485 - Burnout and Quality, Peds Vaccinations 2023, Being Collegial

From the Literature

1)  Physician Burnout, Career Engagement, and Quality of Care

Professional burnout is defined as a syndrome related to work that involves three key dimensions: emotional exhaustion, depersonalization (cynicism), and a sense of reduced personal accomplishment (meaninglessness).  Burnout is not new, but the pandemic has exacerbated an already serious problem, with a recent Medscape Survey

of physicians indicating high burnout rates of between 37-65% depending on specialty. 

A question that comes up regularly in discussions about professional burnout is what the impact of it is on professional engagement and patient care quality (the “so what?” question).  A recently published systematic review and meta-analysis attempted to understand more about this by examining the association of physician burnout with the career engagement, focusing on job satisfaction, career choice regret, career development, productivity loss and turnover intention.  It also examined the impact of burnout on the quality of patient care focusing on patient safety incidents, low professionalism, and patient satisfaction. 

Based on existing frameworks that have studied the relation between occupational distress and impairment related to sleep deprivation in physicians and unsolicited patient complaints, the authors developed a flow diagram of anticipated associations.     

Flow diagram of examined associations of physician burnout with career engagement and quality of patient care.  Outcomes assessed in the analysis are in yellow or red. Outcomes in red emphasize the potential heightened risk of the outcome compared with the outcomes in yellow (which could be less serious to the physician and healthcare system).

After an extensive literature search, 170 observational studies representing >200,000 physicians were included in the meta-analysis.  The study found that overall burnout in

physicians was associated with an almost four times decrease in job satisfaction (OR 3.79, 95% CI 3.24-4.43).  In the presence of increased burnout, career choice regret increased by more than threefold (3.49, 2.43 to 5.00), as did intention to leave (3.10, 2.30 to 4.17).  Productivity had a small but significant association with burnout (1.82, 1.08 to 3.07) and burnout also affected career development (3.77, 2.77 to 5.14).  Overall, physician burnout doubled patient safety incidents compared with no patient safety incidents (2.04, 1.69 to 2.45).  As burnout increased, low professionalism was twice as likely (2.33, 1.96 to 2.70), as was patient dissatisfaction (2.22, 1.38 to 3.57).  The association between burnout and patient safety incidents was greatest in physicians age <30, as well as those working in emergency medicine.  The association of burnout with low professionalism was smallest in physicians older than 50, and greatest in physicians still in training or residency and in those who worked in a hospital. 

The authors concluded that the meta-analysis provided compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organizations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care.

Limitations to the meta-analysis included the generally broad range of data collection methods, criteria, and measurements used across studies, which lead to a large heterogenicity for some of the outcomes and could lead to an overestimation of associations.  Additionally, the use of cross-sectional studies made assessment of direct causality infeasible. 

Mark’s Comments:

I spend much time reading and processing the literature around clinician and care team well-being and distress, and the association between such distress and patient safety and satisfaction continues to become more robust.  Additionally, “engagement” as defined in this study is very different than how engagement is defined and measured in most “employee engagement surveys.”  The engagement of this study is more in line with the definition from social psychologists Christina Maslach, PhD, and Michael Leiter, PhD, who created the Maslach Burnout Inventory.  They define engagement as "an energetic state of involvement with personally fulfilling activities that enhance one's sense of professional efficacy."   Most employee engagement surveys measure engagement with the mission of the organization and satisfaction with the work environment.  While both are informative, they are not the same.  Organizations would be wise to pay more attention the engagement as defined in this study, as a burnout rate of even 40% is neither sustainable nor congruent with high quality, safe healthcare.

References:

·       Hodkinson A, et al.  Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis.  BMJ 2022; 378.   Published 14 September 2022.  Link

·       Kane, MA.  Physician Burnout and Depression Report 2023.  Medscape.  Released on line January 27 2023.  Link

From the Centers for Disease Control and Prevention

2)  Vaccination Schedule for Children 2023

Every February, the Advisory Committee on Immunization Practices to the CDC publishes a new version of the harmonized Adult and Child/Adolescent Vaccination Schedules.  We will summarize the changes to the Child/Adolescent Schedule in this issue, and the Adult Schedule changes next week.

In the Routine Age-Based Schedule, the following changes were made:

·       Addition of routine COVID-19 vaccination for ages 6 months to 18 years. The recommendation is for a 2-3 dose primary series (3 doses for those with immune compromise), and booster vaccines as they become available.

