Collective Intelligence and Healthcare

If hospitals and other healthcare organizations comprise a number of very smart and intelligent individuals, shouldn’t the groups in which they participate in be more collectively intelligent as well?

Not really.

In fact, recent studies by researchers in the area of “collective intelligence” suggest that not only is individual intelligence not a predictor of group intelligence, but another factor may be much more critically important.

First, what is collective intelligence? It’s generally thought of as shared or group thinking, behavior and decision-making that occurs within a group environment. Think of it as the shared mental processes required to achieve a specific task or a variety of different tasks and a way in which to measure their general effectiveness. Researchers figured that it would be valuable to try to identify which characteristics within the group led to better outcomes.

To study collective intelligence, researchers created a variety of groups that ranged from two to five members who spent about five hours together in a laboratory working a series of tasks. The tasks included creative brainstorming problems, puzzles involving verbal or mathematical reasoning, negotiation tasks, and moral-reasoning problems.

In addition, each group was given a more complex “criterion task,” which required a combination of several of the different collaboration tasks measured by the other tasks. For example, in the first study, groups played checkers as a team against a computer opponent. Another study required groups to complete an architectural design.

What were the results?

As predicted by the researchers, the significant predictor of group performance on both of the criterion tasks was not the average individual intelligence of the group members. More precisely, it was found that the average and maximum intelligence of individual group members was correlated with collective intelligence, but only moderately so. Thus, “having a group of smart people is not enough, alone, to make a smart group.”

If individual intelligence is not the strongest predictor—what is?

It turns out a stronger predictor is social perceptiveness of group members. That is, people’s ability to judge others’ emotions ranked highest in terms of predicting whether or not a group would be more effective in completing its task. The higher the number of people in the group who were high in social perceptiveness, the higher their collective “intelligence.” Interestingly, researchers also found a correlation of performance and collective intelligence with the number of women in the group. They cautioned, however, that gender may not be as much a factor as the fact that women in general were more socially perceptive within the groups.

Collective Intelligence, Improvement and Diversity

Researchers found some other interesting aspects to group performance as well.

For example, in another study they found that highly collectively intelligent teams exhibited steady improvement in performance across the series of tests, suggesting teams got better at retaining information collectively and applying it to their assignments over time.

They also demonstrated that diversity plays an important role in performance as well. Based on their studies, the researcher suggested that groups whose members are too similar to each other lack the variety of perspectives and skills needed to perform well on a variety of tasks. But at the same time, “groups whose members are too different have difficulties communicating and coordinating effectively.” Thus, the researchers said that an intermediate level of cognitive diversity might be the best approach towards enhancing collective intelligence.

They also found that more collectively intelligent groups communicate more and participate more equally than other groups.

Despite these studies, several important questions remain.

For example, can the collective intelligence of groups be increased and improved? Can social perceptiveness be trained or is it an inherent trait that some people have and some don’t (or not as much). Also, could a group’s collective intelligence be increased with the use of better electronic collaboration tools?

Whatever the answers to these questions and others, one result is clear from these studies—group performance is not dependent on individual intelligence. Rather, it’s about how the group fits together, communicates and relates to one another that counts. Collective intelligence rules the day, not the intelligence of individuals.

Collective Intelligence and Group Performance,  Anita Williams Woolley, IshaniAggarwal, Thomas W. Malone, Current Directions in Psychological Science , Vol 24, Issue 6, pp. 420 – 424 First published date: December-10-2015 10.1177/0963721415599543

Patient Acuity Tool: Where Are We Now?

Assessing patient acuity has been around in some version for more than 50 years. But has anything changed? Has technology improved the process of capturing a patient’s acuity so that the nursing staff can use that information to better manage its workflow and throughput? Perhaps more importantly, has the use of some kind of patient acuity tool improved patient outcomes and nurse satisfaction?

Recent research suggests that patient acuity tools do positively impact nursing care, but they may also still be a work in progress. First, the benefits.

In a recent study, researchers wanted to know how a patient acuity tool affected both nurse satisfaction and the perception of equitable workloads, specifically as it related to pulmonary care. The study was conducted over a two-month period and included 35 Registered Nurses in an acute care hospital in southwestern Pennsylvania.

