Joshua Khalili

Ambient artificial intelligence (AI) scribes record patient encounters and rapidly generate visit notes, representing a promising solution to documentation burden and physician burnout. However, the scribes’ impacts have not been examined in randomized clinical trials. In this parallel three-group pragmatic randomized clinical trial, 238 outpatient physicians, representing 14 specialties, were assigned 1:1:1 via covariate-constrained randomization (balancing on time-in-note, baseline burnout score, and clinic days per week) to either one of two AI scribe applications — Microsoft Dragon Ambient eXperience (DAX) Copilot or Nabla — or a usual-care control group from November 4, 2024, to January 3, 2025. The primary outcome was the change from baseline log writing time-in-note. Secondary end points measured by surveys included the Mini-Z 2.0, a four-item physician task load (PTL), and Professional Fulfillment Index — Work Exhaustion (PFI-WE) scores to evaluate aspects of burnout; work environment; stress; and targeted questions addressing safety, accuracy, and usability. DAX was used in 33.5% of 24,696 visits; Nabla was used in 29.5% of 23,653 visits. Nabla users experienced a 9.5% (95% confidence interval [CI], −17.2% to −1.8%; P=0.02) decrease in time-in-note versus the control group, whereas DAX users exhibited no significant change versus the control group (−1.7%; 95% CI, −9.4% to +5.9%; P=0.66). Increases in total Mini-Z (scale 10–50; DAX 2.83 [95% CI, +1.28 to +4.37]; Nabla +2.69 [95% CI, +1.14 to +4.23]) and reductions in PTL (scale 0–400; DAX −39.9 [95% CI, −71.9 to −7.9]; Nabla −31.7 [95% CI, −63.8 to +0.4]), and PFI-WE (scale 0–4; DAX 0.32 [95% CI,−0.55 to −0.08]; Nabla −0.23 [95% CI, −0.46 to +0.01]) scores suggest improvement for users of either scribe versus the control. One grade 1 (mild) adverse event was reported, while clinically significant inaccuracies were noted “occasionally” on five-point Likert questions (DAX 2.7 [95% CI, 2.4 to 3.0]; Nabla 2.8 [95% CI, 2.6 to 3.0]). Nabla reduced time-in-note versus the control. Both DAX and Nabla resulted in potential improvements in burnout, task load, and work exhaustion, but these secondary end point findings need confirmation in larger, multicenter trials. Clinicians reported that performance was similar across the two distinct platforms, and occasional inaccuracies observed in either scribe require ongoing vigilance. (Funded by the University of California, Los Angeles, Department of Medicine and others; ClinicalTrials.gov number, NCT06792890.)

Background: Physician burnout is a public health crisis. While one-on-one professional coaching reduces physician burnout, its costs may limit widespread use. Small group professional coaching could offer a more scalable solution, but its effects on attending physician burnout remain unknown. Objective: To determine the effects of small group and one-on-one professional coaching to decrease physician burnout and improve work life, work engagement, self-efficacy, and social support. Design: A randomized, three-arm, waitlist-controlled trial from March 2, 2023 to April 13, 2024. Participants: 79 Internal Medicine faculty attending physicians. Interventions: Six, one-hour, virtual one-on-one or small group professional coaching sessions rooted in positive psychological theory within 4 months. Main Measures: The primary outcome was overall burnout, measured by the Maslach Burnout Inventory (MBI). Secondary outcomes included MBI subscale measures, Areas of Worklife (workload, control, rewards, community, fairness, and values), work engagement (vigor, dedication, absorption), self-efficacy and social support, evaluated by validated measures. Outcomes were also evaluated 6 months post-intervention. Key Results: Small group and one-on-one coaching intervention participants experienced a 29.6% and 13.4% absolute reduction in the rate of burnout respectively, compared with an 11.1% increase among control physicians (difference-in-differences, -40.7% [95% CI, -71.3%, -10.1%], P = 0.01 and -25.0% [95% CI, -53%, 3%], P = 0.09, respectively). There was no significant difference in burnout reduction between small group vs one-on-one interventions (-15.9% [95% CI, -41.7%, 9.9%], P = 0.22). After 6 months, burnout remained stable in the small group intervention and continued to decrease in the one-on-one group, both without further intervention. Conclusions: In this randomized clinical trial, small group professional coaching decreased physician burnout though no statistically significant effect was detected in the one-on-one coaching arm. Small group coaching may offer a less costly and nationally scalable approach to address the physician burnout crisis. Replication of these methods are warranted in a larger, multi-centered randomized trial. Clinical Trial Registration: ClinicalTrials.gov NCT05583435. Graphical

