Time and money: a retrospective evaluation of the inputs, outputs, efficiency, and incomes of physicians

Adverse Events in Genetic Testing: The Fourth Case Series

PURPOSE

In this ongoing national case series, we document 25 new genetic testing cases in which tests were recommended, ordered, interpreted, or used incorrectly.

METHODS

An invitation to submit cases of adverse events in genetic testing was issued to the general National Society of Genetic Counselors Listserv, the National Society of Genetic Counselors Cancer Special Interest Group members, private genetic counselor laboratory groups, and via social media platforms (i.e., Facebook, Twitter, LinkedIn). Examples highlighted in the invitation included errors in ordering, counseling, and/or interpretation of genetic testing and did not limit submissions to cases involving genetic testing for hereditary cancer predisposition. Clinical documentation, including pedigree, was requested. Twenty-six cases were accepted, and a thematic analysis was performed. Submitters were asked to approve the representation of their cases before manuscript submission.

RESULTS

All submitted cases took place in the United States and were from cancer, pediatric, preconception, and general adult settings and involved both medical-grade and direct-to-consumer genetic testing with raw data analysis. In 8 cases, providers ordered the wrong genetic test. In 2 cases, multiple errors were made when genetic testing was ordered. In 3 cases, patients received incorrect information from providers because genetic test results were misinterpreted or because of limitations in the provider's knowledge of genetics. In 3 cases, pathogenic genetic variants identified were incorrectly assumed to completely explain the suspicious family histories of cancer. In 2 cases, patients received inadequate or no information with respect to genetic test results. In 2 cases, result interpretation/documentation by the testing laboratories was erroneous. In 2 cases, genetic counselors reinterpreted the results of people who had undergone direct-to-consumer genetic testing and/or clarifying medical-grade testing was ordered.

DISCUSSION

As genetic testing continues to become more common and complex, it is clear that we must ensure that appropriate testing is ordered and that results are interpreted and used correctly. Access to certified genetic counselors continues to be an issue for some because of workforce limitations. Potential solutions involve action on multiple fronts: new genetic counseling delivery models, expanding the genetic counseling workforce, improving genetics and genomics education of nongenetics health care professionals, addressing health care policy barriers, and more. Genetic counselors have also positioned themselves in new roles to help patients and consumers as well as health care providers, systems, and payers adapt to new genetic testing technologies and models. The work to be done is significant, but so are the consequences of errors in genetic testing.

Pediatrician preferences, local resources, and economic factors influence referral to a subspecialty access clinic

BACKGROUND

Pediatric patients seek timely access to subspecialty care within a complex delivery system while facing barriers: distance, economics, and clinician shortages. Aim We examined stakeholder perceptions about solutions to the access challenge. We engaged over 300 referring primary care pediatricians in the evaluation of Access Clinics at an academic children's hospital.

METHODS

Using an anonymous online survey, we asked pediatricians about their and their patients' experiences and analyzed factors that may influence referrals. Findings Referring pediatricians reported satisfaction; they provided feedback about their patients' experiences, physician communication, and referral influences. Distance from the Access Clinic does not correlate with differences in referral volume; living in areas with higher child populations and higher median income is associated with more referrals. Referring pediatricians have strong opinions about referrals, are attuned to patient experiences, and desire bi-directional communication. Multiple factors influence referral to and acceptance of Access Clinics, but external influences have less impact than expected.

Environmental factors associated with physician's engagement in communication activities

BACKGROUND

Communication between patients and providers is a crucial component of effective care coordination and is associated with a number of desired patient and provider outcomes. Despite these benefits, physician-patient and physician-physician communication occurs infrequently.

PURPOSE

The purpose of this study was to examine the relationship between a medical practice's external environment and physician engagement in communication activities.

METHODOLOGY/APPROACH

This was a cross-sectional examination of 4,299 U.S. physicians' self-reported engagement in communication activities. Communication was operationalized as physician's time spent on communication with patients and other providers during a typical work day. The explanatory variables were measures of environmental complexity, dynamism, and munificence. Data sources were the Health Tracking Physician Survey, the Area Resource File database, and the Dartmouth Atlas. Binary logistic regression was used to estimate the association between the environmental factors and physician engagement in communication activities.