When asked during the qualitative phase of the study what they liked about the patient acuity tool they were asked to use, they said that their assignments were more equal or fair after implementation and that the tool promoted verbal communication. It also made them think more critically. In general, the focus group participants said that their satisfaction was also increased due to having input on their assignments. On the quantitative side of the study, the results also showed increases in the amount of satisfaction and equity among the nurses sampled in the survey.

Those results are consistent with other studies.

For example, a study by a PhD candidate at Valparaiso University showed that 60% of her participants noted marked improvement in equity of shift assignments from using a patient acuity tool, while 85% said they would like to continue using the tool after the project’s completion. In addition, 55% of participants reported better balanced nursing shift assignment with utilizing the tool. A similar study an Indiana hospital in 2014 showed similar results, which suggested higher nursing satisfaction after the implementation of a patient acuity tool.

But current patient acuity tools are not without problems.

First, there’s still a question of what exactly is “acuity.” Since there is no standard for how the term should be measured and categorized, some nursing units have struggled with using tools that don’t accurately capture their unique situation. Conversely, a few tools have so many categories and rules, their use has not only been cumbersome, but in some cases untenable. Any tool is only as good as its utility.

Another problem still associated with patient acuity is the process itself. While some units and hospitals have standardized the different categories associated with acuity, the manner in which they first identify the acuity level and then try to use that criteria to assign patients to nurses is typically done manually. While assigning acuity scores to each patient may not be that difficult, matching up those scores with patient location on the unit, nurse skills, and continuity of care of the staff can be a logistical nightmare. Current patient acuity tools only solve one part of the equation—the acuity categorization. They are not equipped to automatically match up patients with nurses.

Patient acuity tools clearly enable nursing management to make more informed staffing and operational decisions. In addition, the research strongly supports the notion that their use improves nurse satisfaction and the perception of more balanced workloads. But they still at the beginning of their evolution and need to be better integrated into the entire patient assignment process to be fully beneficial.


MedAptus Launches New Patient Assignment Software for Nurses

Assigning patients just got a whole lot easier for charge nurses.

MedAptus has launched ASSIGN for Nurses, a new software program that matches the right patients with the right nurse by applying a proprietary protocol engine designed to handle the complexities of patient assignments.

More than a year in development, ASSIGN for Nurses replaces the cumbersome manual assignment process that most charge nurses or assistants use, which is slow, inefficient and often unfair because of imbalanced workloads.

“This is a sea change when it comes to patient assignments,” says Eugene C. Schneider, MedAptus president and chief executive officer. “Not only can ASSIGN for Nurses handle the complexity of balancing multiple protocols, but it does so quickly and easily.”

Using ASSIGN for Nurses is straight-forward.

First, ASSIGN automatically taps into a patient census from the EHR, along with data from the hospital’s nurse scheduling software. Then, it applies protocols – such as patient acuity, geography, continuity of care and others simultaneously – to intelligently match patients with nurses. Once the assignment process is completed, the final list is then automatically generated and distributed, either electronically or in print. The entire process takes minutes to complete.

“I really like how ASSIGN for Nurses accounts for the many variables that can affect care,” said Lisa Quinn, PhD, RN, OCN. “Too often, we just focus on one factor, such as patient acuity, when in fact patient-centered care involves a whole range of variables.”

Studies show heavy nurse workloads can have a significant impact on patient safety and satisfaction, length of stays and readmissions. Imbalanced workloads can also lead to feelings of unfairness, frustration and even burnout. That’s one reason why developing patient assignment software for nurses was so important to MedAptus.

“We wanted to create a product that specifically addresses one of the most pressing challenges nurses face,” said Schneider. “So much is affected by nurse workloads. It’s nice to be able to provide software that dramatically improves such an important nursing function as patient assignments.”

ASSIGN for Nurses is designed to work in any unit and with any staff size. It also integrates seamlessly with all of the major EHR systems and nurse scheduling software programs, while requiring minimal IT staff involvement during implementation.

