Results of the SWJPCC Healthcare Survey

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA 

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Julene R. Robbins, PhD, NCSP

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Lewis Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

Abstract

Debate is ongoing on how best to pay for healthcare, with a public option gaining increasing popularity. However, the Southwest US has traditionally been politically conservative and, although population demographics are rapidly shifting towards minorities, this shift is not reflected in the physician population. We conducted a voluntary, anonymous, on-line survey of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership to determine if their attitudes differed from the public and/or nationwide surveys of physicians. The respondents, nearly all subspecialty care physicians, were universally consistent in their opinion that healthcare costs too much in the US. About two-thirds felt healthcare is a right. Administrative costs and insurance companies were viewed by most as the culprits for the high costs and hospital administrators and insurance company personnel were perceived as overpaid. Few viewed the electronic medical record as helpful in healthcare. These results seem mostly consistent with other Nationwide physician surveys. 

Introduction

Most Americans continue to see healthcare costs in the U.S. as a major issue, with 79% dissatisfied with healthcare costs (1). Americans who are covered by Medicare or Medicaid are the least dissatisfied (29%), while dissatisfaction is highest among the uninsured (62%) and averages 48% among those with private insurance (2). This dissatisfaction has been reflected in the current political debates with proposals including public options such as “Medicare for All”.

Physicians have also become increasingly dissatisfied with healthcare (3). A variety of factors, such as electronic medical records, income instability and fairness, and the burden of regulations have been identified as affecting physician satisfaction and each is also affected by cost (3). Surveys have reflected this dissatisfaction but none has focused specifically on the Southwest US. The Southwest is undergoing demographic shifting, particularly in Arizona, with an increasing number of minorities, especially Latinos (4). However, this changing racial and ethnic diversity is not reflected in the Southwest physician workforce, with the vast majority remaining Caucasian, although an increasing number are now women (5).

To uncover if attitudes regarding healthcare costs differ amongst the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership, we conducted an on-line survey. The results suggest that healthcare providers agree that healthcare costs too much. Furthermore, the majority favored administrative costs/insurance expenses as the predominate contributors to the increase in costs.

Methods

Survey

An experienced survey designer (JRR) constructed a survey with the goals of determining US Southwest physician attitudes towards healthcare costs and the possible causes for the high cost. Another goal was to keep the survey brief, since previous experience was that long surveys usually have a poor response. A series of 8 questions was developed (Appendix 1).

Data Collection and Statistical Analysis

Data was collected October 9, 2019 through November 27, 2019. Most results were expressed as a percentage of the responses. There were insufficient respondents between different groups (physicians, nurses, patients, etc.) to allow statistical analysis

Results

Demographics

There were 66 respondents, of which there were 61 subspecialty physicians or residents and 5 others (2 patients,1 nurse,1 technician, and 1 other). This likely reflects the readership of a pulmonary, critical care and sleep subspecialty journal such as the SWJPCC.

Healthcare Costs Too Much in the US.

There was universal agreement (all 66 respondents responding in the affirmative) that this statement is true.

Healthcare is a Right.

Forty-three of 65 responses marked this as true (66%). Twenty-two respondents felt that this statement was false (34%) and 1 with no response.

Causes for the Increase in Healthcare Costs.

The perceived causes for the increase in healthcare costs are shown in Figure 1.

Figure 1. Respondents answers for the causes of the increase in healthcare costs.

Although the answers somewhat differed, the majority felt that administrative costs and insurance companies were important contributors to increasing healthcare costs (39 of 62, 63%). None felt that physicians’ fees contributed to the increase in healthcare costs. Other responses are given in Appendix 2.

Which Healthcare Personnel Are Over- or Underpaid. 

There were 87 answers as regards which personnel are overpaid. The healthcare personnel that were felt to be overpaid are show in Figure 2.

Figure 2. Respondents answers to which personnel are overpaid.

There was consensus that hospital administrators and insurance personnel were overpaid with 78 of 87 (90%) responding that they were overpaid (multiple answers could be accepted). In contrast, only 4 respondents felt specialty care physicians, and only one each, viewed nurses and technicians as being overpaid. None felt primary care physicians were overpaid.

Answers to the question “which personnel are underpaid” mirrored the answers to which healthcare personnel were overpaid (Figure 3).

Figure 3. Respondents answers to which healthcare personnel are underpaid.

Forty-five of the 116 (39%) answers felt that primary care physicians were underpaid. A smaller number felt nurses (37 responses, 32%), technicians (26 responses, 22%), and specialty care physicians (8 responses, 7%) were underpaid. None felt that hospital administrators or insurance personnel were underpaid.

Method for Healthcare Payment

Most (65%) favored keeping private insurance but adding a public option or “Medicare for All” (15%) (Figure 4).

Figure 4. Responses to how to pay for healthcare.

Only 4 (6%) favored keeping the present system and only 2 (3%) favored mandatory managed care plans.

Innovations that Have Improved Quality in Healthcare

Innovations that were felt to improve healthcare are shown in Figure 5.

Figure 5. Innovations that have improved healthcare.

Nearly half of the 126 responses (53 responses, 42%) felt better pharmaceuticals had improved healthcare. Many also felt that internet access for medical education, such as looking up specific questions, on-line education (27 responses, 21%), and clinical decision support (26 responses, 21%) had helped. Interestingly, the most widespread innovation in healthcare in the past few years- electronic medical records- received the least support with only 5 positive responses (4%).

Discussion

This survey of readers of the Southwest Journal of Pulmonary and Critical Care strongly reflects the concern that healthcare costs too much in the US. About two-thirds of respondents felt healthcare is a right. Administrative costs and insurance companies were viewed by many as the reasons for the high costs with hospital administrators and insurance company personnel viewed as overpaid. Few viewed the electronic medical record as helpful in healthcare.

The physician opinion that healthcare costs too much is consistent with the US paying the highest cost for healthcare in the world, at over $10,000 per capita in 2017 (6). The concept that administrative costs account for much of these higher costs has only recently become widely accepted. This late realization is despite rising administrative costs highlighted by multiple articles from Woolhandler and Himmelstein, beginning with a 1991 article in the New England Journal of Medicine (7). They referred to medicine as “a spectator sport” with doctors, patients, and nurses performing before an enlarging audience of utilization reviewers, efficiency experts, and cost managers. Many physicians have watched in horror as the trend pointed out by these authors nearly 30 years ago has steadily worsened. Reports of ultrahigh CEO salaries have recently drawn some attention in both the medical and popular literature accenting the high administrative costs (8,9).

The high costs of healthcare have led to an increasing number of patients and physicians supporting a public option. Previously, physician groups, such as the American Medical Association (AMA), have thwarted public health insurance proposals since the 1930s. However, as the next generation of physicians takes on leadership roles, even groups such as the AMA are now reexamining this question (10). A March 2018 New England Journal of Medicine survey found 61 percent of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care (11). This is similar to the 80% of our readership favoring a public option. However, in our survey, most (65%) favored keeping private insurance in addition to the public option. This likely represents a physician reaction to increasing regulatory burdens by the Centers for Medicare and Medicaid Services and the Department Veterans of Affairs, two US government agencies involved in healthcare. 

Despite the changing population demographics in the Southwest US, physicians still tend to be Caucasian, although more are now women (4,5). Our data suggests that support for a public option is high among physicians. We did not ask our readers their age, although younger physicians preferentially seem to be more likely to support a public option (10). Furthermore, most pulmonary physicians are now Democrats who tend to support a public option (12). We also did not ask where the physicians practice, although it seems likely most are in the Southwest US.

