Table of Contents
The Issue in Brief
Burnout and Scope of Practice in New Family Physicians
Lars E. Peterson , and colleagues
Background Family physicians report some of the highest levels of burnout. This study examines associations between family physician scope of practice and self-reported burnout.
What This Study Found Early career family physicians who provide a broader scope of practice report significantly lower rates of burnout. The study--a secondary analysis of the 2016 National Family Medicine Graduate Survey--found that those who practiced in more locations and performed a greater variety of procedures and clinical work were significantly less likely to report feeling burned out once a week or more. The strongest associations were in the practice of obstetrics and inpatient medicine, two areas with a decline in practice by family physicians in recent years. Specifically, the odds of reporting feeling burned out were 36 percent lower among those family physicians practicing obstetrics and 30 percent lower among those practicing inpatient medicine compared to their peers. Making house calls was also significantly associated with lower burnout.
Implications
- If future research confirms a causal relationship between scope of practice and physician wellness, the authors suggest, it would allow for new policy levers and incentives for systems and physicians to improve health care as well as their own health.
Improving Prediction of Dementia in Primary Care
Susan Jongstra , and colleagues
Background The Mini-Mental-State-Examination (MMSE) is a widely used instrument to screen for cognitive defects. When used alone, however, it is not sensitive enough to recognize early symptoms of dementia. This study aims to investigate whether the Visual Association Test, a simple screening tool, improves the predictive value of a decrease in MMSE score for the development of dementia.
What This Study Found In people with a minor decline on the Mini-Mental-State-Examination. follow-up with the Visual Association Test (VAT) can help identify those at increased risk for dementia. As part of a cluster-randomized controlled trial, researchers in the Netherlands analyzed the MMSE of 2690 older adult patients at baseline and two-year follow-up. The Visual Association Test, consisting of six cue cards and six target cards showing an unexpected visual association, was also analyzed at the two-year follow-up. A decline in MMSE scores of two points and three points were associated with an increased risk of developing dementia of 10 percent and 21 percent respectively, significantly higher than the overall risk of developing dementia. Groups with imperfect VAT scores (less than or equal to five out of six) had substantially higher percentages of incident dementia. An imperfect VAT score increased the predictive value of two and three point decreases on the MMSE from 10 percent to 14 percent and from 21 percent to 29 percent respectively.
Implications
- Given the importance of timely diagnosis of dementia, the authors suggest that the VAT may help identify older persons who need further cognitive examination, especially those with a minor decline in MMSE score.
An Updated Analysis of Direct-to-Consumer Television Advertisements for Prescription Drugs
Janelle Applequist , and colleagues
Background In 2015, the American Medical Association called for a ban of direct-to-consumer prescription drug advertising. Yet, the prescription drug industry continues to spend more than ever on broadcast advertisements, with national health care costs largely driven by drug spending. This study analyzes direct-to-consumer television ads using a similar 2007 study as a model and benchmark.
What This Study Found The new analysis finds that the potential educational value of direct-to-consumer television advertising has declined. Compared to the 2007 analysis, this study found a significant decrease in the percentage of ads conveying information about the conditions being targeted, such as risk factors (decreased from 26 percent to 16 percent) and prevalence (decreased from 25 percent to 16 percent). Positive emotional appeals continued to be emphasized (94 percent of ads), with a decrease in the use of negative emotional appeals (from 75 percent to 51 percent), resulting in a more positive portrayal of the medication experience. Lifestyles portrayed in the ads emphasized how products can enable more recreational activities (69 percent of ads), while fewer ads suggested lifestyle change in addition to the product (decreased from 23 percent to seven percent).
Implications
- The authors suggest that portraying positive aspects of the post-medication experience, such as recreational activities, endurance, and social approval, may have motivational value, but may also imply off-label outcomes and encourage an inappropriately broad population to seek the advertised drug.
- According to the authors, improving the educational value of direct-to-consumer advertising is likely to require further regulatory action by the FDA, rather than reliance on self-regulation by the pharmaceutical industry.
Association of the Social Determinants of Health With Quality of Primary Care
Alan Katz , and colleagues
Background In primary care, there is increasing recognition of the difficulty in treating patients� immediate health concerns when their overall well-being is shaped by underlying social determinants of health. To better inform strategies that address social determinants of health, researchers defined �social complexities� and examined their association with patients' quality of care.
What This Study Found Among more than 600,000 primary care patients, half live with some degree of social challenge, which has a negative effect on the quality of care they receive. Researchers in Manitoba, Canada identified 11 social complexities, such as low income, mental health diagnosis, and involvement with the justice system. Fifty-four percent of patients had at least one social complexity, and four percent had more five or more. Social complexity was strongly associated with poorer outcomes on primary care indicators for prevention, e.g., breast cancer screening (OR 0.77, 99% CI); managing chronic disease, e.g., diabetes (OR 0.86, 99% CI); care of older adults, e.g., benzodiazepine prescriptions (OR 1.63, 99% CI); and use of health services, e.g., ambulatory visits (OR 1.09, 99% CI). Patients with more social complexities were less likely to receive preventive services and more likely to seek ambulatory or emergency care.