FINDINGS

Several environmental factors, including per capita income (odds ratio range, 1.17-1.38), urban location (odds ratio range, 1.08-1.45), fluctuations in Health Maintenance Organization penetration (odds ratio range, 3.47-13.22), poverty (odds ratio range, 0.80-0.97) and population rates (odds ratio range, 1.01-1.02), and the presence of a malpractice crisis (odds ratio range, 0.22-0.43), were significantly associated with communication.

PRACTICE IMPLICATIONS

Certain aspects of a physician's external environment are associated with different modes of communication with different recipients (patients and providers). This knowledge can be used by health care managers and policy makers who strive to improve communication between different stakeholders within the health care system (e.g., patient and providers).

Adverse events in cancer genetic testing: medical, ethical, legal, and financial implications

Cancer genetic counseling and testing are now integral services in progressive cancer care. There has been much debate over whether these services should be delivered by providers with specialized training in genetics or by all clinicians. Adverse outcomes resulting from cancer genetic counseling and testing performed by clinicians without specialization in genetics have been reported, but formal documentation is sparse. In this review, we present a series of national cases illustrating major patterns of errors in cancer genetic counseling and testing and the resulting impact on medical liability, health care costs, and the patients and their families.

Predicting pediatricians' communication with parents about the human papillomavirus (hpv) vaccine: an application of the theory of reasoned action

This study examines the ability of the theory of reasoned action (TRA) and the theory of planned behavior (TPB) to predict whether or not pediatricians encourage parents to get their adolescent daughters vaccinated against the human papillomavirus (HPV). Four-hundred and six pediatricians completed a mail survey measuring attitudes, subjective norms, perceived behavioral control, intentions, and behavior. Results indicate that pediatricians have positive attitudes, subjective norms, and perceived behavioral control toward encouraging parents to get their daughters vaccinated, that they intend to regularly encourage parents to get their daughters vaccinated against HPV in the next 30 days, and that they had regularly encouraged parents to get their daughters vaccinated against HPV in the past 30 days (behavior). Though the data were consistent with both the TRA and TPB models, results indicate that perceived behavioral control adds only slightly to the overall predictive power of the TRA, suggesting that attitudes and norms may be more important targets for interventions dealing with this topic and audience. No gender differences were observed for any of the individual variables or the overall fit of either model. These findings have important theoretical and practical implications for the development of health communication messages targeting health care providers in general, and for those designed to influence pediatricians' communication with parents regarding the HPV vaccine in particular.

Protecting health care workers: a pandemic simulation based on Allegheny County

Please cite this paper as: Cooley et al. (2010) Protecting health care workers: a pandemic simulation based on Allegheny County. Influenza and Other Respiratory Viruses 4(2), 61–72.

Background and Objectives  The Advisory Committee on Immunization Practices has identified health care workers (HCWs) as a priority group to receive influenza vaccine. Although the importance of HCW to the health care system is well understood, the potential role of HCW in transmission during an epidemic has not been clearly established.

Methods  Using a standard SIR (Susceptible–Infected–Recovered) framework similar to previously developed pandemic models, we developed an agent‐based model (ABM) of Allegheny County, PA, that incorporates the key health care system features to simulate the spread of an influenza epidemic and its effect on hospital‐based HCWs.

Findings  Our simulation runs found the secondary attack rate among unprotected HCWs to be approximately 60% higher (54·3%) as that of all adults (34·1%), which would result in substantial absenteeism and additional risk to HCW families. Understanding how a pandemic may affect HCWs, who must be available to treat infected patients as well as patients with other medical conditions, is crucial to policy makers’ and hospital administrators’ preparedness planning.

The increasing number of clinical items addressed during the time of adult primary care visits

BACKGROUND

Primary care physicians report that there is insufficient time to meet patients' needs during clinical visits, but visit time has increased over the past decade.