·       Pneumococcal conjugate vaccine 15 valent (PCV15) has now joined PCV13 as an option for routine and catch-up (through age 5 years) in children.

·       A note for 18-year-olds on the polio vaccine row - if they are at increased risk of exposure to polio (through work or during an outbreak or travel), they may receive either a 3 shot series if there is no documentation of completed previous poliovirus vaccination, or a booster if they have completed the primary series.

Catch-up Schedule changes:

·       Clarifying the 4^th dose recommendations for PCV vaccination:  A 4^th dose is indicated routinely between 12-59 months (1 through 4 years) regardless, or between 60-71 months (5 years) if only three doses were given prior to 12 months. PCV is not indicated routinely after 72 months (6 years); only for those with impaired immunity, renal failure, certain cancers, CSF leak, cochlear implant, etc.

Medical Indications Schedule changes:

·       A COVID-19 row has been added for the specific medical indications of immune system compromise (due to HIV or other conditions).

Additional important changes:

·       An added Notes section was added for the Countermeasures Injury Compensation Program for COVID-19 vaccines. We covered this program in Take 3 #417.

·       Multiple small changes to the Notes and Appendix sections to clarify specific indication guidance for several vaccines.

John’s Comments:

In the Appendix (since last year) is the consolidated Contraindication table – a great source of quick information about when you should not give a vaccination. The COVID-19 vaccines are entering the schedule as they become FDA approved and ACIP recommended. There are links to the interim guidance for authorized (under emergency use provisions) booster recommendations and other recent changes – so we must be ready to look in both places to keep up. Finally, remember that the schedule is much more than a colorful table. Both the Notes section and the Appendix are important sources of very detailed and specific information. The work of the Immunization Schedule Workgroup is to nail down the wording of all these areas very carefully to accurately reflect the ACIP’s policy, so consider the whole schedule packet a definitive source of information about vaccination.

Reference:

·       Wodi AP. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Do We “Gather Together” When We No Longer Do?

“One of the gifts of 'Star Trek' is my professional work colleagues have become my lifelong friends.”  George Takei (Hikaru Sulu)

Recently it occurred to me as I was reading a series of consultant notes over the course of a clinic day that I did not know any of the 10 subspecialty colleagues whose notes I was reading.  Though I recognized most of their names, I would have no idea what they looked like if I passed them on the street – or in the hospital.  I don’t even know what their voices sound like.  Which left me wondering, what does it mean to be a “colleague” in 2023? 

In my “medical upbringing,” it was instilled in me that collegial familiarity across specialties was an essential component of effective patient care.  Well, it's been quite some time since I gathered with fellow physicians outside my own department.  This does not seem to be simply a symptom of the pandemic, but of the impersonal way much of healthcare is now delivered in many parts of the country.  Perhaps my training regarding the importance of this interspecialty connection is just a nostalgic remnant of “times gone by” rather than a vital ingredient for providing quality patient care?     

A newly published study might provide some clues.  The authors sought to determine whether having some historical connection between the primary care physician and subspecialist, in this case an overlap in professional training at the same institution for at least 1 year (which they called co-training), might have an impact on patient care quality compared with those who had no such co-training.  The study design didn’t determine whether the physicians even knew each other or were aware they co-trained. 

Using a patient experience rating of specialist care, the authors found that co-training was associated with a more friendly and concerned manner, clearer explanations, greater engagement in shared decision-making, and changes in prescribing by the specialists.  While acknowledging the study limitations, they concluded that there existed the potential for significant gains in care quality by encouraging and harnessing interspecialty physician-peer relationships.

But how do we do this?  At a time when regular physical (or virtual) gathering may not be practical or even desired, how might we gain more familiarity and connection with those whom we regularly share in patient care?   This question takes on even greater importance if our present structure is truly creating poorer quality of patient care.  The literature provides few answers.  So this week, I’d like to tap into the collective wisdom of our PeerRxMed community.  Please take a moment to send your thoughts to mhgreenawald@carilionclinic.org and I’ll follow-up with a summary in future blogs.  In the meantime, why not do an experiment this week and reach out to thank an interspecialty colleague who is sharing the care of a patient with you.  Doing so may positively alter the care of that patient.  Another reason why no one should care alone.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org