Our data are consistent with other surveys, although the Southwest US and the Southern US are often viewed as the home of US conservatism. However, even though most favored a public option in our survey, there seems to be sufficient distrust of “big government” to limit the choice to only a public option (13).

References

1. Jones JM, Reinhart RJ. Americans remain dissatisfied with healthcare costs. Gallup Poll. Nov 28, 2018. Available at: https://news.gallup.com/poll/245054/americans-remain-dissatisfied-healthcare-costs.aspx (accessed 12/17/19).
2. Saad L. Four in 10 in U.S. dissatisfied with their healthcare costs. Gallup Poll. Dec 12, 2016. Available at: https://news.gallup.com/poll/199298/four-dissatisfied-healthcare-costs.aspx (accessed 12/17/19).
3. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q. 2014 Dec 1;3(4):1. eCollection 2014 Winter.
4. Cárdenas V, Kerby S, Wilf R. Arizona’s demographic changes. Center for American Progress. 2012. Available at: https://www.americanprogress.org/issues/poverty/news/2012/02/28/11060/arizonas-demographic-changes/ (Accessed 12/17/19).
5. Xierali IM, Nivet MA. The racial and ethnic composition and distribution of primary care physicians. J Healthcare Poor Underserved. 2018;29(1):556-70.     [CrossRef] [PubMed]
6. Sawyer B, Cox C. How does health spending in the U.S. compare to other countries? Peterson KFF Health System Tracker. December 7, 2018. Available at: https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-start (accessed 12/17/19).
7. Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of the US healthcare system. N Engl J Med. 1991;324(18):1253-8. [CrossRef] [PubMed]
8. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
9. Andrzejewski A.  Top U.S. "Non-Profit" hospitals & CEOs are racking up huge profits. Jun 26, 2019. Available at: https://www.forbes.com/sites/adamandrzejewski/2019/06/26/top-u-s-non-profit-hospitals-ceos-are-racking-up-huge-profits/#48c7a4d119df (accessed 12/17/19).
10. Luthra S. Once its greatest foes, doctors are embracing single-payer. Kaiser Health News. August 7, 2018. Available at: https://khn.org/news/once-its-greatest-foes-doctors-are-embracing-single-payer/ (accessed 12/17/19).
11. Serafini M. Why clinicians support single-payer-and who will win and lose. NEJM Catalyst. January 17, 2018. Available at: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0278 (accessed 12/17/19).
12. Frellick M. Physician specialties correlate with political affiliation. Medscape. October 12, 2016. Available at: https://www.medscape.com/viewarticle/870192 (accessed 12/17/19).
13. Robbins RA, Wang AC. Medicare for all-good idea or political death? Southwest J Pulm Crit Care. 2019;19(1):18-20. [CrossRef]

Cite as: Robbins RA, Gotway MB, Robbins JR, Wesselius LJ. Results of the SWJPCC healthcare survey. Southwest J Pulm Crit Care. 2020;20(1):9-15. doi: https://doi.org/10.13175/swjpcc074-19 PDF 

Nurse Practitioners' Substitution for Physicians

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

Background: To deal with a physician shortage and reduce salary costs, nurse practitioners (NPs) are seeing increasing numbers of patients especially in primary care. In Arizona, SB1473 has been introduced in the state legislature which would expand the scope of practice for NPs and nurse anesthetists to be fully independent practitioners. However, whether nurses provide equal quality of care at similar costs is unclear.

Methods: Relevant literature was reviewed and physician and nurse practitioner education and care were compared. Included were study design and metrics, quality of care, and efficiency of care.

Results: NP and physicians differ in the length of education. Most clinical studies comparing NP and physician care were poorly designed often comparing metrics such as patient satisfaction. While increased care provided by NPs has the potential to reduce direct healthcare costs, achieving such reductions depends on the particular context of care. In a minority of clinical situations, NPs appear to have increased costs compared to physicians. Savings in cost depend on the magnitude of the salary differential between doctors and NPs, and may be offset by lower productivity and more extensive testing by NPs compared to physicians.

Conclusions: The findings suggest that in most primary care situations NPs can produce as high quality care as primary care physicians. However, this conclusion should be viewed with caution given that studies to assess equivalence of care were poor and many studies had methodological limitations.

Physician Compared to NP Education

Physicians have a longer training process than NPs which is based in large part on history. In 1908 the American Medical Association asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote a reformist agenda and hasten the elimination of medical schools that failed to meet minimum standards (1). Abraham Flexner was chosen to prepare a report. Flexner was not a physician, scientist, or a medical educator but operated a for-profit school in Louisville, KY. At that time, there were 155 medical schools in North America that differed greatly in their curricula, methods of assessment, and requirements for admission and graduation.

Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated."

At the time of Flexner's survey many American medical schools were small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. Only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training often left something to be desired. A medical degree was typically awarded after only two years of study.

Flexner used the Johns Hopkins School of Medicine as a model. His 1910 report, known as the Flexner report, issued the following recommendations:

• Reduce the number of medical schools (from 155 to 31);
• Reduce the number of poorly trained physicians;
• Increase the prerequisites to enter medical training;
• Train physicians to practice in a scientific manner and engage medical faculty in research;
• Give medical schools control of clinical instruction in hospitals;
• Strengthen state regulation of medical licensure.

Flexner recommended that admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. He also argued that the length of medical education should be four years, and its content should be to recommendations made by the American Medical Association in 1905. Flexner recommended that the proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even financially.

By and large medical schools followed Flexner's recommendations. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations. As a result the following consequences occurred (2):

• Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving MD-granting institutions in 1935, 57 were part of a university.
• Physicians receive at least six, and usually eight, years of post-secondary formal instruction, nearly always in a university setting;
• Medical training adhered closely to the scientific method and was grounded in human physiology and biochemistry;
• Medical research adhered to the protocols of scientific research;
• Average physician quality increased significantly.

The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day.

Today, physicians usually have a college degree, 4 years of medical school and at least 3 years of residency. This totals 11 years after high school.

The history of NP education is much more recent. A Master of Science in Nursing (MSN) is the minimum degree requirement for becoming a NP (3). This usually requires a bachelor of science in nursing and approximately 18 to 24 months of full-time study.  Nearly all programs are University-affiliated and most faculty are full-time. The curricula are standardized.

NPs have a Bachelor of Science in Nursing followed by 1 1/2 to 2 years of full-time study. This totals 5 1/2 to 6 years of education after high school.

Differences and Similarities Between Physician and NP Education

Curricula for both physicians and nurses are standardized and scientifically based. The length of time is considerably longer for physicians (about 11 years compared to 5 1/2-6 years). There are also likely differences in clinical exposure. Minimal time for a NP is 500 hours of supervised, direct patient care (3). Physicians have considerably more clinical time. All physicians are required to do at least 3 years of post-graduate education after medical school. Time is now limited to 70 hours per week but older physicians can remember when 100+ hour weeks were common. Given a conservative estimate of 50 hours/week for 48 weeks/year this would give physicians a total of 7200 hours over 3 years at a minimum.

Hours of Education and Outcomes

The critical question is whether the number of hours NPs spend in education is sufficient. No studies were identified examining the effect of number of hours of NP education on outcomes. However, the impact of recent resident duty hour restrictions may be relevant.

Resident Duty Hour Regulations

There are concerns about the reduction in resident duty hours. The idea between the duty hour restriction was that well rested physicians would make fewer mistakes and spend more time studying. These regulations resulted in large part from the infamous Libby Zion case, who died in New York at the age of 18 under the care a resident and intern physician because of a drug-drug reaction resulting in serotonin syndrome (4). It was alleged that physician fatigue contributed to Zion's death. In response, New York state initially limited resident duty hours to 80 per week and this was followed in July 2003 by the Accreditation Council for Graduate Medical Education adopted similar regulations for all accredited medical training institutions in the United States. Subsequently, duty hours were shortened to 70 hours/week in 2011.

