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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.

Summary

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.
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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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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.

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.
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Comparing EHR Impact on Hospital-based and Office-based Physicians

mobile charge capture

A recent study compared the interactions of hospital-based physicians to EHRs to the perceptions of office-based physicians. After analyzing comments submitted in response to the 2014 Rhode Island Health Information Technology survey, here are the results of their qualitative analysis.

Overall, when comparing themes across settings, the researchers found that hospital-based physicians more frequently commented on the use of electronic health records (EHRs) to feel more prepared for the clinical encounter, while office-based physicians more frequently commented on alteration of workflow and the depersonalization of relationships.

Four main themes emerged for both groups:

  • EHRs meant less time spent with patients and more time spent on the computer
  • EHRs reduce quality of the interaction and patient-physician relationship.
  • EHRs have no effect on patient interaction.
  • EHRs improve information access.

In terms of spending less time with patients, both groups differentiated the time spent on documentation that resulted in less time in the exam room or at the bedside, compared to the time spent looking at the computer during the clinical interaction itself. Hospital-based physicians were more likely to describe the lesser time in terms of the exam room or bedside, while office-based physicians commented more about time spent looking at the computer and not the patient.

The second most common theme among hospital-physicians revolve around the negative impact of EHRs on the quality of interactions with patients.

Here’s a typical comment: “Negatively affections interactions. Interacting with computer rather than my patient. Like having someone at the dinner table texting rather than paying attention.”

Decreased eye contact was also mentioned.

My nose is now burrowed deep into my computer interface, leaving markedly reduced time to make eye contact and actually interact one on one with my patient.”

Another sub-theme was the depersonalization that EHRs caused. Comments by physicians included words such as: intrusive, impersonal, limits, interferes, distracts and disruptive.  As one physician put it: “The art of medicine and treating is lost in the process.”

Some hospital-based physicians did express their view that the EHRs had no impact on their patient interaction. The primary reason – the physicians had figured out ways to work the EHRs into their workflow and thus had become less intrusive.

Finally, hospital-based physicians described how easy access to information has had a positive impact on their interactions with patients. For example, several of them noted that viewing problem lists and lab results helped them prepare for the clinical encounter and made them more efficient. In addition, physicians also saw EHRs helping with communication by allowing the patient and physician to review test results together and by providing ready access to educational materials. Office-based physicians noted that EHRs allowed for more communication through patient portals.

Pelland K.D, Baier R.R, Gardner R.L. ‘It is like texting at the dinner table’: a qualitative analysis of the impact of electronic health records on patient–physician interaction in hospitals. J Innov Health Inform. 2017;24(2):216–223.
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Hospital Medicine: Physician Burnout Roundup

Here are some of the latest stories on physician burnout:

A simple but effective tip for physician leaders: Ask your patients what they want.

Too often physicians are looking at computer screens instead of into the eyes of their patients, said Steven Strongwater, M.D., president and CEO of Atrius Health. His organization is trying to reduce burnout by creating so-called communities of practice—hubs that create a sense of community and enable healthcare professionals to interact with their colleagues and promote interaction not isolation in the workplace. (FierceHealthcare)

Ernst & Young Survey: Small Hospitals Struggling With Switch to Value-Based Models

Healthcare spending keeps climbing, but much of America’s health report card gets poor grades: chronic disease rates are rising, gaps between rich and poor are widening, and last year life expectancy fell for the first time in decades.

What’s going on? Ernst & Young sought to find out through its 2017 Health Advisory Survey, which gathered insights from 700 chief medical officers, clinical quality executives, and chief financial officers at health systems across the country. (AJMC)

Physician burnout: Running on an empty tank

If you are feeling utterly exhausted and disconnected from your patients, perhaps even wondering if you still want to be a doctor, then rest assured – you are not alone. Chances are these days that your colleagues may be feeling the same. (Medical News Today)

Physician heal thyself: Simple coping strategies for pervasive physician burnout

The proverb, ‘physician heal thyself,’ is probably more relevant today than it was in biblical times with the fast pace of life, the impact of multitasking and the unending bombardment of information, which have made emotional exhaustion almost certain. And this is especially true for obstetricians and gynecologists who experience professional burnout rates between 40 to 75 percent. (Science Daily)

To learn more about how Medaptus’ ASSIGN for Physicians software significantly improves the patient assignment process, click here

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Teamwork, Hospitalists and Hospital Medicine

Teamwork is one of the most important elements in hospital medicine. And yet, it continues to be one of the greatest challenges and roadblocks to improved patient outcomes. There are numerous reasons. First, hospitals are complex organizations, requiring interaction from a number of people – often under tense and life-threatening circumstances. Second, teamwork training is limited, both in medical school and in acute care settings. While most people agree that teamwork is necessary for positive outcomes, little time is carved away for actual team training. There simply isn’t enough time in the day to take care of patients and conduct team-building exercises.