The software is the second patient assignment product MedAptus has launched in the past year. Previously, the company unveiled ASSIGN for Physicians, which applies similar rules-based algorithms to rounding assignments. The company is also developing a proprietary software for case managers and therapists as well, creating a full suite of care coordination products.


Errors and Omissions: How Healthcare and Aviation Compare

If there’s one common trait aviation and healthcare share, it’s the notion that both are expected to function without error. We expect pilots and the planes they fly to operate flawlessly, to get us safely to our intended destination. The same is true for physicians. We expect them to treat us accurately and effectively and get us up and moving again. Perhaps more importantly, we expect the participants in both industries to not kill us.

Aviation has done a superlative job over the past several decades or so of living up to that expectation. For example, in the United States from 2000 to 2010 there were about 0.2 deaths per 10 billion passenger-miles. In the years since then, the safety record is even better.

In contrast, a 2016 study in the number of deaths in the U.S. that were a result of medical error placed the yearly death rate at 251,454 deaths.

Healthcare continues to address the causes and preventative techniques that will reduce medical errors. But a group of researchers wanted to know—is there something to be learned by comparing aviation and healthcare? Specifically, they wanted to know how attitudes concerning error, stress and teamwork compared.

To help answer these questions, questionnaires were distributed to cockpit crew members from 40 different airlines and operating room personnel in urban teaching and non-teach hospitals in Italy, Germany, Switzerland, Israel and the United States. Four surveys were administrated, all of which measured attitudes towards stress, status hierarchies, leadership and interpersonal interaction issues.

Here’s a summary of the results.

Perceptions of Stress and Fatigue

Sixty percent of all medical respondents agreed with the statement – “Even when fatigued, I perform effectively during critical times.” Meanwhile, only 26% of all pilots agreed with the same statement.

Attitudes to Teamwork and Hierarchy

According to the results of the study, 70% of respondents did not agree that junior team members should not question the decisions made by senior team members. Consultant surgeons were least likely to advocate flat hierarchies. By contrast, 94% of cockpit team members advocated flat hierarchies.

Teamwork in Medicine

When it came to working with their colleagues in medicine, the research indicated that those individuals in surgery reported good teamwork with those in anesthesia, but anesthesia staff do not necessarily hold a reciprocal attitude. Similarly, although 77% of intensive care doctors reported high levels of teamwork with nurses, only 40% of nurses report high levels of teamwork with doctors.

Attitudes About Error and Safety

More than half of the medical respondents reported that they find it difficult to discuss mistakes. The reasons for not discussing mistakes included: personal reputation (76%), possible disciplinary actions by licensing boards (64%), threat to job security (63%), and expectations or egos of other team members (61% and 60%). The most common recommendation for improving patient safety in intensive care was to acquire more staff to handle workload, while the most common recommendation in the operating theatre was to improve communication.


According to researchers, aviation has made tremendous progress in developing a culture that deals effectively with error. On the other hand, in medicine “substantial pressures still exist to cover up mistakes, thereby overlooking opportunities for improvement.”

The researchers also said that medical staff play down the effects of stress and fatigue, while tired pilots acknowledge their own limitations to manage fatigue and have strategies to deal with it. They also say research in aviation has shown that individuals can be trained to recognize stress as an “error inducer” and continue to improve with recurrent training, which they say is typically non-punitive and proactive. Medicine, they say, doesn’t have comparable training.

 2000 Mar 18;320(7237):745-9. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. Sexton JB1Thomas EJHelmreich RL.

Position Available: Regional Sales Executive

Summary Description

 MedAptus has been in business for over 15 years and we are known for our KLAS award-winning charge capture software and services.  We continue to be committed to the revenue cycle market but have recently expanded into the Care Team Assignment and Communication segment of the Care Coordination market.  Assign for Physicians has been in the market for about one year and we are now expanding to Assign for Nursing, Assign for Case Managers and Assign for Therapists.  Because of our product suite expansion, we are excited to hire a Regional Sales Executive to help drive our continued growth. The ideal person will be a nurse or someone with a strong clinical workflow background that has a software and services sales background, particularly in selling to hospital based nursing.