The duty hour regulations were adopted despite a lack of studies on their impact and studies are just beginning to emerge. A recent meta-analysis of 27 studies on duty hour restriction, demonstrated no improvements in patient care or resident well-being and a possible negative impact on resident education (5). Similarly, an analysis of 135 articles also concluded here was no overall improvement in patient outcomes as a result of resident duty hour restrictions; however, some studies suggest increased complication rates in high-acuity patients (6). There was no improvement in education, and performance on certification examinations has declined in some specialties (5,6). Survey studies revealed a perception of worsened education and patient safety but there were improvements in resident wellness (5,6).

Although the reasons for the lack of improvement (and perhaps decline) in outcomes with the resident duty hour restriction are unclear, several have speculated that the lack of continuity of care resulting from different physicians caring for a patient may be responsible (7). If this is true, it may be that the reduction in duty hours has little to do with medical education or experience but the duty hour resulted in fragmentation which caused poorer care.

Comparison Between Physician and NP Care In Primary Care

A meta-analysis by Laurant et al. (8) in 2005 assessed physician compared to NP primary care. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent outpatient visits. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilization or cost.

However, Laurant et al. (8) advised caution since only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. Noted was a lower NP productivity compared to physicians (Figure 1).

  

Figure 1. Median ambulatory encounters per year (9).

The lower number of visits by NPs implies that cost savings would depend on the magnitude of the salary differential between physicians and nurses, and might be offset by the lower productivity of nurses compared to physicians.

More recent reviews and meta-analysis have come to similar conclusions (10-13). However, consistent with Laurant et al's. (8) warning studies tend to be underpowered, poor quality and often biased.

Despite the overall similarity in results, some studies have reported to show a difference in utilization. Hermani et al. (14) reported increased resource utilization by NPs compared to resident physicians and attending physicians in primary care at a Veterans Affairs hospital. The increase in utilization was mostly explained by increased referrals to specialists and increased hospitalizations. A recent study by Hughes et al. (15) using 2010-2011 Medicare claims found that NPs and physician assistants (PAs) ordered imaging in 2.8% episodes of care compared to 1.9% for physicians. This was especially true as the diagnosis codes became more uncommon. In other words, the more uncommon the disease, the more NPs and PAs ordered imaging tests.

NPs Outside of Primary Care

Although studies of patient outcomes in NP-directed care in the outpatient setting were few and many had methodological limitations, even fewer studies have examined NPs outside the primary care clinic. Nevertheless, NPs and PAs have long practiced in both specialty care and the inpatient setting. My personal experience goes back into the 1980s with both NPs and PAs in the outpatient pulmonary and sleep clinics, the inpatient pulmonary setting and the ICU setting. Although most articles are descriptive, nearly all articles describe a benefit to physician extenders in these areas as well as other specialty areas.

More recently NPs may have hired to fill “hospitalist” roles with scant attention as to whether the educational preparation of the NP is consistent with the role (16). According to Arizona law, a NP "shall only provide health care services within the NP's scope of practice for which the NP is educationally prepared and for which competency has been established and maintained” (A.A.C. R4-19-508 C). The Department of Veterans Affairs conducted a study a number of years ago examining nurse practitioner inpatient care compared to resident physicians care (17). Outcomes were similar although 47% of the patients randomized to nurse practitioner care were actually admitted to housestaff wards, largely because of attending physicians and NP requests. A recent article examined also NP-delivered critical care compared to resident teams in the ICU (18). Mortality and length of stay were similar.

Discussion

NP have less education and training than physicians. It would appear that the scientific basis of the curricula are similar and there is no evidence that the aptitude of nurses and physicians differ. Therefore, the data that nurses care for patients the same as physicians most of the time is not surprising, especially for common chronic diseases. However, care may be divergent for less common diseases where lack of NP training and experience may play a role.

Physicians have undergone increased training and certification over the past few decades, nurses are now doing the same. The American Association of Colleges of Nursing seems to be endorsing further education for nurses encouraging either a PhD or a Doctor of Nurse Practice degree (19). However, the trend in medicine has been contradictory requirements for increasing training and certification for physicians while substituting practitioners with less education, training and experience for those same physicians. An extension of this concept has been that traditional nursing roles are increasingly being filled by medical assistants or nursing assistants (20). The future will likely be more of the same. NPs will be substituted for physicians; nurses without advanced training will be hired to substitute for NPs and PAs; and medical assistants will increasingly be substituted for nurses all to reduce personnel costs. It is likely that studies will be designed to support these substitutions but will frequently be underpowered, use rather meaningless metrics or have other methodology flaws to justify the substitution of less qualified healthcare providers.

Much of this "dummying down" has been driven by shortage of physicians and/or nurses. The justification has always been that substitution of cheaper providers will solve the labor shortage while saving money. However, experience over the past few decades in the US has shown that as education and certification requirements increase, compensation has decreased for physicians (21). NPs can likely expect the same.

Some are asking whether physicians should abandon primary care. After years of politicians, bureaucrats and healthcare administrators promising increasing compensation for primary care, most medical students and resident physicians have realized that this is unlikely. Furthermore, the increasing intrusion of regulatory agencies and insurance companies mandating an array of bureaucratic tasks, has led to increasing dissatisfaction with primary care (22). Consequently, most young physicians are seeking training in subspecialty care. It seems apparent that it is less of a question of whether physicians will be making a choice to abandon primary care in the future, but without a dramatic change, the decision has already been made.

Arizona SB1473, the bill that would essentially make NPs equivalent to physicians in the eyes of the law, is an expected extension of the current trends in medicine. Although physicians might object, supporters of the legislation will likely accuse physicians of merely protecting their turf. Personally, I am disheartened by these trends. The current trends seem a throwback to pre-Flexner report days. The poor studies that support these trends will do little more than allow the unscrupulous to line their pockets by substituting a practitioner with less education, experience and training for a well-trained, experienced physicians or nurses.