Importance Ambient artificial intelligence (AI) scribes record patient encounters and generate visit notes almost instantaneously, representing a promising solution to documentation burden and associated physician burnout. Despite swift and widespread adoption of AI scribes, their impacts have not been examined in randomized-clinical trials. Objective To test the effectiveness of two AI scribes in reducing time spent writing notes and associated burnout in a randomized-clinical trial. Design Parallel three-arm pragmatic randomized-clinical trial where physicians were assigned 1:1:1 via covariate-constrained randomization (balancing on time-in-note, baseline burnout score, and clinic days /week) to either one of two AI scribe applications—Microsoft DAX or Nabla—or a usual-care control group from 11/4/2024-1/3/2025. Setting A large academic health system in California. Participants 313 outpatient physicians were recruited based on leadership referrals and department-wide emails. 238 participants representing 14 specialties qualified. Intervention Intervention-arm physicians gained access to an AI scribe for two months. Main Outcomes and Measures The primary outcome was change from baseline log writing time-in-note. Secondary outcomes measured by surveys included Mini-Z 2.0, 4-item physician task load (TL), and Professional Fulfillment Index-Work Exhaustion (PFI-WE) scores to evaluate aspects of burnout, work environment, and stress, as well as targeted questions addressing safety and accuracy. Results DAX was used in 33.5% of 24,696 visits; Nabla was used in 29.5% of 23,653 visits. Nabla users experienced a 9.5% [95% CI:-17.2%,-1.8%] (p=.02) decrease in time-in-note versus the control group and a 7.8% [-15.5%,-0.1%] (p=.05) decrease versus DAX users, while DAX users exhibited no significant change versus control (-1.7% [-9.4%,+5.9%]; p=.66). Total Mini-Z, scaled 10-50 with higher scores indicating improvement, increased with users of any scribe (+2.76 [+1.41,+4.10]; p<.001). Reductions in TL (scale 0-400, TL=-35.8 [-63.7,-7.9]; p=.01) and work exhaustion (scale 0-4, PFI-WE=-0.27 [-0.48,-0.07]; p=.01) were seen with users of any scribe. One Grade 1 (mild) adverse event was reported, while clinically-significant inaccuracies were noted “occasionally” on 5-point Likert questions (DAX 2.7 [2.4-3.0] vs. Nabla 2.8 [2.6-3.0]; p=.68). Conclusion and Relevance Use of Nabla reduced time-in-note, while use of any scribe led to modest improvements in physician burnout, work exhaustion, and task load. Performance was remarkably similar across two distinct vendor platforms, and occasional inaccuracies observed in either scribe require ongoing physician vigilance. Trial Registration ClinicalTrials.gov Identifier: NCT06792890

OBJECTIVES: High-need, high-cost (HNHC) patients represent a small proportion of patients in the US, but result in disproportionately higher healthcare utilization. Teaching Internal Medicine (IM) resident trainees to provide high value care for HNHC patients is critical. We sought to improve resident attitudes and increase clinical skills associated with treating HNHC patients by creating a curriculum that leveraged the UCLA Extensivist Program, a patient-centered medical home for HNHC patients. METHODS: We developed a curriculum for PGY-2 and PGY-3 IM residents centered on caring for HNHC patients over the course of 6, 4h sessions during 1 academic year. Participants completed pre- and post-intervention surveys assessing self-rated attitudes and skills associated with caring for an HNHC patient population. RESULTS: Twenty-one IM residents completed the curriculum and 41 were in the control group. There were no statistically significant differences in assessed attitudes and skills, but there were trends of improvement, including a decrease in participants who agreed or strongly agreed they felt overwhelmed when seeing patients for posthospital discharge follow up (45.0% pre- to 41.7% post-intervention) and an increase in participants who agreed or strongly agreed they have the skills to successfully transition HNHC patients between inpatient and ambulatory settings (20.0% pre- to 33.3% post-intervention). Participants reported better understanding of resources available to HNHC patients, effective coordination of transitions of care, and comprehensive assessment of social determinants of health. CONCLUSION: A curriculum to improve resident attitudes and skills associated with caring for HNHC patients was successfully implemented in an IM program at a large academic medical center. The curriculum may be adapted for other training programs; long-term training woven throughout training may be important to significantly improve resident education on how to care for HNHC patients.

This Teachable Moment describes a man in his 70s with a medical history of noninvasive bladder cancer who presented to his primary care clinic with significant weight loss and was subsequently found to have previously undiagnosed acquired immunodeficiency syndrome.