC patients was promoted across sites. RESULTS:Of 2247 patients assessed, 922 were enrolled of which 147 (16%) were BIPOC patients. Eligible Black participants were significantly less likely (p < .001) to enroll (102, 11%) than trial-eligible White participants (185, 15%). The enrollment rate of BIPOC patients varied by site. The inclusion and prioritization of clinical practices that care for more BIPOC patients contributed to a higher enrollment rate into the trial. Specific efforts to reach BIPOC clinic attendees and prioritize their enrollment had lower yield. CONCLUSIONS:Best practices to optimize the enrollment of BIPOC participants into trials that examined complex and culturally sensitive interventions remain to be developed. This study suggests a high yield from enrolling BIPOC patients from practices that prioritize their care. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov (NCT02905032).

OBJECTIVE:During the coronavirus disease 2019 pandemic, as a safety-net organization with a substantial percentage of patients of color and with limited English proficiency (LEP), we were wary of furthering health disparities in our community. We analyzed gaps in telemedicine (telephone and video) delivery in our communities, quantified the effects of our tests of change, and began the process of accumulating evidence to create a road map for other organizations. METHODS:We leveraged Lean problem-solving strategies to identify modifiable gaps across multiple domains that could inhibit equity in telemedicine. We implemented tests of change across domains of community engagement, technology, education, and access. We observed the proportion of telemedicine encounters across races and languages between April and November, 2020. Regression analyses tested the impact of race and language on telemedicine controlling for age, gender, insurance, and time. RESULTS: < 0.05). CONCLUSION:Our roadmap to improve equitable delivery of telemedicine was associated with a significant improvement in telemedicine use among certain minority populations. Most populations of color used telephone more often than video. This preference changed over time and with equity-focused changes in telemedicine delivery.

IMPORTANCE:The COVID-19 pandemic has affected clinician health and retention. OBJECTIVE:To describe trends in burnout from 2019 through 2021 with associated mitigating and aggravating factors. DESIGN, SETTING, AND PARTICIPANTS:Cross-sectional surveys were sent to physicians and advanced practice clinicians throughout 120 large US health care organizations between February 2019 and December 2021. From 56 090 surveys, there were 20 627 respondents. EXPOSURES:Work conditions and COVID-19. MAIN OUTCOMES AND MEASURES:Surveys measured time pressure, chaos, work control, teamwork, electronic health record use, values alignment, satisfaction, burnout, intent to leave, and in 2021, feeling valued. Multivariate regressions controlling for gender, race and ethnicity, years in practice, and role determined burnout, satisfaction, and intent-to-leave correlates. RESULTS:Of the 20 627 respondents (median response rate, 58% [IQR, 34%-86%; difference, 52%]), 67% were physicians, 51% female, and 66% White. Burnout was 45% in 2019, 40% to 45% in early 2020, 50% in late 2020, and 60% in late 2021. Intent to leave increased from 24% in 2019 to more than 40% as job satisfaction decreased. Higher burnout was seen in chaotic workplaces (odds ratio [OR], 1.51; 95% CI, 1.38-1.66; P < .001) and with low work control (OR, 2.10; 95% CI, 1.91-2.30; P < .001). Higher burnout was associated with poor teamwork (OR, 2.08; 95% CI, 1.78-2.43; P < .001), while feeling valued was associated with lower burnout (OR, 0.22; 95% CI, 0.18-0.27; P < .001). In time trends, burnout was consistently higher with chaos and poor work control. For example, in the fourth quarter of 2021 burnout was 36% (95% CI, 31%-42%) in calm environments vs 78% (95% CI, 73%-84%) if chaotic (absolute difference, 42%; 95% CI, 34%-49%; P < .001), and 39% (95% CI, 33%-44%) with good work control vs 75% (95% CI, 69%-81%) if poor (absolute difference, 36%; 95% CI, 27%-44%; P < .001). Good teamwork was associated with lower burnout rates (49%; 95% CI, 44%-54%) vs poor teamwork (88%; 95% CI, 80%-97%; absolute difference, 39%; 95% CI, 29%-48%; P < .001), as was feeling valued (37%; 95% CI, 31%-44%) vs not feeling valued (69%; 95% CI, 63%-74%; absolute difference, 32%; 95% CI, 22%-39%; P < .001). CONCLUSIONS AND RELEVANCE:Results of this survey study show that in 2020 through 2021, burnout and intent to leave gradually increased, rose sharply in late 2021, and varied by chaos, work control, teamwork, and feeling valued. Monitoring these variables could provide mechanisms for worker protection.