References

1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. New York, NY: The Carnegie Foundation for the Advancement of Teaching; 1910. Available at: http://archive.carnegiefoundation.org/pdfs/elibrary/Carnegie_Flexner_Report.pdf (accessed 2/6/16).
2. Barzansky B; Gevitz N. Beyond Flexner. Medical Education in the Twentieth Century. New York, NY: Greenwood Press; 1992.
3. National Task Force on Quality Nurse Practitioner Education. Criteria for evaluation of nurse practitioner programs. Washington, DC: National Organization of Nurse Practitioner Faculties; 2012. Available at: http://www.aacn.nche.edu/education-resources/evalcriteria2012.pdf (accessed 2/6/16).
4. Lerner BH. A case that shook medicine. Washington Post. November 28, 2006. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html (accessed 2/9/16).
5. Bolster L, Rourke L. The effect of restricting residents' duty hours on patient safety, resident well-being, and resident education: an updated systematic review. J Grad Med Educ. 2015;7(3):349-63. [CrossRef] [PubMed]
6. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041-53. [CrossRef] [PubMed]
7. Denson JL, McCarty M, Fang Y, Uppal A, Evans L. Increased mortality rates during resident handoff periods and the effect of ACGME duty hour regulations. Am J Med. 2015;128(9):994-1000. [CrossRef] [PubMed]
8. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271. [CrossRef]
9. Medical Group Management Association. NPP utilization in the future of US healthcare. March 2014. Available at: https://www.mgma.com/Libraries/Assets/Practice%20Resources/NPPsFutureHealthcare-final.pdf (accessed 2/17/16).
10. Tappenden P, Campbell F, Rawdin A, Wong R, Kalita N. The clinical effectiveness and cost-effectiveness of home-based, nurse-led health promotion for older people: a systematic review. Health Technol Assess. 2012;16(20):1-72. [CrossRef] [PubMed]
11. Donald F, Kilpatrick K, Reid K, et al. A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nurs Res Pract. 2014;2014:896587. [CrossRef] [PubMed]
12. Bryant-Lukosius D, Carter N, Reid K, et al. The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review. J Eval Clin Pract. 2015;21(5):763-81. [CrossRef] [PubMed]
13. Kilpatrick K, Reid K, Carter N, et al. A systematic review of the cost-effectiveness of clinical nurse specialists and nurse practitioners in inpatient roles. Nurs Leadersh (Tor Ont). 2015;28(3):56-76. [PubMed]
14. Hemani A, Rastegar DA, Hill C, al-Ibrahim MS. A comparison of resource utilization in nurse practitioners and physicians. Eff Clin Pract. 1999;2(6):258-65. [PubMed]
15. Hughes DR, Jiang M, Duszak R Jr. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits. JAMA Intern Med. 2015;175(1):101-7. [CrossRef] [PubMed]
16. Arizona Board of Nursing. Registered nurse practitioner (rnp) practicing in an acute care setting. Available at: https://www.pncb.org/ptistore/resource/content/faculty/AZ_SBN_RNP.pdf (accessed 2/12/16).
17. Pioro MH, Landefeld CS, Brennan PF, Daly B, Fortinsky RH, Kim U, Rosenthal GE. Outcomes-based trial of an inpatient nurse practitioner service for general medical patients. J Eval Clin Pract. 2001;7(1):21-33. [CrossRef] [PubMed]
18. Landsperger JS, Semler MW, Wang L, Byrne DW, Wheeler AP. Outcomes of nurse practitioner-delivered critical care: a prospective cohort study. Chest. 2015;148(6):1530-5. [CrossRef] [PubMed]
19. American Association of Colleges of Nursing. DNP fact sheet. June 2015. Available at: http://www.aacn.nche.edu/media-relations/fact-sheets/dnp (accessed 2/13/16).
20. Bureau of Labor Statitistics. Occupational outlook handbook: medical assistants. December 17, 2015. Available at: http://www.bls.gov/ooh/healthcare/medical-assistants.htm (accessed 2/13/16).
21. Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. [CrossRef]
22. Peckham C. Physician burnout: it just keeps getting worse. Medscape. January 26, 2015. Available at: http://www.medscape.com/viewarticle/838437_3 (accessed 2/13/16).

Cite as: Robbins RA. Nurse pactitioners' substitution for physicians. Southwest J Pulm Crit Care. 2016;12(2):64-71. doi: http://dx.doi.org/10.13175/swjpcc019-16 PDF 

Special Article: Physician Burnout-The Experience of Three Physicians

Robert A. Raschke, MD

University Banner Good Samaritan Medical Center

Phoenix, AZ

Our fellowship held a discussion on physician burnout which was facilitated by Kris Cooper PhD, a psychologist who has long experience working with struggling physicians. We were joined by three physicians who volunteered to share their personal experiences regarding burnout. Each of these three physicians are exceptional in their devotion to their profession, high self-expectation, and level of professional achievement. Yet the commendable personal characteristics they share may have actually set them up to ultimately suffer burnout. Each of them responded to burnout in a different way.

The first physician is an intensivist who left work suddenly 6 months ago, likely never to return. Over a long career, this physician had earned the respect of his colleagues and was beloved by the nurses for seeming to always knowing the right thing to do and dedicating himself fully to the care of the sickest patients and their families. For most of his career he rarely experienced anxiety even under the most stressful situations - “I did not even know really what it meant to be anxious”. He typically slept soundly 8 hours a night no matter what had happened at work. But nearing the end of his career he felt he had been floundering, essentially “propped-up” by the housestaff and his partners as he became progressively unable to function. At the time of his sudden departure, he was suffering unremitting insomnia, anxiety, and low self-confidence. He routinely avoided taking the sickest patients. His anxiety became so severe that he suffered anticipatory nausea even when simply accepting hand-off of the ICU service by phone.   

He relates the beginning of his professional difficulties to seven years previously when his wife of 20 years unexpectedly announced her intention to divorce him. This was emotionally highly traumatic and essentially caused a situation of unremitting stress both at work and at home. He recalled often having to deal with divorce lawyers even while at work – once having been called by a lawyer while was trying to run a code. He was not able to remediate his marriage. The process was frustrating and costly, however, he was able to seemingly recover over a prolonged course. He continued functioning at a high level at work during this process and for a number of years afterwards however he found himself socially isolated and with new financial worries.

Several years later a series of complaints were lodged against him at work. In one case, he was reprimanded for publically berating a colleague regarding an inappropriate patient transfer to the ICU. Several of his patients suffered bad outcomes and were submitted for peer review. However, the reviewers were not intensivists, and he felt were not truly “peers” in the sense that they couldn’t relate to the types of decisions required in ICU emergencies. In one case, a hematologist criticized his decision to give activated factor VII to a patient who was coding from uncontrollable obstetrical hemorrhage after the blood bank was unable to provide plasma. It was decided that his action in this case was outside the standard of care, although the reviewer did not offer any therapeutic alternative. In another incident, the physician extubated a patient who was subsequently unable to maintain independent breathing. Attempts to reintubate were unsuccessful and consequently fatal. In each case, the physician knew he had done the best he possibly could for the patient, but this chain of events cumulatively resulted in enduring workplace anxiety and a loss of self-confidence. Although he continued to provide good patient care, he felt he was “faking it”, by avoiding the sickest patients and leaning heavily on residents and fellows. He sometimes asked as many as three physicians (a critical care colleague, surgeon, and anesthesiologist) to back him up when one of his patients required endotracheal intubation, although his airway skill level demonstrated over the long course of his career was excellent.

A tremor which he had suffered with for several years worsened, making it even more difficult to perform procedures. He complained of neck pain and arm weakness but a neurological evaluation was unrevealing. He was repeatedly sick with the stomach flu and upper respiratory tract infections. He was diagnosed with depression, anxiety and post-traumatic stress disorder (PTSD), but prescription medications provided no benefit and seemed to worsen somatic complaints. Insomnia became unremitting. He would go for weeks on end, sleeping only a few hours per night, or not at all. Although he was overcome by anxiety, he became detached from more situationally-appropriate emotions – relating that he could run a code, watch the patient die, then “go right to the doctor’s lounge and eat a cheeseburger”- as though his feelings about things that were happening around him were irrelevant. The realization that he could no longer go on this way hit him suddenly and somewhat expectedly, although in retrospect it should have been obvious much sooner.

Up to 50% of physicians and nurses experience “burnout” at some point in their career – the highest incidence is in critical care (1). Burnout is characterized by the triad of emotional exhaustion, depersonalization, and a loss of any satisfaction in doing your job. It is caused by long term exposure to emotionally demanding situations in an environment of high responsibility and low control. Physicians with high empathy and high self-expectation and introspection are particularly at risk. It is associated with having made mistakes, perceptions of unreasonable work demands, feeling unsupported by the organization, and interpersonal conflicts. Symptoms include somatic complaints, frequent minor illnesses, social withdrawal, cynicism, exhaustion, and feeling underappreciated and overworked. Burnout may overlap with compassion fatigue, PTSD, depression, anxiety, alcoholism and drug abuse in some providers. The risk of suicide is increased by 600% for physicians, particularly female physicians.

