Proliferation of Risk Factors for Physician Burnout

Several authors have promoted various risk factors for physician burnout. Below are some that I noticed in my email:

Moral Injury:

Kopacz MS, Ames D, Koenig HG. It's time to talk about physician burnout and moral injury. Lancet Psychiatry. 2019 Nov;6(11):e28. doi:10.1016/S2215-0366(19)30385-2. PubMed PMID: 31631880.

Low or lack of Mindfulness:

Lebares CC et al. Key factors for implementing mindfulness-based burnout interventions in surgery. The American Journal of Surgery (in Press)

Lack of Resilience and Grit

Shakir HJ, Cappuzzo JM, Shallwani H, Kwasnicki A, Bullis C, Wang J, Hess RM,Levy EI. Relationship of Grit and Resilience to Burnout Among US NeurosurgeryResidents. World Neurosurg. 2019 Oct 16. pii: S1878- 750(19)32658-0. doi:10.1016/j.wneu.2019.10.043. [Epub ahead of print]  PubMed PMID: 31629138.

Attacks on the Calling of Medicine

Stewart MT, Serwint JR. Burning without burning out: A call to protect thecalling of medicine. Curr Probl Pediatr Adolesc Health Care. 2019 Oct 17:100655. doi: 10.1016/j.cppeds.2019.100655. [Epub ahead of print] PubMed PMID: 31631025

Above are some of the examples of risk factors cited in literature and the list continues to grow with each passing day. There are folks who have developed ‘Burnout Prevention Programs’ around these risk factors. Some even market these programs and make money.

My concern stems from the fact that while there may be strong conceptual underpinnings for at least some of these risk factors, rigorous studies examining the relationship are missing. The current state of evidence is so poor that a clinician will not take seriously risk factors with such limited evidence when managing a patient. Then, why, physicians doing this to themselves.

In particular, the worrisome part is the so-called prevention programs. Where is the evidence to support that such interventions work? If we don’t accept evidence for our patients without randomized clinical trials or at least strong observational studies, why we accept such intervention programs without evidence of efficacy?

Waste in US Healthcare System

US healthcare system is quite unique; it is the costliest system in the world but the outcomes are poor. In other words, the value of healthcare (outcomes/cost) is low and a significant amount expense goes in waste. There have been efforts to reduce waste in the healthcare system but it is unclear how effective such efforts have been.

In one estimate, the overall annual cost of waste in the healthcare is between $760 to $935 billion or 25% of the total healthcare spending. Authors also tried to estimate the amount of waste in different domains. Of interest is that fact that administrative complexity and pricing failure are the largest ticket items but there are only meager attempts to address these.

Below are the numbers:

Domain	Waste (in billions)
Failure of Care Delivery	$102.4 to $165.7
Failure of Care Coordination	$27.2 to $78.2
Low-value Care	$75.7 to $101.2
Pricing Failure	$230.7 to $240.5
Fraud and Abuse	$58.5 to $83.9
Administrative Complexity	$265.6

Selepressin: Not so useful in Septic Shock

Septic shock is an advanced stage of body’s response to an infection and manifests as marked decrease in blood pressure with resulting decrease blood flow (and hence nutrients and oxygen) to the tissues. The decreased blood pressure is due to vasodilatation and increased capillary permeability (leaky capillaries).

The treatment of septic shock includes antibiotics to treat the infection, intravenous fluids to replenish fluid that has seeped out into the tissues from leaky capillaries, and vasopressors (such as norepinephrine) to counter vasodilation. Not uncommonly, norepinephrine is not sufficient to raise blood pressure and increase blood flow to the tissues. Vasopressin, another vasopressor, is sometimes used in addition to norepinephrine to support blood pressure. However, vasopressin has other adverse effects. These adverse effects are due to the fact that vasopressin stimulates three types of vasopressin receptors (V1a, V1b, and V2). Stimulation of V1a has vasopressor effect while stimulation of V1b and V2 results in increased coagulation activity, nitric oxide release, corticosteroid secretion, and excessive water retention.

Selepressin is a selective V1a receptor agonist and has only vasopressor effect. One would assume that selective stimulation of V1a receptors with selepressin will result in beneficial outcome. However, in a clinical trial (N=868), selepressin was not found to be effective in reducing ventilator-free days, norepinephrine-free days, mortality, lower ICU days, or lower need for kidney replacement therapy.

High-Flow Nasal Cannula vs. Noninvasive Ventilation

In patients who are being mechanically ventilated and are at high risk of extubation failure, this randomized controlled trial (N=641) found non-invasive ventilation with high-flow oxygen superior to high-flow nasal cannula alone. Here is the study.