 The Regional Sales Executive will be a key resource in achieving the planned expansion of company.  He/she must be a strong strategic thinker with an in-depth understanding of large physician practice and hospital workflows with a specific emphasis on patient assignment, care coordination and the revenue cycle. The Regional Sales Executive will be responsible for all sales activities, from lead generation through close in an assigned territory.  He/she will be responsible for developing and executing a marketing plan for the assigned territory.   This individual will be expected to meet annual new sales goals with effective management of the overall sales process within the territory.  As the Regional Sales Executive, this individual must be skilled in complex and consultative sales settings, and be comfortable articulating customer value.  He/she will work very closely with the Director of Marketing, other sales executives and our customer support groups. This role currently reports to the Director of Sales and Account Management

Duties and Responsibilities

  • Is accountable for meeting personal revenue objectives and promoting long-term customer relationships within their territory
  • Cultivates C-level customer and supporting partner relationships to develop insights into market needs, customer pain points, and customer buying behavior to create and deliver value propositions that respond to the customer’s value drivers
  • Forecasts new business and manages sales pipelines as required, updating management on the status of all prospects, in process sales opportunities, and potential revenue
  • Leads the successful execution of the MedAptus sales cycle and consultative sales process for opportunities within their territory
  • Enhances performance and sales productivity by effective territory planning, strategic account planning where appropriate, driving the proper balance between prospecting (cold and warm calling, conference participation, event networking) and pipeline management activities
  • Collaborates with marketing to design and implement lead generation campaigns, marketing material, messaging, industry analysis, etc. within their territory
  • Develops an annual “territory plan” outlining key targets, marketing and lead generation strategies
  • Participates directly in key “National Accounts” whenever appropriate
  • Recommends and adheres to effective sales processes and supporting tools and materials, leveraging existing processes and tools when possible
  • Develops and executes effective sales presentations
  • Provides leadership and effective negotiating skills during the contracting phase with prospects

Required Knowledge, Skills, and Abilities

  • BA/BS degree; a clinical degree is highly desirable (RN, NP, PHD or PA)
  • 8-10 years of relevant enterprise-scale and consultative sales experience in healthcare IT. A focus in selling to hospital based Nursing is preferred.
  • Is a respected sales executive with direct familiarity of hospital and large physician practice markets. A network of relevant senior level industry contacts – CMO, CMIO, CNO, CFO and CIO– is a significant plus.
  • Direct sales experience with revenue cycle and clinical workflow products to large physician practices and hospitals/hospital systems
  • Proven track record of consistently meeting and/or exceeding sales performance metrics, e.g. quotas, pipeline, forecast accuracy, etc. Proficient in managing complex and consultative sales cycles, typically defined as six months or longer with a variety of stakeholders, decision-makers and influencers at multiple levels
  • Demonstrates effective oral and written communication skills, especially in the ability to present concepts and articulate business value
  • Self-starter with a strong work ethic
  • Presents a professional appearance and displays effective interpersonal skills. Demonstrated ability to build positive, productive, and effective professional working relationships.
  • Travel required
  • Location is flexible but Raleigh or Boston would be ideal
  • Compensation is competitive and includes base plus commission and benefits

To apply to this position, send your resume to jobs@medaptus.com


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Is Physician and Nurse Burnout Contagious?

Is burnout contagious? Is it communicated from one provider to another?

Two different studies—on focusing on physicians and another on nurses—tried to answer that question and, not surprisingly, both came to same conclusion. Burnout is contagious.

In one study, a questionnaire on work and well-being was completed by 1,849 intensive care unit nurses working in 12 different European countries in 1994. Burnout was measured using several established criteria and the participants were surveyed regarding the perceived burnout complaints among colleagues, using a common measurement called the Maslach Burnout Inventory. The areas measured for burnout were emotional exhaustion, depersonalization, and personal accomplishment.

What did the results show?

Nurses who reported the highest prevalence of burnout among their colleagues were also the most likely to experience high levels of burnout themselves. In addition, perceived burnout complaints among colleagues had a positive, independent impact on each of the three burnout dimensions.