The first physician said that he had a number of strikes against him, and took a number of wrong turns along the way. He recalled coming home from work exhausted many nights, and having no one to talk to, but at the same time, turning down opportunities to socialize more with friends. He felt he sometimes created more workplace stress than necessary by futilely resisting the hospital administration on a number of trivial issues. His partners were supportive, but really did not understand enough about what he was going through to effectively help him. He waited too long to get himself out of the environment.

But since removing himself from the ICU, he has been slowly improving under professional guidance. At this point, he has been away from work for about six months. [Many of the ICU staff – nurses and physicians alike – consider him the finest doctor they have ever worked with, and often ask when he can return.] But he is fairly certain that he will ever be able to return to work in the ICU.

The second physician is a highly respected intensivist who retired about a year ago, unrelated to burnout. He was described by the first physician as “the best intensivist that I ever met over the course of my career”. However, the second physician suffered significant setbacks and frustration that greatly reduced enjoyment of his career. He distinguished himself as being “fed-up” vs. being burned-out by saying that if we asked him to come into the ICU tomorrow to cover a shift, he would be eager to chip-in.

He also distinguished himself from the first physician by acknowledging that his wife of 42 years had been a huge source of support throughout the course of his many professional setbacks.

In the 1980s, in an era long before the practice of palliative care was accepted, he recalled being approached by several families of patients with end-stage COPD. At the time such patients often suffered through prolonged courses of futile ventilatory support before dying. He made a personal decision to instead offer these patients the option of morphine palliation. This was of clear benefit to his patients, but was considered well outside the standard of care at the time. He was accused of performing euthanasia, and his medical license was threatened. He was offered a deal to continue practicing medicine if he would desist and admit that what he had been doing was wrong. But his wife reassured him that he was doing the right thing and advised him not to give in. He successfully fought the complaint and continued practice. He earned a reputation for being one of the hardest-working, dedicated, and experienced physicians in the city.

In the 1990s, at the peak of his career, he diagnosed a patient with Miller Fisher variant of Guillain Barré, and placed a subclavian line to accomplish therapeutic plasmapheresis. He had previously placed perhaps thousands of subclavian lines over the course of his career. This time however, he lacerated the subclavian artery during the procedure. The patient suffered a life-threatening hemothorax requiring emergent surgical repair. The patient slowly recovered over a month-long ICU stay, during which the physician rarely left the hospital. But despite the eventual favorable outcome, he was sued, and a settlement was not reached. The case went to trial. He recalls that his wife sat in court with him every day. Ultimately he was exonerated by the jury, and he feels his wife’s constancy at his side was likely favorable in their eyes. But the cumulative stress of the traumatic and prolonged legal process changed how he felt about coming to work in the ICU. He tried to return, but his partner convinced him that he needed a break from patient care. He became a successful researcher for a few years. Then he tried his hand at general internal medicine “which was terrible – unless you enjoy writing Percocet scripts for everyone”. He even did a stint as an administrator, which he felt was a mistake in retrospect “you can't make yourself into something you are not”. Eventually, he found his way back to critical care, which he still says is “in my DNA”. Although now retired, he enthusiastically volunteers to do locums work in the ICU (but only with his wife’s approval) and remains a highly effective bedside intensivist and great favorite of the entire ICU staff.

This physician felt several things helped explain his ability to survive the difficult tribulations of his career. He credits his wife being by his side, and his work partner for actively intervening when he was floundering but did not see that he needed a break from patient care. He also thinks his personal philosophy helped him deal with setbacks. “Essentially, bad things happen in the ICU. If you gave it all that you could, you ought to be able to live with yourself, no matter how things turn out. If you cannot do that, you won’t last long in the ICU”.

The third physician pioneered his specialty in the state of Arizona. When he went into single practice in the 1980s, he estimates that he went at least three years without having a single night that wasn’t interrupted by a pages or phone calls. On top of his rapidly growing patient practice, he travelled around the state, lecturing at dozens of venues to establish his specialty in the state. As his practice grew, physicians started to refer him their most complicated patients, many of whom already had complicated medical-legal issues before he was involved. This resulted in his being included in multiple law suits. At one point he was named in over two dozen open suits. Even though he was not found guilty of malpractice in a single case, the cumulative stress of repeated medical legal conflicts took a heavy toll on him. He felt that there was absolutely no support available from the hospitals he worked at, or from professional societies of that time period. He became irritable, angry, and increasingly disengaged. “If you want to know if you’re burned-out, just ask your wife”. He began suffering a series of physical complaints including headaches, palpitations, blepharospasm, and symptoms of irritable bowel for which extensive medical workups were negative. Finally one day he snapped. His pager went off for the ten-thousandth time, and he put his fist through the wall, and told his wife “that’s it – I’m though with (expletive deleted) medicine”.

Fortunately his partners supported his decision to step back from patient care, but advised him to concentrate his considerable experience and interpersonal and organizational skills into the administrative side of their practice. He subsequently achieved a high level of accomplishment and job satisfaction, and currently runs the national professional society of his specialty.

This physician subsequently became a strong advocate for recognition of physician burnout, within his practice, and within his specialty on a national level. He offered some good advice for the audience: Learn what burnout is. If you have the symptoms, you have to stop pretending you’re not burned-out and get professional help. If you notice behaviors of burnout in a colleague, reach out and talk to them.

He pointed out a number of ways to resist the effects of burnout:

• Maintain harmony in your life. It’s not all about work. Family, community, your personal needs, and your spirituality should all be integrated into a healthy lifestyle.
• Do something non-medical that you love to do every day – whether that is walking your dog, playing guitar or reading a good (non-medical) book.
• Get some control of your work schedule and how many hours you are working. Overwork will ultimately ruin both your productivity and the quality of your care. Remember why you went into medicine.
• Don’t build a lifestyle that fosters greed. Studies have shown that once a relatively modest income is achieved, more money does not make life more satisfying or happy. Be altruistic.
• The best way to feel good about yourself is by helping others.
• Meditate each day about the good things that happened and people that you helped, rather than allow your mind to ruminate on negative events and worries.
• If you have interpersonal stress, talk to the person who is the source. Except for the occasional adversary with a personality disorder, open communication usually relieves interpersonal tensions.
• Exercise regularly - Your brain and body are connected.
• Don’t accept a job in which you are routinely asked to sacrifice important life experiences, such as being with your children as they grow up. These experiences cannot later be replaced by or compensated for by job promotions or greater financial income.

Reference

1. Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007;13(5):482-8. [CrossRef] [PubMed]

Reference as: Special article: physician burnout-the experience of three physicians. Southwest J Pulm Crit Care. 2015;10(4):190-4. doi: http://dx.doi.org/10.13175/swjpcc056-15 PDF

Finding a Mentor: The Complete Examination of an Online Academic Matchmaking Tool for Physician-Faculty

Guadalupe F. Martinez, PhD¹

Jeffery Lisse, MD¹

Karen Spear-Ellinwood, PhD, JD²

Mindy Fain, MD¹

Tejo Vemulapalli, MD¹

Harold Szerlip, MD³

Kenneth S. Knox, MD¹

¹Departments of Medicine and ²Obstetrics and Gynecology, University of Arizona, Tucson, AZ

³Department of Medicine, University of North Texas Health Science Center Department of Medicine, Fort Worth, TX

Abstract

Background: To have a successful career in academic medicine, finding a mentor is critical for physician-faculty. However, finding the most appropriate mentor can be challenging for junior faculty. As identifying a mentor pool and improving the search process are paramount to both a mentoring program’s success, and the academic medical community, innovative methods that optimize mentees’ searches are needed. This cross-sectional study examines the search and match process for just over 60 junior physician-faculty mentees participating in a department-based junior faculty mentoring program. To extend beyond traditional approaches to connect new faculty with mentors, we implement and examine an online matchmaking technology that aids their search and match process.