Hospital Readmission Penalty Might be Increasing Mortality

Hospital Readmission Reduction Program and association penalties for higher than average/expected readmissions have resulted in a significant decrease in 30-day readmissions after hospital discharge. This also appears to have saved money to the CMS. When looking at the readmissions only, this programs appears to be a resounding success. However, its unintended consequences are becoming clear only now.

Using a national database of almost all hospitals, this study found that hospitals that were able to decrease readmission rates for patients with acute exacerbation of COPD, also had an increase in mortality for such patients within 30-days after discharge. While the underlying mechanisms are open for speculation, this association needs to be taken seriously and possibility of a casual relationship needs to be explored.

Stacked ICU Admissions and Mortality

This interesting study shows that when ICU admissions are stacked, that is two or more admissions come too close to each other, there is an increased risk of patient mortality, longer hospital stay, and higher odds of nursing home discharge.

Investigators enrolled 13,234 consecutive ICU admissions of which 1/4rth had an elapsed time since the last admission (ETLA) of < 55 min. Stacked admissions had on average, a higher unadjusted [1.16 (95% CI 1–1.35, P = 0.05)] and adjusted [1.23 (95% CI 1.04–1.44, P = 0.01)] odds ratio of ICU death, higher unadjusted [1.11 (95% CI 0.99–1.24, P = 0.06)] and adjusted [1.20 (95% 1.05–1.35, P = 0.004)]  odds ratio of hospital death, and a lower adjusted OR of home discharge of 0.91 (95% CI 0.84–0.99, P = 0.04).

Log-transformed Predictor in Regression Model

It is not uncommon in a regression model that a predictor is log-transformed to meet the normality assumption of the residuals. Below is an example where our goal is to examine a relationship between urinary arsenic concentration and white blood cell (WBC) count (in thousands). Urinary arsenic distribution had right-skew and hence the predictor was log-transformed for this regression. The output is below and the coefficient is highlighted in yellow.

The interpretation of regression coefficients can be sometimes confusing. However, when the predictor variable is a continuous variable (here it is LNUARS), it is easy to visualize it graphically. Simply, think that the coefficient is slope for a line on a graph where Y-axis has outcome (WBC count here) and X-axis has predictor. Now, we can interpret it as ‘change in Y (WBC here) for each unit change in X (LNUARS here)’. Note, we are saying a unit change and this unit can be any unit depending on a given variable.

Now, we have our predictor (urinary arsenic) log-transformed due to its skewed distribution. The coefficient (or slope of the graph) here means change in WBC count (unit is in thousands for this output) for one unit change in log of total normalized urinary arsenic. While this is an accurate interpretation of the coefficient, we don’t use log-scale measurements in our regular life. Further, we may find it difficult to communicate with others when describing results. Hence, it makes much more sense to convert total arsenic from log-scale to our usual scale.

As a general rule, and without going into mathematical details, the interpretation of a log-transformed variable is slightly different than usual interpretation that we would do otherwise. A simplest way is to multiply the coefficient with 0.01; the resulting value will be change in Y for 1% change in X. Note, it is not one unit change bur rather one percent change. Here, the coefficient is -0.195. Multiplying it with 0.01 gives us -0.00195. The Y = WBC here has unit in 1000 cells and X here is total urinary arsenic. Hence, we will say that for each 1% increase in total urinary arsenic, the WBC decreases by 0.00195 (in thousands). We can multiply 0.00195 by 1000 (=1.95) and then each 1% increase in normalized total urinary arsenic decreases WBC by about 2 cells.

The p-value is significant but the change of 2-cells for 1% change in urinary arsenic may not be large enough to be clinically meaningful; however, that is another topic of discussion – difference between statistically significant and clinically meaningful – for another day.

Anti-Mullerian Hormone in Men

Anti-Müllerian hormone (AMH) is a Sertoli cell-secreted protein that plays a major role in the development of internal male genitalia during embryonic life. Around the 7th week of gestation, AMH causes regression of the Mullerian duct and hence it is also known as Müllerian-inhibiting substance (MIS). Persistent Mullerian duct leads to formation of female internal sex organs. During adult life, AMH continues to be produced by the Sertoli cells in the testis in men although its functional relevance remains unclear.

In 2016, an very strong association of AMH with all-cause mortality was reported in men.

“In unadjusted analysis, each unit increase in serum anti-mullerian hormone level was associated with a 13 % lower risk of death (HR = 0.87; 95 %CI = 0.83-0.92). In multivariable models, the inverse association between serum anti-mullerian hormone levels and mortality remained significant (HR = 0.94; 95 %CI = 0.90-0.98) and was independent of confounding variables. Similarly, individuals in the highest quartile had significantly lower risk of death as compared to individuals in the lowest quartile (unadjusted HR = 0.13, 95 %CI = 0.07-0.25; adjusted HR = 0.36, 95 %CI = 0.16-0.81).”