In another study, researchers looked at whether burnout was contagious among physicians. For this study, the sample was 507 general practitioners in the Netherlands and they wanted to know if there existed a positive relationship between perceived burnout complaints among colleagues and emotional exhaustion.

Burnout was measured using the same Maslach Burnout Inventory format described earlier, and susceptibility to emotional contagion was measured with a scale that included 6 items, including such statements as “I cannot continue to feel O.K. if people are me are depressed” and “I tend to remain calm even though those around me worry.”

According to the researchers, the perceived burnout complaints among colleagues, and individual differences in the susceptibility to emotional contagion were positively associated with emotional exhaustion. Emotional exhaustion, in turn, was positively associated with negative attitudes, leading to developing negative, cynical attitudes towards patients and the tendency to believe that “one is no longer effective in working with clients and in fulfilling one’s job.”

J Adv Nurs. 2005 Aug;51(3):276-87.
Burnout contagion among intensive care nurses.
Bakker AB1Le Blanc PMSchaufeli WB.
Journal of Social and Clinical Psychology: Vol. 20, No. 1, pp. 82-98.
Burnout Contagion Among General Practitioners
Arnold B. Bakker1, Wilmar B. Schaufeli2, Herman J. Sixma3, Willem Bosveld4
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Computer-Generated Infusion Coding Explained

Recently, MedAptus has introduced a new and innovative product – Charge Capture INFUSION – which automatically converts start/stop times for infusion events into the correct codes and then automatically sends the code to billing. This means that because of computer-generated infusion coding, nurses no longer have to worry about compliance or accuracy, while other coders can now be re-directed to other areas.

Charge Capture INFUSION builds on MedAptus’s long experience in developing charge capture software. One of the primary architects of the software’s development has been Gary Bernklow, product director. Gary shared with us some of the interesting aspects of this product and where he thinks it’s going.

To start with, Gary, how long have you been with MedAptus and what has been your role or roles?

I have been with MedAptus now for 10 years. I was originally brought onboard as the product director for our Facility Charge Capture product, which also includes our Infusion module. Of course, I have served in a variety of other roles within the company as well, including project manager and implementation manager. I was hired primarily as a subject matter expert for Professional and Facility billing and coding. Prior to my service with MedAptus, I had nearly 20 years of experience in Revenue Cycle management at a large private practice and at the Massachusetts General Hospital and I have extensive experience with both professional billing and coding and facility billing and coding.

What changes have you seen in charge capture over the years and specifically infusion?

The biggest trend I have seen is that there has been a continuous movement away from inpatient hospital services. Many key inpatient revenue centers now offer many of the services in outpatient clinics. Payers and CMS realize that ambulatory care is cheaper and they are incenting payments accordingly. That means hospitals must now compete with physician freestanding clinics for the same patient services and there are ever-shrinking margins for much of the DRG/Inpatient services.

Outpatient infusion centers have been coping with very small margins ever since the current OP Infusion billing rules went into effect around 2006. The rules changed every year, adding and removing codes, defining time limits, creating the specific hierarchy—first as a recommendation then as an immutable rule—and defining the primary or “initial” service. At most infusion centers, Nurses were responsible for recording the infusion charge and the highly complex rules meant intensive training and re-training every year for them to be able to record and accurately charge. They had to become coders in addition to their nursing duties. More paperwork, less patient work.

Infusion centers adapted to the new rules in a variety of ways, but the two most popular were to either continue to let nurses record their infusion start and stop times in documentation and then try to figure out the time-based codes and record those themselves, or the organization chose to address the problem by assigning a bunch of trained coders to review the documentation and convert the times to codes. Neither is an ideal solution. Nurses will not be as accurate as coders, and while hiring large numbers of coders to review infusion times and documentation may produce accurate codes, it is also a huge expenditure of resources that could better be used in other areas. Since the billing codes are determined by the time and duration of the infusion service, miscalculating that duration by even one minute could result in missed charges worth hundreds of dollars. And forcing nurses to record start and stop times twice (once for documentation and once for billing) increases the possibility of manual errors to be present.