Methods: We describe the software used and events leading to implementation. A concurrent mixed method design was applied wherein quantitative and qualitative data, collected via e-surveys, provide a comprehensive analysis of primary usage patterns, decision making, and participants’ satisfaction with the approach.

Results: Mentees reported using the software to primarily search for potential mentors in and out of their department, followed by negotiating their primary mentor selection with their division chief’s recommendations with those of the software, and finally, using online recommendations for self-matching as appropriate. Mentees found the online service to be user-friendly while allowing for a non-threatening introduction to busy senior mentors.

Conclusions: Our approach is a step toward examining the use of technology in the search and match process for junior physician-faculty. Findings underscore the complexity of the search and match process.

Introduction

Across the spectrum of disciplines within the academy, it is well documented that mentorship is key to career advancement and satisfaction among faculty (1). For physician-faculty, mentoring is “considered to be a core component of the faculty duties…to fulfill…th(e) academic medicine mission” (2). Although important, structural barriers to mentorship still exist (2,3). Finding an appropriate mentor is critical not only in establishing a productive and engaging mentorship, but in having a successful career in academic medicine (4). However, scholars note that finding the most appropriate person is not without its challenges: especially for junior faculty (3-7,9). Some studies find that junior faculty (and faculty new to institutions) depict the search process as the most difficult step in establishing a mentorship (3,7,9,10). In these studies, mentees recommend a match process that begins with a comprehensive list of potential mentors that includes contact information (3,7). Although noteworthy, this recommendation fails to elaborate on the extent to which a mere list could improve the search and match process. How such lists are implemented or if supplemental mechanisms were used to connect unfamiliar faculty is unclear.

Prior literature stresses the importance of “effort and persistence” when embarking on a search (3,4,9). Through this seemingly daunting process, scholars specifically advise mentees to ask colleagues to connect them to others with similar interests, and invest time into researching the backgrounds of potential mentors to determine their suitability. However, there are inherent challenges to this approach. First, the time spent investigating mentor backgrounds may vary greatly depending on the number and quality of resources available to conduct such an investigation. Second, mentees new to an institution could find it difficult and/or unproductive to ask new colleagues to connect them to potential mentors as colleagues may not be able to make an appropriate connection if they are unfamiliar with the mentor pool. Although this could point mentees in the right direction, they could spend an inordinate amount of time meeting with numerous contacts only to find academic and clinical interests to be unrelated or tangentially related to theirs. Previous studies found that mentees who self-match with a mentor, are more likely to be satisfied with their mentorship experience (3,4,7,8). Yet, if the institutional mentoring culture functions as described above, mentees would have to rely solely on their division chief or department chair for an assigned mentor. This could be problematic if the chief or chair is unfamiliar with the strengths of the mentor pool.

In hallmark studies by Williams et al. (7), and Straus et al. (3), they highlight perceived barriers to mentorship from the mentee perspective, and find those to be: a) a lack of local and adequate mentor selection, b) time constraints for the mentors, c) inadequate access, and d) a lack of formal programs and mechanisms to connect faculty. Straus et al.’s (3) study also sheds light on mentees desire to choose a mentor instead of being assigned. They find that mentees perceive assigned partnerships as superficial, but that assigned matches are sometimes useful because the search process is challenging for those new to an institution. Given the conflicting perceptions, these authors call for additional strategies to improve the search and match process as well as an examination of those strategies. Methods to optimize mentees’ time and diversify searches have yet to be delineated. More importantly, the role technology could play in mentoring remains understudied. As identifying the mentor pool and improving the search process are paramount to both, a mentoring program’s success, and the academic medical community, innovative approaches are needed.

We build on the work of Straus et al. (3), and Sambunjak et al. (10) by examining the search and match process for physician-faculty mentees participating in our department-based mentoring program. In our cross-sectional study we seek to better understand internal matching behaviors and the role technology could play. We detail and explore technology aimed at improving the search and match process for our mentees. This “matching” tool further advances our knowledge about the role technology could (or could not) play in addressing the challenges associated with the search and match process. Our research questions ask: If a “matching” tool is implemented, what would the matching behavior be within the department? What are the primary usage patterns among mentees? How receptive have mentees been in adopting this mechanism to aid their search and matching efforts?

Methods

The University of Arizona’s Department of Medicine developed a department-based faculty mentoring program in March 2011 during which a needs assessment was conducted on junior physician-faculty. First, like Straus et al.’s (3) findings, mentees partaking in our needs assessment desired assistance with the search and match process. Mentees reported a lack of knowledge about available mentors, their areas of expertise, and difficulty establishing contact with senior faculty.  The committee concluded experimenting with a computer program that functioned much like an online matchmaking service would improve the process; extending matching beyond the common strategies of contact list distribution, top down assignments, and informal social forums. The committee then customized an online matchmaking program, Mentor Match© (Intrafinity Inc., Ontario), to create a “virtual space” for mentor and mentee use. The committee crafted a “one-stop shop” where faculty accessed mentor/ mentee profiles containing academic interests, department mentoring events, and mentorship contract templates (Figure 1).

Figure 1. University of Arizona department of medicine opening user console view.

It was suspected that our faculty demographics included an overrepresentation of junior faculty (assistant professor rank) as compared with the number of senior faculty (associate and full professor rank) (11,12).  Also evident was that commitments to medical students and trainees prevented senior faculty from being able to devote sufficient time to mentor junior faculty. As such, the committee piloted an interdisciplinary approach and included mentors outside the department and College of Medicine to compensate for the low number of available mentors in Medicine (e.g. Public Health).

Methodology

A concurrent mixed method design was applied. We triangulated quantitative (numerical) and qualitative (descriptive) data to provide a comprehensive analysis of the primary usage patterns related to search and match behavior, and understand satisfaction with the online tool (13). We generalized results to our sample and then explored nuances based on narrative feedback.

Implementation

With the official launch of the mentoring program in January 2012, Mentor Match© went live to connect over 100 physician-faculty and faculty-researchers. At this time, the Department of Medicine had 65 junior faculty in search of mentors. A combined total of 54 mentors (N=32 full professors; N=22 associate professors) from the Department of Medicine, Department of Emergency Medicine, and College of Public Health served as mentors for this group.

Faculty profiles include email addresses and detailed background information about each faculty member (e.g. academic track, age range, overall years teaching) (Figures 2 and 3).

Figure 2. University of Arizona department of medicine mentor/mentee profile and skills inventory.

Figure 3. University of Arizona department of medicine mentor/mentee profile and skills inventory.

Once faculty data is entered, Mentor Match© produces a complete listing of top recommended mentors based on similarities between mentees and mentors. One-on-one demonstration of how Mentor Match© works occurs during new faculty orientation. Current CVs are uploaded and available for in depth review of publication record, training history and current funding. Junior faculty can also access other junior faculty profiles in the department to form peer mentoring groups.

Participants, data, and analysis

Voluntary mid-year and annual assessments are components of the mentoring program. IRB approved questionnaires developed by the committee were disseminated to program participants as part of a broader study and program quality control. For ongoing program evaluation and to inform the committee, we collected data from five sources: a) committee meeting minutes, b) observation notes, c) human resources faculty rosters from 2011-2012; 2012-2013, d) 2011 junior faculty needs assessment report, and e) voluntary end-of-the-year questionnaires.