OBJECTIVE

To determine whether the number of clinical items addressed during the primary care visit has increased, and if so, whether this has been associated with changes in visit length and the pace of clinical work.

DESIGN

Analysis of non-hospital-based adult primary care visits from 1997 to 2005, as reported in the National Ambulatory Medical Care Survey.

PARTICIPANTS

A total of 46,431 adult primary care visits.

MEASUREMENTS

We assessed changes over time for the total number of clinical items addressed per visit (including diagnoses, medications, tests ordered, and counseling), visit duration, and average available time per clinical item. In adjusted analyses we controlled for patient and physician characteristics.

RESULTS

The number of clinical items addressed per visit increased from 5.4 to 7.1 from 1997 to 2005 (p < 0.001). Visit duration concurrently increased from 18.0 to 20.9 min (p < 0.001). The increase in the number of clinical items outpaced the increase in duration, resulting in a decrease in time per clinical item from 4.4 to 3.8 (p = 0.04). These changes occurred across patient age and payer status and were confirmed in adjusted analyses.

CONCLUSIONS

The volume of work associated with primary care visits has increased to a greater extent than has visit duration, resulting in less available time to address individual items. These findings have important implications for reimbursing physician time and improving the quality of care.

The impact of malpractice burden on Michigan obstetrician-gynecologists' career satisfaction

BACKGROUND

Medical services for pregnancy and childbirth are inherently risky and unpredictable. In many states, obstetrician-gynecologists (OB-GYNS) who attend the majority of childbirths in the United States and provide the most clinically complex obstetric procedures are struggling with increasing malpractice insurance premiums and litigation risk. Despite its significant implications for patient care, the potential impact of malpractice burden on OB-GYN physicians' career satisfaction has not been rigorously tested in previous research.

METHODS

Drawing on data from a statewide survey of obstetric providers in Michigan, this paper examined the association between medical liability burden and OB-GYNs' career satisfaction. Malpractice insurance premiums and malpractice claims experience were used as 2 objective measures for medical liability burden. Descriptive statistics were calculated and multivariable logistic regressions estimated for data analysis.

RESULTS

Although most respondents reported satisfaction with their overall career in medicine, 43.7% had become less satisfied over the last 5 years and 34.0% would not recommend obstetrics/gynecology to students seeking career advice. Multivariable regression analysis showed that compared to coverage through an employer, paying > or =$50,000/year for liability insurance premium was associated with lower career satisfaction among OB-GYNs (odds ratio, 0.35; 95% confidence interval, 0.13-0.93). We found no significant impact of malpractice claims experience, including both recent malpractice claims (during the last 5 years [2001--2006]) and earlier malpractice claims (>5 years ago), on overall career satisfaction.

CONCLUSIONS

The findings of this study suggest that high malpractice premiums negatively affect OB-GYN physicians' career satisfaction. The impact of the current medical liability climate on quality of care for pregnant women warrants further investigation.

Access intervention in an integrated, prepaid group practice: effects on primary care physician productivity

OBJECTIVE

To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice.

DATA SOURCES

Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information.

STUDY DESIGN

Dependent measures per quarter per FTE were office visits, work relative value units (WRVUs), WRVUs per visit, panel size, and total cost per member per quarter (PMPQ), for PCPs employed >0.25 FTE. General estimating equation regression models were included provider and enrollee characteristics.

PRINCIPAL FINDINGS

Panel size and RVUs per visit rose, while visits per FTE and PMPQ cost declined significantly between baseline and full implementation. Panel size rose and visits per FTE declined from baseline through rollout and full implementation. RVUs per visit and RVUs per FTE first declined, and then increased, for a significant net increase of RVUs per visit and an insignificant rise in RVUs per FTE between baseline and full implementation. PMPQ cost rose between baseline and rollout and then declined, for a significant overall decline between baseline and full implementation.

CONCLUSIONS

This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.

Do gender disparities persist in gastroenterology after 10 years of practice?

BACKGROUND

Cross-sectional studies confirm gender disparity in many aspects of the practice of medicine and surgery. Some data suggest the disparities diminish after 10 yr of practice. This study aims to examine gender discrepancies in income, social, and professional status of gastroenterologists after 10 yr of practice.

