Joy Melnikow

Background: A concern before 2020, physician burnout worsened during the COVID-19 pandemic. Little empirical data are available on pandemic workplace support interventions or their influence on burnout. We surveyed a national sample of frontline physicians on burnout and workplace support during the pandemic. Methods: We surveyed a stratified random sample of 12,833 US physicians most likely to care for adult COVID-19 patients from the comprehensive AMA Physician Professional Data ™ file. The sample included 6722 primary care physicians (3331 family physicians, 3391 internists), 880 hospitalists, 1783 critical care physicians (894 critical care physicians, 889 pulmonary intensivists), 2548 emergency medicine physicians, and 900 infectious disease physicians. The emailed survey elicited physicians’ perceptions of organizational interventions to provide workplace support and/or to address burnout. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Proportional specialty representation and response bias were addressed by survey weighting. Logistic regression assessed the association of physician characteristics and workplace interventions with burnout. Results: After weighting, respondents were representative of the total sample. Overall physician burnout was 45.4%, significantly higher than in our previous survey. Open-ended responses mentioned that staffing shortages (physician, nursing, and other staff) combined with the increased volume, complexity, and acuity of patients during the pandemic increased job demands. The most frequent workplace support interventions were direct pandemic control measures (increased access to personal protective equipment, 70.0%); improved telehealth functionality (43.4%); and individual resiliency tools (yoga, meditation, 30.7%). Respondents placed highest priority on workplace interventions to increase financial support and increase nursing and clinician staffing. Factors significantly associated with lower odds of burnout were practicing critical care (compared with emergency medicine) OR 0.33 (95% CI 0.12 – 0.93), improved telehealth functionality OR 0.47 (95% CI 0.23 – 0.97) and being in practice for 11 years or longer OR 0.44 (95% CI 0.19–0.99). Conclusions: Burnout across frontline specialties increased during the pandemic. Physician respondents focused on inadequate staffing in the context of caring for more and sicker patients, combined with the lack of administrative efforts to mitigate problems. Burnout mitigation requires system-level interventions beyond individual-focused stress reduction programs to improve staffing, increase compensation, and build effective teams.

Background: A concern before 2020, physician burnout worsened during the COVID-19 pandemic. Little empirical data are available on pandemic workplace support interventions or their influence on burnout. We surveyed a national sample of frontline physicians on burnout and workplace support during the pandemic.Methods: We surveyed a stratified random sample of 12833 US physicians most likely to care for adult COVID-19 patients from the comprehensive AMA Physician Professional Data ™ file. The sample included 6722 primary care physicians (3331 family physicians, 3391 internists), 880 hospitalists, 1783 critical care physicians (894 critical care physicians, 889 pulmonary intensivists), 2548 emergency medicine physicians, and 900 infectious disease physicians. The emailed survey elicited physicians’ perceptions of organizational interventions to provide workplace support and/or to address burnout. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Proportional specialty representation and response bias were addressed by survey weighting. Logistic regression assessed the association of physician characteristics and workplace interventions with burnout.Results: After weighting, respondents were representative of the total sample. Overall physician burnout was 45.4%, significantly higher than in our previous surveys. Open-ended responses mentioned that staffing shortages (physician, nursing, and other staff) combined with the increased volume, complexity, and acuity of patients during the pandemic increased job demands. The most frequent workplace support interventions were direct pandemic control measures (increased access to personal protective equipment, 70.0%); improved telehealth functionality (43.4%); and individual resiliency tools (yoga, meditation, 30.7%). Respondents placed highest priority on workplace interventions to increase financial support and increase nursing and clinician staffing. Factors significantly associated with lower odds of burnout were practicing critical care (compared with emergency medicine) OR 0.33 (95% CI 0.12–0.93), improved telehealth functionality OR 0.47 (95% CI 0.23–0.97) and being in practice for 11 years or longer OR 0.44 (95% CI 0.19–0.99).Conclusions: Burnout across frontline specialties increased during the pandemic. Physician respondents focused on inadequate staffing in the context of caring for more and sicker patients, combined with the lack of administrative efforts to mitigate problems. Burnout mitigation requires system-level interventions beyond individual-focused stress reduction programs to improve staffing, increase compensation, and build effective teams.