Study participants included only mentee MD’s, DO’s, PhD’s, MD/PhD’s, and MD/MPH’s with the rank of Assistant Professor, Lecturer or Research Scholar in the Department of Medicine on one of three faculty tracks: clinical-educator, clinical, and research.  

Cross tabulations formulated in SPSSv21 were used as part of survey analysis to compare categorical data from faculty rosters and questionnaires relevant to matching behavior and usage patterns. Qualitatively, document analysis using thematic coding for trend identification was conducted using Nvivo 10 to analyze narrative comments. Similarly, document analysis and thematic coding was implemented on committee meeting minutes, observation notes, and faculty roster to report the events and decision making process involved in the implementation of the program and matching tool (Figures 4 and 5).

Figure 4. Mentor match questionnaire (end-of-year).

Figure 5. Analysis coding scheme for setting description in methods and results.

Results

The program began with 65 mentees in January 2012. After annual faculty attrition, 72% of mentees (44/61) reported using the software and completed the voluntary end-of-year questionnaire in January 2013.

Selection patterns

Mentees were asked to report their primary use of Mentor Match©. Three usage patterns were apparent (Appendix D, Table 1.0a). Over half of mentees reported primarily using the software to search for potential mentors both in and out of the department. Almost a third of mentees reported mainly using the software to search for potential mentors within the department only. Just under 10% (4/44) of mentees reported primary usage of the software to expand their professional peer network. Slightly over half of males utilized the software to search for potential mentors both in and out of the department. However, among females, this latter usage pattern was even more prevalent (17/25; 68%). Among those reporting primary usage to search for professional network expansion, males reported this practice at a disproportionately higher rate (3/19; 15%) than that of their female counterparts (1/25; 4%).

While mentees considered the recommended list of potential mentors from Mentor Match© in their match decision, just over half reported negotiating their primary mentor selection with their division chief’s recommendations (25/44; 57%). This means that mentees discussed their search results and interests with their chief to come to an agreement about who would serve as their mentor (Tables 1-3).

Table 1. Questionnaire results: gender.

Table 2. Questionnaire results: Search and matching behavior after Mentor Match© implementation in the department primary use and gender cross tabulation.

Table 3. Match results and gender cross tabulation.

In this “negotiation” the mentee and chief come to a consensus instead of the chief assigning a partnership with no input from the mentee, a relatively common practice prior to this mentoring initiative. For the mentee, there is a sense of self-matching with guidance from the chief. This match pattern occurred proportionate to the respective totals of male and female mentees. An extremely small minority of junior faculty, all males, did not have mentors at the time of data collection (2/19; 10.5%). Finally, the next most common match patterns were the forced assignment (9/44; 20%) followed by the self-matched (8/44; 18%). At almost an even rate, female (5/25; 20%) and male (4/19; 21%) mentees reported considering the software’s top recommended mentors, but were ultimately assigned a mentor by their division chief. Remaining mentees (4/25; 16% females and 4/19; 21% males) reported considering the software’s recommendations, but eventually self-matched to a mentor of their choice.

Mentee feedback

The vast majority of mentees (40/44; 91%) found the software user-friendly, reporting that they would use the software for ongoing searches (Table 4). Questionnaire comments included positive feedback. Mentees’ appreciated the: a) non-threatening forum enabling access to detailed information about potential mentors, b) forum’s convenience, and c) functionality allowing access to research scholars outside the department. Finally, recommended improvements called for introductory training on website navigation, and viewing access to junior peer profiles.

Table 4. Mentee feedback.

Discussion

Building on Zerzan et al.’s (9) guide, we provide a robust description of implementing a software-based mentoring program. This software serves as a faculty directory and matching tool to facilitate mentors-mentee relationships in a large clinical department. Our systematic approach toward matching is a first step toward examining the use of technology to ease the search and match process for junior physician-faculty. We discovered that a “negotiated approach”, where junior faculty Mentor Match© selections were then explicitly discussed with division chiefs and department heads, was highly used and valued. Our data suggest that knowledge of local organizational culture or other information that can only be imparted through discussions with their chiefs and colleagues, are also highly valued.

Sambunjak et al.’s (10) qualitative study highlights the complexity of navigating partnerships. Our findings extend these observations to the search and match process, which is just as complex. More in-depth examination of the decision making process for those using software based matching or self-matching is needed to better understand what leads to junior faculty securing successful mentoring relationships. The shortage of mentors found in our needs assessment mirrored findings from national studies,^11,12 implying that mentoring junior faculty is a challenge or not a priority compared to students, residents, and fellows. Given today’s heavy emphasis on clinical productivity and formal responsibilities teaching \ trainees at all levels, inspiring senior faculty to mentor junior faculty could be particularly difficult (5,15).  Departmental leaders and program administrators must realize mentor shortages will impact the search experience regardless of methodology employed. The consequences of not addressing barriers in mentorship may include frustration with the search process, junior faculty turnover, and erosion of an important part of the academic culture. In addition to heeding recommendations by Straus et al. (3) of providing protected time and formal recognition for mentoring, departments should foster interdisciplinary networks inside and outside of the medical discipline, leverage the emeritus professor workforce, and embrace mentor panels. Technology based mentor searches could facilitate implementation of such initiatives with the goal of improving professional satisfaction among mentees.

Limitations

Our study examines the usage patterns of and feedback on Mentor Match© from the junior faculty mentee perspective, but there are limitations. First, we have not assessed whether and how mentors use Mentor Match© to research mentees who have reached out to them. Knowing if immediate access to mentees’ backgrounds and skills assists mentors in deciding whether to accept a mentorship or refer them to a colleague could inform us about the potential benefits of this software tool for mentors. This study also draws on a small mentee self-reporting sample in one department with just over half of all junior faculty participating. Although the sample is small, particularly regarding software feedback, findings provide a starting point to learn the technological needs of faculty related to the search and match challenge. Such data helps us tailor online profiles and site navigation. Finally, we also do not know whether there is a significant advantage to “negotiated” mentorships as compared with those established solely by using Mentor Match©.

Despite these limitations our study is the first to assess the role technology could play in the search and match process for physician-faculty. Casting the online matchmaking net more broadly to include other colleges and including trainees could add another dimension toward understanding how to improve the search and matching process in academic medicine.  

Conclusion

Our study details Mentor Match© implementation and illustrates that software driven approaches can assist physician-faculty in establishing mentoring relationships. This approach may complement other search and matching efforts ongoing in departments and may be used to connect faculty across disciplines. In general, this tool continues to have a positive impact in our department, helping to achieve our goal of facilitating and expanding the mentee’s professional networks.

Acknowledgments

Role of each author in manuscript preparation:

• Dr. Martinez is the lead author of this paper. Participation included mentoring program committee membership, IRB documentation, data collection, study design, analysis, initial manuscript draft, revision implementation, approve final version.
• Dr. Lisse’s participation included mentoring program committee membership, questionnaire design, manuscript review/editing, approve final version.
• Dr. Spear-Ellinwood’s participation included data member checking, manuscript review/editing, approve final version.
• Dr. Fain’s participation included mentoring program committee membership, questionnaire design, study design, manuscript review, approve final version.
• Dr. Vemulapalli’s participation included mentoring program committee membership, questionnaire design, study design, approve final version.
• Dr. Szerlip’s participation included chairing the mentoring program committee, manuscript review/editing, approve final version.
• Dr. Knox is the senior mentor on this paper. Participation included mentoring program committee membership, IRB documentation review, study design, questionnaire design, manuscript review/editing, approve final version.

Funding:

This study was partially funded by an internal educational research award by the University of Arizona College of Medicine Academy of Medical Education Scholars in November 2012 and the Department of Medicine Administration.