In most EHR’s the drug, start, and stop time is already documented. That is really all the information required to produce accurate coding. If we could grab that information directly from the EHR, we could apply the time and hierarchy rules and produce the billing codes automatically.

Tell us how computer-generated infusion coding and specifically Charge Capture INFUSION works?

We are introducing fully automatic coding based on the documentation of the infusion service found in the EHR. Our product looks at the documentation for the service, finds the drug, the infusion start time, the infusion stop time, and calculates the exact billing codes required for that specific service. When an infusion is performed and documented in the chart, we can pull that documentation, produce an accurate billing charge, and send that directly to the client’s billing system (or back in the EHR) with no other intervention required. The resulting charge codes will match the documentation exactly and be 100% compliant. There would be no lost charges due to “estimating” the duration of the infusion, and no need for coders to review every encounter for billing accuracy. What is in the chart reflects what is in the charge.

Since the start and stop times are recorded once, and the billing codes derived from those values, there is zero chance for manual errors in the codes. If a value is incorrect in the documentation, it can be corrected there and the new values corrected in our system as well, automatically.

Basically, we do all the math to calculate the type of infusion (Chemo, Med, Hydration; Long infusion or Push), the duration of that infusion, and the number of billable units resulting from that duration. With complex coding like we have for hydration, we believe it is much more efficient and accurate to let the technology do the hard work.

We accomplish this with several interfaces, one from the EHR into MedAptus providing drug identifiers and start/stop times for those drugs, and another from MedAptus into our clients billing system or into the EHR with accurate codes.

What makes this product so different than what’s currently out there in the marketplace?

The biggest differentiator with our system is the automatic code creation. There are several products that allow users to manually plug in their drug types and start/stop times, and have the billing codes created from that information. We even have that option available in MedAptus as well.

However, this requires that information to be entered twice—once in the EHR and again in the charge capture software. Users have to record the drug, the start, and the stop time in the EHR and then record the drug, the start, and the stop time in our manual infusion system.  If the information already exists in the EHR, why can’t we just pull that information into our MedAptus Infusion system and calculate the correct codes without having to have someone enter the same information again?

I don’t believe there is any other Infusion product that does that, but it seems to be the most efficient way to generate an accurate charge.

What are the biggest misconceptions people have about Charge Capture INFUSION?

The biggest misconception I have heard is that this is an incredibly complex solution that will take  months and months to implement. While there is some integration work that will need to be done, we don’t have to create the logic to convert time to billing codes. We already have that in place and have had it since 2007.  We have a tremendous Integration team that has developed interfaces with the major EHR systems including Epic, Cerner, Allscripts, McKesson, and we have developed integration specs to help our clients address their questions. Training is minimal due to the product being mostly automatic.

Implementation can be very quick. The process is not the same as implementing an EHR for example. I often hear potential clients worried that the process will be long and painful. That is not the case.

Another misconception that I see often is that clients believe their EHR already has the necessary tools in place to create accurate infusion coding. It’s true that most EHRs now provide some kind of mechanism for charge capture, but none of them can translate infusion duration into billing codes. So if your EHR representative says they can provide that service, please ask for a demonstration.

Lastly, I hear from a great many organizations that their Infusion department is too small to take advantage of our system. In those cases, I typically ask them about their Emergency Department and the volume in that area. There are statistics that show 35% of all ED patients receive some kind of intravenous infusion service during their treatment. Those services must follow the same guidelines and hierarchy for outpatient infusion billing. Our solution would also be a good fit for those departments as well.

Tell us about some success stories you’re familiar with in terms of hospitals changing the way they capture infusion events for coding, especially in terms of computer-generated infusion coding.

As I have noted, Infusion coding is incredibly complex. I have often provided an evaluation of Infusion billing for our perspective clients, using our tool to analyze a subset of their infusion services for coding and billing accuracy. I have examined hundreds of infusion services and have found very high error rates with all records examined. I have seen error rates as high as 90%, and have yet to find any services with an error rate lower than 40%.