Implications
- To achieve better health equity for vulnerable patient populations, the authors recommend expanding interdisciplinary team-based care tailored to individual practices� patient populations and exploring alternative funding models that acknowledge the complexity of addressing social determinants of health in the primary care setting.
Care Transitions From Patient and Caregiver Perspectives
Suzanne E. Mitchell , and colleagues
Background The transition from hospital to home can be hazardous for patients and caregivers, yet little is known about their experiences during such transitions. This study describes patient and caregiver experiences and desired outcomes during care transitions.
What This Study Found In the transition from hospital to home, patients and caregivers seek clear accountability, continuity, and caring attitudes across the care continuum. One-hundred and thirty-eight patients and 110 family caregivers participating in focus groups and interviews identified three desired outcomes of care transition services: feeling prepared and able to implement care plans, unambiguous accountability from the health care system, and feeling cared for and cared about by clinicians. Five services or clinician behaviors were linked to these outcomes: providing actionable information; collaborative discharge planning involving patient and caregiver; using empathic language and gestures; anticipating the patient's need to support self-care at home; and providing uninterrupted care with minimal handoffs. When participants' desired outcomes were realized, they characterized care as excellent and trustworthy. In addition, caregivers experienced less distress and reported adherence to discharge plans increased. When desired outcomes were not met, patients and caregivers felt deserted by the health care system and perceived medical care as transactional and unsafe.
Implications
- Poor and fragmented care transition experiences, the authors suggest, can have substantial consequences, including creating patient and caregiver mistrust, anxiety, and confusion; precipitating family conflict; and contributing to inefficient care delivery, avoidable health system use, and delayed recovery.
- To ensure that care transitions are safe and supportive of patients' recovery, the authors state that health systems must better prepare patients and caregivers for self-care at home and design accessible means of ongoing care support when and where it is needed.
Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study
Catherine Hudon , and colleagues
Background Frequent users of healthcare services with chronic disease and complex care needs often experience fragmented, uncoordinated and ineffective health care. This study evaluates the effects of a nurse-delivered case management intervention on such frequent users of primary care services, with a focus on psychological distress and patient activation.
What This Study Found The study finds that case management reduces psychological distress and creates a sense of security in patients who frequently use health services. In this randomized controlled trial of 247 patients, the intervention group (n=126) received six months of case management including evaluation of patients� needs and resources, a service plan tailored to patients� priorities, care coordination between healthcare and community partners, and self-management support for patients and families. Compared with usual care, the intervention reduced psychological distress (OR 0.43, 95% CI, 0.19-0.95) but had no effect on patient activation. In addition, interviews were conducted with 25 intervention group patients, six case management nurses, and nine health managers, and focus groups were held with eight patients� spouses and 21 participating family physicians. Overall, stakeholders had positive perceptions of the case management intervention. Many noticed that improved accessibility and self-management support led to a sense of security and better self-management of patients� health.
Implications
- The authors note that future research is needed to evaluate the effect of a case management intervention on the use and cost of services and to assess if a longer intervention would result in a change in self-management.
Roles and Functions of Community Health Workers in Primary Care
Andrea L. Hartzler , and colleagues
Background Community health workers have the potential to enhance primary care access and quality, but they remain underutilized.
What This Study Found An analysis of existing research finds that community health worker functions include care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, targeted health education, and health literacy support. A cost-effective workforce that includes primary care community health workers could help overburdened care teams.
Implications
- The authors suggest that decisions about how to best utilize community health workers be based on needs of patients and care teams, clinical workflow, and financial viability.
Free Children's Visits and General Practice Attendance
Michael Edmund O'Callaghan , and colleagues
Background In July 2015, all children under six years of age gained free access to daytime and out-of-hours general practice services in the Republic of Ireland. This study examines subsequent changes in service utilization.
What This Study Found Comparing the year prior to the introduction of free GP care with the following year, daytime general practitioner visits by children under six years increased from 9,789 to 12,600, while out-of-hours visits increased from 15,087 to 18,958. In the post-period, nine percent more children were seen at least once in daytime services and 20 percent more children were seen at least once out-of-hours. While visits by patients of all ages increased in the post-period, children under age six were responsible for a disproportionate increase in service utilization, accounting for 45 percent of additional daytime visits and 73 percent of additional out-of-hours visits.
Implications
- Given the inevitable increase in service utilization that accompanies the availability of free care, and with indications that Ireland's GP workforce may soon struggle to meet demand, the authors call for careful workforce planning if state-funded general practice care is extended to other groups.