METHODS

Prospective, observational, cohort study of gastroenterologists incepted upon graduation from a U.S. GI fellowship program in 1993 and 1995. A 36-item questionnaire was sent to the cohort at 3, 5, and 10 yr after graduation from GI fellowship training. The following are the results of the final, 10th year survey.

RESULTS

A total of 168 men and 25 women (mean age 45.5 yr) responded. Men and women were equally likely to be board certified and married, however, women had fewer children. Men earned a mean annual gross income of $375,000 versus$245,000 for women (P= 0.001). After adjusting for practice setting, work hours, practice-ownership, free endoscopy center practice, and vacation time, female gastroenterologists earned $82,000 (22%) less per year than their male colleagues (95% CI $34,000-130,000, P= 0.001). Women were more frequently in academic practice (38%vs 17%), but were less likely to hold the most advanced academic positions.

CONCLUSIONS

After 10 yr of practice, significant economic, professional, and social disparities persist between male and female gastroenterologists in this cohort. Women were more likely to practice in a setting with flexible work hours, a family leave provision, and in a practice with other women. Initiatives to equalize pay and ensure opportunities for professional advancement for women may diminish the significant practice disparities incurred by women in gastroenterology.

Gender Differences in Ophthalmologists’ Annual Incomes

OBJECTIVE

To understand the association between provider gender and ophthalmologists' annual incomes.

DESIGN

Retrospective analysis of survey data collected from ophthalmologists by the American Medical Association (AMA) between 1992 and 2001.

PARTICIPANTS

Six hundred thirty white male and 62 white female actively practicing ophthalmologists who responded to the AMA's survey of physicians between 1992 and 2001 and who worked in an office-based practice.

METHODS

A linear regression model was generated to determine the association between provider gender and ophthalmologists' annual incomes after controlling for work effort, provider characteristics, and practice characteristics.

MAIN OUTCOME MEASURES

Annual incomes of male and female ophthalmologists in 2004 dollars after controlling for work effort, provider characteristics, and practice characteristics.

RESULTS

White female ophthalmologists reported having 24% fewer visits and working 5% fewer annual hours than their white male counterparts. White female ophthalmologists had practiced medicine for fewer years than white males and were more likely to be employees, as opposed to having an ownership interest in the practice, but less likely to be board certified. After adjustment for work effort, provider characteristics, and practice characteristics, white females' mean annual income was $219,194, or $55,091 (20%) lower than white males' (95% confidence interval, -$93,611 to -$16,572; P = 0.005).

CONCLUSIONS

During the 1990s, female gender was associated with lower annual incomes among ophthalmologists. Observed differences may be attributable to factors that we were not able to measure, such as whether the clinician practice was predominantly medical or surgical. However, just as policymakers are exploring gender differences in access to and outcomes of health care, they should further explore gender-based income differences among physicians.

"Patient-time", "doctor-time", and "institution-time": perceptions and definitions of time among doctors who become patients

OBJECTIVE

To examine views and experiences of conflicts concerning time in healthcare, from the perspective of physicians who have become patients.

METHODS

We conducted two in-depth semi-structured 2-h interviews concerning experiences of being health care workers, and becoming a patient, with each of 50 doctors who had serious illnesses.

RESULTS

These doctor-patients often came to realize as they had not before how patients experience time differently, and how "patient-time", "doctor-time", and "institution-time" exist and can conflict. Differences arose in both the long and short term, regarding historical time (prior eras/decades in medicine), prognosis (months/years), scheduling delays (days/weeks), daily medical events and tasks (hours), and periods in waiting rooms (minutes/hours). Definitions of periods of time (e.g., "fast", "slow", "plenty", and "soon") also varied widely, and could clash. Professional socialization had heretofore impeded awareness of these differences. Physicians tried to address these conflicts in several ways (e.g., trying to provide test results more promptly), though full resolution remained difficult.