In the case above with the 90% error rate, Nurses were recording the charge codes on paper but had been trained for years to always round the infusion time down to the nearest 15 minutes. This resulted in thousands of dollars of lost revenue. In the first 8 months of using our solution, their revenue jumped by nearly $4 million. The nurses were doing nothing wrong, but they had been trained incorrectly for years. Our product paid for itself within weeks. Miscalculating the infusion duration by even 1 minute can have disastrous effects on the bottom line.

This was an extreme case, but certainly not an unusual one. By “rounding” the duration of infusions downward, this client was effectively removing valid billing units from their charges. Other common errors include not charging for Hydration when it was delivered, incorrectly charging multiple units for concurrent infusions, and choosing the wrong infusion as the “initial” service.

Is there anything else you’d like to add or mention?

We have been managing Infusion coding for more than 10 years now, and during that time the single request we have had from our clients and perspective clients has been that we figure out a way to provide this product without requiring our clients to have to “repeat” their infusion times. Nurses and coder both told us, “Don’t make me enter the same information twice”. We listened to our clients and have provided a solution that makes their documentation easier, provides a proven return on investment, and assures 100% compliance between billing records and patient documentation.

I am very proud of this product and I do believe it can make a positive impact to any organization delivering outpatient intravenous infusion services.

To learn more about Charge Capture INFUSION, click here.


Physician Burnout at Different Career Stages

Physician burnout is often discussed in broad terms as if it affects everyone equally. But research a few years ago indicates some significant differences based on a physician’s career stage.

The study was conducted by a group of researchers in the summer of 2011 and designed to gauge the differences in terms of burnout among early career (10 years or less of practice, middle career (11-20 years), and late career physicians (20 years or more) in the U.S. More than 7,200 physicians completed the survey – 22% and 23% were early and middle career, while 54% were late career. In addition, the sample included a wide variety of specialties, including primary care, surgery, dermatology, emergency medicine, radiology and others.

What did the results show?

Overall, the middle stage of one’s career appeared to be the most challenging time for physicians. Middle career physicians worked more hours, took more overnight calls, had the lowest satisfaction with their specialty choice and work-life balance, and had the highest rates of emotional exhaustion and burnout.

But some other results stood out as well.

Work-Life Balance

Despite working fewer hours, early career physicians were more likely to have experienced a work-home conflict and were least likely to have been able to resolve the conflict in a manner that allowed both home and work responsibilities to be met.

Researchers suggest that these conflicts often result from the fact that many early career-stage physicians have younger children, which increases the likelihood of conflicts. In addition, a greater proportion of early career physicians were women and often experience more work-home conflicts than men.

Middle career physicians worked more hours, took more overnight calls, had the lowest satisfaction with their specialty choice and work-life balance, and had the highest rates of emotional exhaustion and burnout.


Middle career physicians were more likely to have high emotional exhaustion and be burned out than early or late career physicians. Depersonalization, on the other hand, which is the psychological withdrawal from relationships, was found to be highest among early career physicians and then decreased incrementally in prevalence among middle and later career doctors.

Career Satisfaction

Satisfaction overall with their career choice was lowest among early career physicians and highest among later career doctors. It was also lowest regardless of gender and showed no difference for those who worked in private practice compared to academia and veterans’ hospitals. Satisfaction levels were lowest among primary care physicians and surgeons, but lowest among middle career physicians for internal medicine and the pediatric subspecialty.

Intent to Reduce Workload

In terms of planning to reduce clinical work or leaving medicine, late career physicians were most likely to report that they intended to reduce their clinical hours in the next 12 months. The reasons for reducing clinical time varied by career stage. Younger physicians, for example, wanted to spend more time with their families or pursue research or, if they decided to leave their current environment, it was to relocate to a new practice. Middle career physicians, on the other hand, wanted to reduce hours because of frustration with Medicare or insurance reimbursements. Middle career physicians were also more likely to consider leaving medicine all together.

Researchers pointed out that the implications of middle career physicians reducing clinical time or leaving medicine were significant. For example, the middle section of a physician’s career is often the most productive, plus the organizational costs of replacing a physician can be enormous. Some studies suggest that a single physician can cost $115,000 to $587,000 to replace, depending on the specialty.