BACKGROUND:Patient trust in their clinicians is an important aspect of health care quality, but little evidence exists on what contributes to patient trust. PURPOSE:The aim of this study was to determine workplace, clinician, and patient correlates of patient trust in their clinician. METHODOLOGY/APPROACH:The sample used baseline data from the Healthy Work Place trial, a randomized trial of 34 Midwest and East Coast primary care practices to explore factors associated with patient trust in their clinicians. A multivariate "best subset" regression modeling approach was used, starting with an item pool of 45 potential variables. Over 7 million models were tested, with a best subset of correlates determined using standard methods for scale optimization. Skewed variables were transformed to the fifth power using a Box-Cox algorithm. RESULTS:The final model of nine variables explained 38% of variance in patient trust at the patient level and 49% at the clinician level. Trust was related mainly to several aspects of care variables (including satisfaction with explanations, overall satisfaction with provider, and learning about their medical conditions and their clinician's personal manner), with lesser association with patient characteristics and clinician work conditions. CONCLUSION:Trust appears to be primarily related to what happens between clinicians and patients in the examination room. PRACTICE IMPLICATIONS:System changes such as patient-centered medical homes may have difficulty succeeding if the primacy of physician-patient interactions in inspiring patient trust and satisfaction is not recognized.

Background Guidelines promote shared decision-making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within-encounter SDM tool to usual care (UC) increases patient involvement in decision-making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results We conducted a multicenter, encounter-level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow-up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: clinicaltrials.gov. Identifier: NCT02905032.

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).

OBJECTIVES/UNASSIGNED:Determine whether there are different longitudinal patterns of treatment burden in people living with multiple chronic conditions (MCC) and, if so, explore predictors that might reveal potential routes of intervention. METHODS/UNASSIGNED:We analyzed data from a prospective mailed survey study of 396 adults living with MCC in southeastern Minnesota, USA. Participants completed a measure of treatment burden, the Patient Experience with Treatment and Self-management (PETS), and valid measures of health-related and psycho-social concepts at baseline, 6, 12, and 24 months. Latent class growth mixture modeling (LCGM) determined trajectories of treatment burden in two summary index scores of the PETS: Workload and Impact. Multivariable logistic regressions were used to identify independent predictors of the trajectories. RESULTS/UNASSIGNED:< .05). CONCLUSIONS/UNASSIGNED:Different longitudinal patterns of treatment burden exist among people with MCC. Raising health literacy, enhancing self-efficacy, and lessening the effects of negative social interactions might help reduce treatment burden.

Rates of burnout among clinicians have been exacerbated by the COVID-19 (COVID)pandemic. A survey of Missouri primary care professionals at federally qualified health centers was conducted during a COVID surge in August 2021 to assess burnout, stress, and job satisfaction as well as if respondents had sought assistance for burnout or attended resiliency training. Despite respondents reporting rates of burnout (56%) that exceed those reported nationally (48%), only 17% sought help for burnout. Most (81%) had not attended resiliency training; of those who did, 16% said sessions "make me feel less alone," while an equivalent number found sessions not useful, identifying an absence of resources within their organization. Comments focused on the need for dedicated time to receive support, including time to seek assistance during working hours, time to take breaks, and time for self-care. The data suggest one path forward to remediate burnout: provide the workforce with time to access support.