CONCLUSIONS

Doctors who became patients often now realized how physicians and patients differ in subjective experiences of time. Medical education and research have not adequately considered these issues, which can affect patient satisfaction, doctor-patient relationships and communication, and care.

PRACTICE IMPLICATIONS

Physicians need to be more sensitive to how their definitions, perceptions, and experiences concerning time can differ from those of patients.

Race and gender differences in pediatricians' annual incomes

OBJECTIVE

To determine the association between race, gender, and pediatricians' annual incomes after controlling for work effort, provider characteristics, and practice characteristics.

METHODS

We conducted a retrospective analysis of 1172 actively practicing black and white male and female pediatricians who responded to the American Medical Association's annual survey of physicians between 1992 and 2001. We used linear regression modeling to calculate annual incomes adjusted for work effort, provider characteristics, and practice characteristics.

RESULTS

White men reported annual incomes of $183,430. After adjusting incomes for work effort, provider characteristics, and practice characteristics, black male pediatricians' mean annual income was $175,640 (95 per cent confidence interval [95 per cent CI], $150,344-201,138). This was $7790 (4.2 per cent) lower, but not statistically different from that of white men (P = .5). However, compared with white male pediatricians' incomes, white female pediatricians' incomes were $150,636 (95 per cent CI, $140,975-$160,298), or $32,794 (18 per cent) lower (P < .001); and black female pediatricians' incomes were $133,018 (95 per cent CI, $108,736-$157,300), or $50,412 (27 per cent) lower (P < .001).

CONCLUSIONS

During the 1990s, female gender was associated with lower annual incomes among pediatricians; differences were greatest for black women. These findings warrant further exploration to determine what factors might cause the gender-based income differences that we found.

The influence of provider sex on neurologists’ annual incomes

OBJECTIVE

We sought to determine the influence of provider sex on neurologists' annual incomes after controlling for work effort, provider characteristics, and practice characteristics.

METHODS

We used survey responses collected throughout the 1990s from 216 actively practicing neurologists and linear regression modeling to determine the independent influence of provider sex on neurologists' annual incomes.

RESULTS

White female neurologists reported seeing 11% fewer visits and working 6% fewer annual hours than their white male counterparts. White female neurologists had practiced medicine for fewer years than white males (p = 0.01). In addition, females were less likely to be employees, as opposed to having an ownership interest in the practice, and were more likely to be board certified, though not statistically significantly so. After adjustment for work effort, provider characteristics, and practice characteristics, white female neurologists' mean annual income was 165,321 dollars, or 47,854 dollars (22%) lower than that for white males (95% CI: 82,710 dollars lower to 12,997 dollars lower, p = 0.007).

CONCLUSION

During the 1990s, female sex was associated with lower annual incomes among neurologists. Just as policymakers are exploring sex differences in access to and outcomes health care, they should further explore these findings to ensure that income differences among physicians who provide that care are not unjustly driven by provider sex.

Race and gender differences in general internists' annual incomes

BACKGROUND

Specialty, work effort, and female gender have been shown to be associated with physicians' annual incomes; however, racial differences in physician incomes have not been examined.

OBJECTIVE

To determine the influence of race and gender on General Internists' annual incomes after controlling for work effort, provider characteristics, and practice characteristics.

DESIGN

Retrospective survey-weighted analysis of survey data.

PARTICIPANTS

One thousand seven hundred and forty-eight actively practicing General Internists who responded to the American Medical Association's annual survey of physicians between 1992 and 2001.

MEASUREMENTS

Work effort, provider and practice characteristics, and adjusted annual incomes for white male, black male, white female, and black female General Internists.

RESULTS

Compared with white males, white females completed 22% fewer patient visits and worked 12.5% fewer hours, while black males and females reported completing 17% and 2.8% more visits and worked 15% and 5.5% more annual hours, respectively. After adjustment for work effort, provider characteristics, and practice characteristics, black males' mean annual income was 188,831 dollars or 7,193 dollars (4%) lower than that for white males (95% CI: -31,054 dollars, 16,669 dollars; P=.6); white females' was 159,415 dollars or 36,609 dollars (19%) lower (95% CI: -25,585 dollars, -47,633 dollars; P<.001); and black females' was 139,572 dollars or 56,452 dollars (29%) lower (95% CI: -93,383 dollars, -19,520 dollars; P=.003).