Hospitalists are at the center of any discussion about teamwork.

Not only must they bridge the work of specialists, consultants and other care providers, but they must try to work with the patients themselves as a care coordination team. They are often juggling multiple and overlapping roles, both as a team “leader” and as part of an overall team of care. In other words, they must maneuver through and around an entire array of interpersonal relationships that are critical to the success of their patients’ care.

Researchers have long been interested in how hospitalists work within a total hospital medicine setting. For example, a group of researchers wanted to know what formal and informal strategies they used to “effectively enact teamwork and care coordination.”

To answer that question, the group conducted fieldwork in 2011 in which they observed the work of four hospitalists in three hospitals, closely studying the behavior of the group in their everyday context. While the overall sample was small, each setting was different, giving researchers a broad view of the physicians in action.

FORCES WORKING AGAINST TEAMWORK IN HOSPITAL MEDICINE

Here is what they found.

Not surprisingly, hospitalists had to face a number of different forces that worked against them to bring about care coordination. There were three primary drivers towards dysfunction.

First, a hospital’s spatial organization created a difficult environment for hospitalists to work closely with their teammates. They were often assigned patients located in different areas. In fact, observers found some circumstances where patients were located on every floor of the hospital. As a result, they often interacted with a different care team depending on the location of the patient.

Another problem for hospitalists revolved around multiple internal information systems. While electronic health records have improved the overall distribution of patient information, researchers found that some information was not recorded. In fact, they noted that in one instance, “no one record system captured all of the needed information around any one patient, nor did the formal systems show a complete picture. As a result, care coordination was not fully realized.

Another roadblock getting in the way of hospitalists achieving better care coordination revolved around uncoordinated teams, often the result of the loose coupling of units, services and professions within the hospital. This lack of interconnection, especially between professions and specialties made it difficult at times for the hospitalists to even determine who was on a patient’s “team.” As the researchers noted, when each hospital unit or specialty department assigned patients to a given provider for the day,  “these allocations were often not communicated to other groups or reflected in their record.” In fact, researchers also said that providers could go through at least some of their shift not knowing who else was on their patients’ teams for the day.

Finally, researchers noted that processes that were intended to be relatively automatic, such as ordering standard tests or procedures, were not very reliable in practice. As a result, hospitalists often had to resort to personal contacts and relationships to keep track of an order placed in the system. One example – during a handoff from the night to day shift, two hospitalists discussed a computerized tomography (CT) scan that should have been done overnight, but was not.

All of these roadblocks not only compound the challenges of building cohesive teams within a hospital setting, but they “pose serious threats to patient safety.”

COPING WITH TEAMWORK ROADBLOCKS

How did the hospitalists in this research cope?

For some, rounding became an important routine for team building. By establishing their physical presence throughout the hospital, these somewhat-predictable encounters helped establish dialogue and association with the various team members. Just “being there” was sometimes the most expeditious way to be the basic, necessary information about who else is caring for their patients.

Another way of bypassing the roadblocks was simply having local knowledge of the hospital’s diverse microsystems. This provided hospitalist with very practical ways to manage their patients’ care.

And finally, some hospitalists developed ad hoc systems of cataloguing their local knowledge. For example, one rounding physician carried a handwritten sheet of important phone numbers that she might need at any given time, information which was not readily available on any standard phone directory she could carry around.

In summary, navigating the many potholes and roadblocks associated with providing true care coordination and teamwork in hospital medicine requires stamina, ingenuity and strong interpersonal communication skills. Researchers confirmed that getting a team approach to work often requires the individual attitude of each physician, especially since the internal systems themselves often don’t advance the cause.

J Health Organ Manag. 2015;29(7):933-47. doi: 10.1108/JHOM-01-2015-0008.
How hospitalists work to pull healthcare teams together.
Chesluk B1, Bernabeo E, Reddy S, Lynn L, Hess B, Odhner T, Holmboe E.

To learn about how our patient assignment software — ASSIGN for Physicians — can improve care coordination, click here

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Physician Burnout and Medicine as a Calling

Could physician satisfaction and burnout be tied to whether or not that person sees medicine as a calling?

That was the question researchers wanted to answer – the degree to which seeing medicine as a calling is a bellwether of a physician’s mental state as it relates to the job.

Physician burnout is clearly a hot topic in healthcare today. Not only do surveys indicate that it’s affecting more physicians than ever before, but it’s also causing some physicians to leave the profession altogether. And the problem is not isolated to a few specialties. For example, emergency room physicians continue to report the highest level of burnout among their peers (60%), but rheumatology has also seen a big jump in burnout as well. While approximately one-third of rheumatologists reported burnout in 2013, that number jumped to more than one-half in 2017.

Physician burnout has been attributed to a number of different causes — chief among them (at least reported by the physicians themselves) the added burden of having too many bureaucratic tasks. Other factors that lead to burnout: spending too many hours at work, increasing computerization, income that is not high enough, and the feeling that physicians are just a “cog in the wheel.”