Nurse Practitioner-Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain
Allison A. Norful , and colleagues
Background As a result of shortages of primary care clinicians, policy makers are calling for new models of care delivery. One proposed model is co-management of patients by more than one primary care clinician. This study presents a theoretical model of co-management by nurse practitioners and primary care physicians.
What This Study Found According to the model, effective nurse practitioner-physician co-management requires three core attributes: effective communication, mutual respect and trust, and a shared philosophy of care. These attributes must be supported by a practice environment and policies that recognize nurse practitioners as autonomous primary care clinicians, as well as the willingness of nurse practitioners and physicians to co-manage patients. The authors find that effective nurse practitioner-physician co-management can reduce the primary care clinician's workload, including both clinical care and administrative tasks, thus reducing burnout and fatigue.
Implications
- This new co-management model lays the groundwork for potential care partnerships between nurse practitioners and physicians. The authors suggest that combining the experience and expertise of clinicians from nursing and medicine can result in better care.
Creating a Centralized Infrastructure to Facilitate Medical Education Research
Dean A. Seehusen , and colleagues
Background Building research capacity is a goal of family medicine leaders, but the specialty has struggled to establish a research agenda and expand its research footprint. This report describes the work of the Council of Academic Family Medicine Educational Research Alliance (CERA), which was created to help overcome barriers and increase scholarly production.
What This Study Found The Council of Academic Family Medicine Educational Research Alliance has enabled a large number of research teams to conduct meaningful scholarship with a fraction of the usual time and energy. CERA regularly conducts omnibus surveys of key family medicine education leaders, a process that includes collaboration with experienced mentors, centralized institutional review board clearance, pilot testing, and centralized data collection. As of October 2017, CERA completed 30 omnibus surveys resulting in more than 75 scientific presentations and more than 55 peer reviewed publications. By creating an infrastructure capable of overcoming some of the key barriers to conducting research, CERA has increased family medicine's research productivity and increased the number of family medicine faculty participating in research, including scholars with less experience and/or fewer resources.
Implications
- The authors state that the CERA model could be replicated in other specialties to facilitate collaborative research.
White Privilege in a White Coat: How Racism Shaped my Medical Education
Max J. Romano
Background In this essay, the author reflects on some of the ways racial privilege has influenced his experience as a white physician in training.
What This Study Found "Our medical system is structured to individually and systemically favor white physicians and patients in ways that white people are trained to ignore," states family medicine resident Max Romano, MD, MPH. Reflecting on his medical training, Romano describes how he, a white physician, has benefited from the racial privileges he has been afforded. Among the privileges he identifies are the pervasive belief that people of his race can become doctors; the ease with which he found professors and academic role models of his race during college and medical school; and patients' assumptions that, when he enters an examination room with a person of color, he is the physician in charge, even if that is not the case. He calls on other white physicians to speak out against the racism from which they have benefited and to work towards racial justice for clinicians and patients in the medical system.
The Mid-Career Demon
Timothy P. Daaleman
Background When family physician Timothy Daaleman felt a "greyness" shading his practice of medicine--a restlessness and lack of meaning in his work--he sought insight in the ancient concept of acedia. Acedia, which dates back to the fourth-century, is characterized by lack of caring and typically afflicts those in mid-life.
What This Study Found Dr. Daaleman, a mid-career physician, found that other physicians in his cohort reported the lowest satisfaction with their specialty choice and work-life balance and highest rates of emotional exhaustion and burnout. He reasoned that acedia and burnout could be part of a continuum of professional and personal challenges facing doctors across their careers. As he continued caring for patients, however, he developed a new understanding of hope, one that strengthened his capacity to trust and helped him "see light in the midst of such darkness."
Physician Burnout: Resilience Training is Only Part of the Solution
Alan J. Card
Background Although many health systems have turned to resilience training as a solution to physician burnout, quality/safety researcher Alan Card, PhD, MPH, argues in an essay that such training alone is not enough.
What This Study Found Dr. Card advocates for "picking the right tool for the job," i.e., selecting between two approaches to burnout based on a more nuanced understanding of the condition. Specifically, he distinguishes between two types of suffering related to burnout: unavoidable occupational suffering, i.e., the psychological stress and grief that are inherent in physicians� work, and avoidable occupational suffering: systems failures that can be prevented, such as overwork, a hostile work environment, or unsafe working conditions. For burnout caused by unavoidable psychological stress, resilience training may be a helpful tool. Burnout caused by systems failure, however, requires improved systems. Engaging physicians in the redesign of such systems will likely promote better mental health, he suggests.
Implications
- Card calls for health care organizations to offer resilience training, as well as peer support and stigma-free mental health treatment, in parallel with efforts to improve systems.