Secondary Publication Notice:

This descriptive article is an unabridged report. A 500 word version of the full length manuscript is under review for primary publication in Medical Education’s Really Good Stuff section. This section presents short reports that illustrate general lessons learned from innovation in medical education, and include very little data and description.

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Reference as: Martinez GF, Lisse J, Spear-Ellinwood K, Fain M, Vemulapalli T, Szerlip H, Knox KS. Finding a mentor: the complete examination of an online academic matchmaking tool for physician-faculty. Southwest J Pulm Crit Care. 2014;9(6):320-32. doi: http://dx.doi.org/10.13175/swjpcc138-14 PDF

Professionalism: Introduction

Robert A. Raschke, MD

Banner Good Samaritan Medical Center

Phoenix, AZ

Editor's note: This is the first of a multi-part series on professionalism. The remaining parts will be posted over the next few weeks.

An important event in my career occurred about 20 years ago, late on a Friday afternoon. I was scheduled on call in the ICU for the entire 72-hour weekend, and even though I was just getting started, I was already tired and in a lousy mood. At 5 PM, I got a consult to see a patient in the neuro ICU. He was a 34-year-old man who had attempted suicide by drinking ethylene glycol antifreeze after an argument with his girlfriend. He had initially stabilized from a medical standpoint, but then developed delayed-onset cerebral edema. The team that was taking care of him had unsuccessfully pursued all treatment options. After 8 days of effort, he remained in a deep coma, near brain death. Now, with nothing left to try, and no hope left for a good outcome, they were dumping responsibility onto me just in time for the weekend.

I considered this unhappily as I began to page through his thick chart, trying to suppress my frustration so that I could concentrate, but I was interrupted by the patient's nurse – Terry - before I could get very far. She told me that the patient's mom had just stormed into the unit, and was demanding to talk with her son’s doctor - which as of the last 10 minutes was now me.  She warned me that the patient’s mother was inpatient, accusatory and totally unrealistic about her son's prognosis, but despite all this, Terry acted somewhat relieved that I was there. The impression that she was somehow happy about the situation made me even more angry than I already was. 

I had had enough. I really gave Terry an earful– outlining all my suspicions about the bad motivations of the referring team and concluding with my refusal to do their dirty work. Somehow, in my self-centeredness, I expected her to empathize with me. But she didn't. Instead, she appeared to be somewhat shocked and deflated. She listened silently to my rant, then turned and walked away without saying anything.

It took me a few minutes to realize that she had a higher opinion of me than I had of myself. She had thought I was a good doctor– strong enough to shoulder a tough situation– compassionate and empathic for a bereaved mother - ready to take on this challenge and make a bad situation a little better. I had proved her wrong.

I always thought of myself as a good doctor, but I realized then that I really wasn't all that good. I composed myself and tried to reset my thinking. I introduced myself to the patient’s mother briefly after explaining that I hadn't had time to review all the records– later, we would sit down and really talk. She actually wasn’t as unreasonable as I imagined she might be. It turned out I did have an important job to do in this case– to help a grieving mother come to terms with the death of her beloved son. The next day I apologized to Terry– this turned out to be a good long-term investment, since we continue to work together to this day.

This was an experience that got me thinking about how I could try to become a better doctor. Not by studying in order to get smarter, but by having the proper goals and attitude– the things this series is about.  Recounting this story also gives me the opportunity to admit that I claim no special personal legitimacy to write a series for SWJPCC on professionalism. I am pretty lazy at times. I have a temper when I’m under pressure. I can sometimes be hurtful to nurses and residents. There are even a few people who would consider it the height of hypocrisy for me to come off like I know anything about being good.  During the week in which I first began writing this section, I did a bunch of very unprofessional things– things I was ashamed of them even as I was proceeding forward with them:

1. I got a page about a patient that was deteriorating just as I sat down to a very nice lunch. The patient was a young, otherwise– healthy alcoholic. I decided to relax and finish my lunch before heading up to see him. By time I finished dessert, he had deteriorated and was extremely unstable. 
2. I had misgivings about a patient’s DNR status. I thought the family might rescind the DNR order if they fully understood the clinical situation. But I didn’t want them to rescind DNR status, so I purposely avoided talking to them. 
3. I missed the essential (and not obscure) physical finding of abdominal pain in a patient with septic shock on steroids– a clinical mistake that I’ve repeatedly lectured others about during Mortality and Morbidity conference. This error delayed diagnosis of a life-threatening bowel perforation.
4. I declined a personal invitation to attend the memorial service of a patient that I felt very close to– who had in fact asked me for a hug the last time I had seen her before she died. Instead, I sat at home and watched TV.

So no, I am not an expert at professionalism. But I do care about it. So I am not going to write about the doctor I am, but about the doctor I want to be. Please look at this series in that spirit and do not allow my personal shortcomings to undermine our consideration of this topic.

Why discuss professionalism in medicine? I've considered the possibility that the age of professionalism is over– that talking about it is like trying to get your kids interested in playing the board-game Monopoly. Technology is the thing nowadays. It’s incredibly satisfying to help save a patient’s life with ECMO in the ICU. Yet some technological advances increasingly distance us from our patients.     

I have heard that when Laennec invented the stethoscope in 1816, there was widespread concern about the negative effect it might have on the doctor-patient relationship. Prior to the invention of the stethoscope, doctors placed their ear directly upon the patient's chest to listen to the heart and lungs. At this point in history, the stethoscope actually came between the doctor and patient– a barrier to the intimacy of the physical examination.

In a modern ICU, all patients are under "standard precautions" for infectious disease control– this means doctors and nurses are supposed to wear gloves when we shake their hand. Other infection control precautions require that masks, eye-shields and gowns be worn inside patient rooms. When we employ a proning bed, the patient is totally cocooned– it’s is difficult to even see a patient inside a prone bed, much less touch them.

Telemedicine is increasingly incorporated into patient care– this allows a physician anywhere in the world to take care of patients in our hospital remotely, utilizing video cameras. Mobile devices– almost like robots– with a face display video screen for a head, can be wheeled into a patient’s room to facilitate electronic interactions between doctors and patients.

The advent of the hospitalist has all but destroyed the traditional continuity of the doctor patient relationship. Patients who are sick enough to land in the hospital are rarely seen by their family doctor. Within the hospital, many doctors (including myself) work shifts– taking care of individual patients only within the time slots of their work schedule. Technically, my responsibility for my patients ends at "quitting time”.

More physicians are employed by healthcare systems than ever before. The choices that patients and doctors once made together are thereby increasingly influenced by non-physician administrators. Politicians have increasingly attempted to create financial incentives for doctors to behave as they think we should behave. The very semantics of related constructs such as the “physician report card” diminishes us as a profession, turning us back to a time before we could be trusted to know and do what was best for our patients.

I think it's fair to say that the risk that might lose our professionalism, our humanism, has never been greater than it is at this point in the history of medicine. So there has probably never been a better time to reconsider professionalism as an essential part of being a doctor.

Many of us were taught in medical school about how to “act professional” – maintaining a detached demeanor, not allowing yourself to get emotionally-involved, appearing confident in all situations, etc. That’s not the kind of professionalism I’m going to talk about. Sir William Osler once said “the secret to the care of the patient is in caring for the patient” I think that’s a much better place to start our consideration of professionalism.

In the next installment we will consider the Oath of Maimonides and how it applies to the practice of medicine in a modern ICU:

"The eternal providence has appointed me to watch over the life and health of Thy creatures.

May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.

Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."

Reference as: Raschke RA. Professionaism: introduction. Southwest J Pulm Crit Care. 2014;8(5):284-7. doi: http://dx.doi.org/10.13175/swjpcc067-14 PDF