CONCLUSIONS

During the 1990s, both black race and female gender were associated with lower annual incomes among General Internists. Differences for females were substantial. These findings warrant further exploration.

Gender differences in diagnostic radiologists' annual incomes

RATIONALE AND OBJECTIVES

Specialty, work effort, and gender have been shown to be associated with physicians' annual incomes; however, careful examination of the association between provider gender and physician incomes after correcting for other factors likely to influence income has not been conducted at the subspecialty level. We sought to determine the association between provider gender and diagnostic radiologists' annual incomes after controlling for work effort, provider characteristics, and practice characteristics.

MATERIALS AND METHODS

Using survey responses that were collected throughout the 1990s from 491 actively practicing white diagnostic radiologists, we generated a linear regression model to determine the association between provider gender and radiologists' annual incomes after controlling for work effort, provider characteristics, and practice characteristics.

RESULTS

White female radiologists reported working 2% fewer annual hours than their white male counterparts. Female radiologists had practiced medicine for fewer years than males, were more likely to be employees, as opposed to having an ownership interest in the practice, and were equally likely to be board certified. After adjustment for work effort, provider characteristics, and practice characteristics, female radiologists' mean annual income was $273,907, or $80,090 (23%) lower than that for white males (95% CI: $113,930 lower to $46,250 lower, P < .001).

CONCLUSIONS

During the 1990s, female gender was associated with lower annual incomes among diagnostic radiologists. Researchers should further explore the relationship between physician gender and incomes to determine what factors might cause the differences that we found.

The Influence of Physician Race and Gender on Obstetrician–Gynecologistsʼ Annual Incomes

OBJECTIVE

A study using 1998 data concluded that incomes of male and female obstetrician-gynecologists were essentially equivalent, after considering only differences in productivity. We examined the association between gender, race, and obstetrician-gynecologists' incomes, after correcting for productivity and other important practice and provider characteristics.

METHODS

Survey responses obtained from 1992 to 2001 from 962 actively practicing obstetrician-gynecologists and linear regression modeling were used to estimate the influence of race and gender on physicians' annual incomes after controlling for work effort, provider characteristics, and practice characteristics.

RESULTS

Compared with white male and black female obstetrician-gynecologists, black men reported seeing 5% more patient visits and working 18% more hours, while white women reported seeing 18% fewer visits and working 10% fewer annual hours. Women were more likely to be nonowner employees than men. White female obstetrician-gynecologists were less likely than the other groups to be board certified. After adjustment for work effort, provider characteristics, and practice characteristics, black men's mean reported annual income was 210,859 dollars, or 78,905 dollars (27%) lower than that for white men (95% confidence interval [CI] 120,082 dollars to 37,729 dollars lower; P < .001); white women's was 242,721 dollars, or 47,043 dollars (16%) lower (95% CI 70,127 dollars to 23,958 dollars lower; P < .001); and black women's was 246,355 dollars, or 43,409 dollars (15%) lower (95% CI 92,296 dollars to 5,478 dollars higher, P = .08).

CONCLUSION

During the 1990s, both black race and female gender were associated with substantially lower annual incomes among obstetrician-gynecologists. These findings warrant further exploration to ensure that income differences among physicians are not unjustly driven by race or gender.

Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.

Time spent in face-to-face patient care and work outside the examination room

PURPOSE

Contrary to physicians' concerns that face-to-face patient time is decreasing, data from the National Ambulatory Medical Care Survey (NAMCS) indicate that between 1988 and 1998, durations of primary care outpatient visits have increased. This study documented how physicians spend time during the workday, including time outside the examination room, and compared observed face-to-face patient care time with that reported in NAMCS.

METHODS

Using time-motion study techniques, for each of 11 physicians, 2 patient care days were randomly selected and documented by direct observation. Physician time spent on face-to-face patient care and 54 activities outside the examination room were documented. Data represent 12,180 minutes of work and 611 outpatient visits.