Mayo Clin Proc. 2013 Dec;88(12):1358-67. doi: 10.1016/j.mayocp.2013.07.016.
Physician satisfaction and burnout at different career stages.
Dyrbye LN1Varkey PBoone SLSatele DVSloan JAShanafelt TD.

Hospitalists in Rural Hospitals

The hospitalist movement has typically been associated with urban hospitals, which have used these physicians to support community doctors, assume care for unassigned patients, and improve patient flow and quality of care.

But what about rural hospitals? Do hospitalists provide similar benefits there or is it an entirely different environment with its own set of challenges and opportunities?

To answer these questions, researchers conducted a survey of 402 rural hospitals with 100 beds or less in the U.S. Most had at least one hospitalist on its staff, although several had none. A total of 350 hospitals responded to the survey.

The results?

  • The most common reason for using hospitalists was that the primary physicians either requested it or required that the hospital do it by refusing to provide inpatient coverage. Other reasons for using hospitalists included the cover call and give physicians time off, improve quality of care and allow primary care physicians to focus on their outpatient clinical practices. Several hospitals said the establishment of a hospitalist program was a key factor in their ability to retain current physicians and recruit new ones.
  • Internal medicine was cited as the most common hospitalist specialty among small rural hospitals, but over half of the hospitals said they use family  physicians as hospitalists, while nearly a quarter use physician assistants, nurse practitioners, or both in the hospitalist role.
  • Hospitalist provide inpatient care 24 hours a day/7 days a week in 41% of the hospitals. They also frequently play multiple roles, providing care in the emergency department (17%), outpatient department (29.5%) and clinics or physician offices (29.5%).
  • Rural hospitalists care for adult medical patients in all of the hospitals and add surgical patients in most hospitals. However, they are less likely to care for pediatric patients, obstetric patients or newborns.
  • The vast majority of the respondents believe that hospitalists have had a positive impact on the quality of care in their hospital, and none believed that had a negative impact. The positive aspects mentioned included ability to respond quickly to changes in patients’ conditions and the amount of time they spend with patients. Other benefits included hospitalists’ expertise and ability to handle more acute patients and improvements in hospital quality and patient safety scores. Respondents also mentioned improved teamwork and communication with nurses as a result of having hospitalists.
  • The assessment of the financial impact of hospitalists were mixed. Two thirds reported either a wholly positive financial impact or both positive and negative impacts. The most frequently reported positive financial impacts related to increases in admission, fewer transfers to other hospitals, and improved abilities to treat higher acuity patients. The most common negative financial impacts were the hospitalist program costs more than the revenue directly generated by hospitalists and, as a result, had to be subsidized.
  • Almost three quarters of hospitals reported that hospitalist use made it easier to recruit and retain primary care physicians. Respondents also mentioned that hospitalist use provides work-life balance for primary care physicians and improves their quality of life.
  • Survey respondents reported that nearly all admitting physicians were very satisfied or satisfied having hospitalists care for their patients. Similarly, the majority of patients were reportedly very satisfied or satisfied with hospitalists’ care. In the 87.88% of hospitals where some or all the hospitalist live in their community, respondents were significantly more likely to report that patients were satisfied with the hospitalists, compared with the 12.2% of hospitals where none of the hospitalists lived in the community.

“… having hospitalists may be the most important factor in the hospital’s ability to remain open and continue providing inpatient care.”

The researchers concluded by saying that hospitalist programs have potential to help address rural primary care workforce shortages and may also help rural hospitals document and improve the quality of care they provide. And while inpatient revenue directly generated by hospitalists may not cover the direct costs of their salaries or contracts, the researchers suggested that using hospitalists may allow small rural hospitals to provide a greater volume of inpatient care and handle more complex patients. In some cases, “having hospitalists may be the most important factor in the hospital’s ability to remain open and continue providing inpatient care.”

Med Care Res Rev. 2014 Aug;71(4):356-66. doi: 10.1177/1077558714533822. Epub 2014 May 14.
The Use of Hospitalists by Small Rural Hospitals: Results of a National Survey.
Casey MM1, Hung P2, Moscovice I2, Prasad S3.