Background: Physician burnout and wellbeing are an ongoing concern. Limited research has reported on the impact of the COVID 19 pandemic on burnout over time among U.S. physicians.Methods: We surveyed U.S. frontline physicians at two time points (wave one in May–June 2020 and wave two in Dec 2020-Jan 2021) using a validated burnout measure. The survey was emailed to a national stratified random sample of family physicians, internists, hospitalists, intensivists, emergency medicine physicians, and infectious disease physicians. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Responses were weighted to account for sample design and non-response bias. Random effects and quantile regression analyses were used to estimate change in conditional mean and median PFI-BC scores, adjusting for physician, geographic, and pandemic covariates.Results: In the random effects regression, conditional mean burnout scores increased in the second wave among all respondents (difference 0.15 (CI: 0.24, 0.57)) and among respondents to both waves (balanced panel) (difference 0.21 (CI: − 0.42, 0.84)). Conditional burnout scores increased in wave 2 among all specialties except for Emergency medicine, with the largest increases among Hospitalists, 0.28 points (CI: − 0.19,0.76) among all respondents and 0.36 (CI: − 0.39,1.11) in the balanced panel, and primary care physicians, 0.21 (CI: − 0.23,0.66) among all respondents and 0.31 (CI: − 0.38,1.00) in the balanced panel. The conditional mean PFI-BC score among hospitalists increased from 1.10 (CI: 0.73,1.46) to 1.38 (CI: 1.02,1.74) in wave 2 in all respondents and from 1.49 (CI: 0.69,2.29) to 1.85 (CI: 1.24,2.46) in the balanced panel, near or above the 1.4 threshold indicating burnout. Findings from quantile regression were consistent with those from random effects.Conclusions: Rates of physician burnout during the first year of the pandemic increased over time among four of five frontline specialties, with greatest increases among hospitalist and primary care respondents. Our findings, while not statistically significant, were consistent with worsening burnout; both the random effects and quantile regressions produced similar point estimates. Impacts of the ongoing pandemic on physician burnout warrant further research.

Background: Physician burnout and wellbeing are an ongoing concern. Limited research has reported on the impact of the COVID 19 pandemic on burnout among U.S. physicians. Methods: We surveyed U.S. frontline physicians at two time points (wave one in May-June 2020 and wave two in Dec 2020-Jan 2021) using a validated burnout measure. The survey was emailed to a national stratified random sample of family physicians, internists, hospitalists, intensivists, emergency medicine physicians, and infectious disease physicians. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Quantile regression was used to estimate the change in median PFI-BC scales, adjusting for physician, geographic, and pandemic covariates. Results: Overall, 38.1% of 286 respondents reported PFI-BC scores consistent with burnout in wave one, and 33.1% of 262 respondents in wave two. Burnout declined or was unchanged among all specialties surveyed apart from hospitalists. 34.2% of primary care physicians reported burnout in wave one and 29.7% in wave two. Burnout declined among critical care (53.5% to 43.1%) and emergency physicians (50.6% to 44.5%); but hospitalist burnout rates increased (27% to 44.2%). Conclusions: Rates of physician burnout during the first year of the pandemic appear to be comparable to pre-pandemic rates. We found no evidence of increasing burnout over a six month period, apart from hospitalist respondents. Impacts of the ongoing pandemic on physician burnout warrant continued research.

PURPOSE We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion. METHODS We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county. RESULTS Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees. CONCLUSIONS In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.

Digital breast tomosynthesis (DBT), a form of supplemental screening mammography, is not recommended for routine screening in any clinical practice guidelines.

Introduction: Frequent users of emergency departments (ED) account for 21–28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs. Methods: This retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009–2014 used patient-level data from California’s Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder. Results: In the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR [4.02], 95% confidence interval [CI] [3.92-4.12]), homelessness (2.9% vs 1.1%, odds ratio [1.35], 95% [CI] [1.27-1.43]) were more likely to be frequent users. Those covered by Medicare (aRR [3.37], 95% CI [3.20-3.55]) or the state’s Medicaid program Medi-Cal (aRR [3.10], 95% CI [2.94-3.25]) were also more likely to be frequent users compared with those with private insurance coverage. Conclusion: Patients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.