RESULTS

The average workday duration was 8.6 hours, and face-to-face patient care accounted for 55% of the day. Work outside the examination room relevant to a patient currently being seen averaged 14% of the day. Work related to a patient not physically present accounted for one fifth (23%) of the workday. The combination of face-to-face time and time spent on visit-specific work outside the examination room assessed by direct observation was significantly less than the 2003 NAMCS estimate of visit duration assessed by physician report (13.3 vs 18.7 minutes, P <.001).

CONCLUSIONS

Nearly one half of a primary care physician's workday is spent on activities outside the examination room, predominately focused on follow-up and documentation of care for patients not physically present. National estimates of visit duration overestimate the combination of face-to-face time and time spent on visit-specific work outside the examination room by 41%.

Life after 80 Hours: The Impact of Resident Work Hours Mandates on Trauma and Emergency Experience and Work Effort for Senior Residents and Faculty

BACKGROUND

The purpose of this study was to evaluate the impact of work hours mandates on (1) senior resident patient exposure and operating experience in trauma and emergency surgery and (2) faculty work effort.

METHODS

We measured resident and faculty work on the trauma and emergency surgery services at our Level I trauma center during two comparable 6-month periods. Period 1 (July 1-December 31, 2002) had no call restrictions, separate trauma and emergency service resident call, and some overlap of faculty call responsibilities. Period 2 (July 1-December 31, 2003) had resident work hours compliance and complete integration of resident and faculty trauma and emergency call. Work hours were measured by surveys for faculty and residents. All data were collected prospectively.

RESULTS

Resident exposure to trauma patients was similar during both time periods. Emergency surgery admissions declined during period 2; however, intensive care unit admissions increased. The number of operations performed by senior residents did not change; however, there was a shift in the median number of emergency surgery cases to more senior residents. Faculty work hours increased slightly despite a decrease in faculty call.

CONCLUSION

Work hours compliance resulted in a 50% reduction in senior resident call and a 19% decrease in their work hours with no significant change in trauma/emergency patient care exposure or operative case load. Service call amalgamation reduced faculty call by 21% but did not result in a corresponding change in work hours or productivity.

Surgeon workhours in the era of limited resident workhours

BACKGROUND

Resident workhours have received much attention, yet there is little information concerning faculty workhours. In addition, the perspectives of surgical faculty on the anticipated effects of reducing resident hours have not been studied.

STUDY DESIGN

An anonymous survey was distributed to all clinical faculty in the Departments of Surgery, Neurosurgery, Orthopaedics, and Otolaryngology at a single, large academic institution. Surgeons completed a detailed retrospective report of hours worked during a 1-week period. Opinions regarding resident workhour restrictions were also elicited. Chi-square or Student's t-tests were used to determine p values as appropriate, with p </= 0.05 considered significant.

RESULTS

Of 120 surveys distributed, 102 (85%) were returned. Subspecialty departments comprised 51% of respondents with 49% from general surgeons. The mean number of hours worked per week by faculty was 70.4 +/- 12.5 (SD) (73.8 +/- 14.1 for general surgeons versus 67.1 +/- 9.9 for subspecialists, p = 0.006), with only 44.1% having at least 1 day per week free from clinical duties. Up to 95% of general surgeons are paged overnight at least once per week (mean 13.6 +/- 11.2 calls/week), with 73% returning from home at least once during the week (mean 1.8 +/- 1.1 returns/week). Importantly, 84% of general surgeons believe reducing resident workhours will increase faculty hours, compared with 57% of subspecialists (p = 0.004). In addition, 87% predict that reducing resident hours will compromise surgical education, with only 11% believing the benefits of hour reduction will outweigh the negatives.

CONCLUSIONS

The recommended limit for resident workhours closely approximates the average number of hours worked by surgical faculty in an academic center. Despite this, significant concern exists among the majority of surgical faculty regarding the impact of resident workhour restriction, both on faculty workhours and on resident education.