Researchers at the Mayo Clinic wanted to look at a different cause – the physicians’ sense of calling.

MEDICINE AS A CALLING

Medicine as a calling has a long history and has been an important element for both physicians and patients. For individual physicians, those who identify with medicine as a calling are typically more engaged in their work and experience less turnover. From a societal standpoint, the general public benefits from having physicians who are motivated to do work that goes beyond their own self-interests. In fact, trust in medicine has been built on this sense of altruism.

But over the past decade or more, concerns have grown that the changing face of the healthcare landscape is eroding the professional identify often associated with medicine as a calling. With a growing frustration of physicians about how their time is being spent in their profession, it’s no wonder physician burnout has been increasing. This raises the question – is there an association between physician burnout and a medicine-as-a-calling attitude.

To answer this question, researchers associated with the Mayo Clinic survey a canvassed a large group of U.S. physicians in 2014 and received completed responses from 2,263 (63% response rate). Among those respondents, nearly 29% of them self-identified themselves as having burnout syndromes. They also had physicians self-report their attitude towards medicine as a calling. Some of the six true/false questions used were:

  • I find my work rewarding.
  • My work is one of the most important things in my life.
  • My work makes the world a better place.
  • I enjoy talking about my work to others.
  • I would choose my current work life again if I had the opportunity.
  • If I were financially secure, I would continue with my current line of work even I were no longer paid.

THE ASSOCIATION BETWEEN BURNOUT AND A SENSE OF CALLING

Multivariable logistic regression associated with the results showed a significant association between the degree of professional burnout and each of the 6 calling items the researchers used. For example, compared with experiencing no burnout – experiencing at least one symptom of burnout was associated with lower odds of identifying with each of the 6 calling items. Physicians who were completely burned out had even lower odds of identification with those characteristics associated with medicine as a calling.

The type of specialty the physician was associated with had no bearing on the results, with the exception of pediatricians – who had higher odds of reporting that they would continue with their work if they were not paid for it. Also, those in medical school setting had higher odds of seeing their work as one of the most important things in their life.

The bottom line according to the researchers – physicians who experienced greater professional burnout were less likely to see medicine as a calling. One potential consequence of this association, according to the researchers, is that physicians who are burnt out may be less intrinsically and socially motivated because they see medicine more as a job and less as a calling—a way to simply earn a paycheck. The researchers concluded that payers, policymakers and physician leaders should “take care to foster a workplace environment that promotes physician well-being and should implement performance-based incentives that support this sense of calling.

Mayo Clin Proc. 2017 Mar;92(3):415-422. doi: 10.1016/j.mayocp.2016.11.012. Epub 2017 Feb 8. Association Between Physician Burnout and Identification With Medicine as a Calling. Jager AJ, Tutty MA, Kao AC

To learn about how our patient assignment software — ASSIGN for Physicians — might help with physician burnout, click here

Tomorrow’s Hospital Leaders

As a card-carrying member of the Society of Hospital Medicine (SHM), I might be biased, but I’m continually impressed by the caliber of people who speak and attend SHM conferences.

Our MedAptus team had a wonderful experience at the recent SHM Leadership Academy in Orlando FL. It seems that at most industry events, attendees wander through the exhibit hall, picking up free stuff along the way, and primarily planning out the next session that they’re going to. However, at the Leadership Academy, our team had meaningful interactions with dozens of attendees who were actively engaged. The thing that struck me the most was how interested they were in finding out about new products that could help their hospitalist group, and how quickly they grasped the subtleties of the larger impact that even small changes can make.

Those of us from MedAptus participating in the conference were particularly excited to talk about Assign, our newest software product (and part of our care coordination suite) that automates the process of assigning patients to providers each morning. Normally when I begin speaking about the benefits of Assign, such as improving continuity of care, facilitating geographic/multi-disciplinary rounds, improving charge reconciliation, driving physician labor savings, etc., the light goes on for people. At SHM though after describing what Assign does, we barely had to start talking about the benefits, and our audience members were already two steps ahead. These attendees could immediately see the value, and were already coming up with new ideas for making Assign even better. This is what is so great about SHM events: rather than merely cursory interactions with people who just happened to catch your eye, we instead had genuine interactions with people who want to continue to drive the field of hospital medicine forward.

I was also lucky enough to spend some time picking Dr. John Nelson’s brain about what we’re doing with Assign and how we can continue to improve it to better meet the needs of hospitalist groups. As a practicing hospitalist, one of his pet peeves is when a hospitalist is unable to tell a patient who will be caring for them the next day, post-handoff. It felt really good to be able to tell him that we have a solution to deal with this problem, today.

So, thanks to all of the great attendees we met, and thanks to SHM for assembling such a worthwhile event attracting so many dedicated professionals. As the saying goes, we’re all in this together.