While the study showed an association the underlying mechanistic pathways remained unclear.

Recently, AMH has been shown to be associated with serum C-reactive protein (CRP) levels in men raising the possibility that the underlying mechanism may include modulation of inflammatory response. It is a potentially an exciting area of research and new discoveries in future may highlight important relationships between AMH and health, morbidity, and mortality in humans.

Soft Drink Consumption and Mortality

In this population-based cohort study of 451,743 individuals from 10 countries in Europe, greater consumption of total, sugar-sweetened, and artificially sweetened soft drinks was associated with a higher risk of all-cause mortality.

1. 17% higher all-cause mortality was found among participants who consumed 2 or more glasses per day (vs consumers of <1 glass per month) of total soft drinks (hazard ratio [HR], 1.17; 95% CI, 1.11-1.22; P < .001),

2. 8% higher mortality in participants who consumed sugar-sweetened soft drinks (HR, 1.08; 95% CI, 1.01-1.16; P = .004), and

3. 26% higher mortality in participants who drank artificially sweetened soft drinks (HR, 1.26; 95% CI, 1.16-1.35; P < .001).

Consumption of artificially sweetened soft drinks was positively associated with deaths from circulatory diseases, and sugar-sweetened soft drinks were associated with deaths from digestive diseases.

Direct Oral Anticoagulants vs Warfarin in Older Patients With Atrial Fibrillation and Ischemic Stroke

This observational study examined 11,662 patients with atrial fibrillation who had had an ischemic stroke and were anticoagulation naïve, patients discharged while receiving:

1. Direct oral anticoagulants (DOACs) had more days at home post-discharge
2. Were less likely to experience major adverse cardiovascular events, all-cause mortality, all-cause readmissions, cardiovascular readmissions, or hemorrhagic strokes
3. Had a small but significant increase in gastrointestinal bleeding.

Overall, DOACs appear to be an effective and safe treatment option compared with warfarin for patients with atrial fibrillation who have ischemic stroke and may be even more beneficial despite a small in crease in gastrointestinal bleeding.

Perioperative Direct Oral Anticoagulant Use

This study of 3007 patients with atrial fibrillation who were undergoing surgery enrolled patients to have:

1. Direct Oral Anticoagulants (DOACs) were omitted 1-day before a low-bleeding-risk procedure
2. DOACs were omitted 2 days before a high-bleeding-risk procedure
3. Patients with renal impairment had the pre-operative omission duration readjusted

Study investigators found that the perioperative risk of bleeding and arterial thromboembolism were low with this simplified strategy. The 30-day postoperative rate of major bleeding was 1.35% (95% CI, 0%-2.00%) in the apixaban cohort, 0.90% (95% CI, 0%-1.73%) in the dabigatran cohort, and 1.85% (95% CI, 0%-2.65%) in the rivaroxaban cohort. The rate of arterial thromboembolism was 0.16% (95% CI, 0%-0.48%) in the apixaban cohort, 0.60% (95% CI, 0%-1.33%) in the dabigatran cohort, and 0.37% (95% CI, 0%-0.82%) in the rivaroxaban cohort.

DOACs	Bleeding Risk	Arterial Thromboembolism
Apixaban	1.35	0.16
Dabigatran	0.90	0.60
Rivaroxaban	1.85	0.37

Hospital Visits After Discharge in Readmission Reduction Program Era

This study raises interesting questions about the effectiveness of the Hospital Readmission Reduction Program. While readmissions are going down, the hospital ED visits and observation admits are going up. Are hospitals gaming the system?

A Case For More Vacations!

Vacationing more may reduce your risk of metabolic syndrome. So, don’t bypass your vacations and give sometime to yourself.

Here is the link

Longitudinal Study of Physician Burnout

Here is the study

The most interesting part is “burnout trends among staff tended to move in the opposite direction from trends among clinicians.”

Delirium in Hospitalized Patients and Family Visitation

Often elderly patients develop delirium during hospitalization. Delirium is waxing and waning cognitive function and often manifests as memory lapses, agitation, unable to understand care being provided, and limited cooperation in the provision of care.

One of the reasons offered for the possible causation of delirium is an unfamiliar environment and people (in addition to the underlying illness). However, while this is plausible, it has not been rigorously studied.

A recent study published in the JAMA is trying to address the ‘casualty question’ in addition to the therapeutic effect of family presence. What investigators wanted to see was that if there is a difference in the incidence of delirium between patients who get frequent family visitation versus those who did not. To increase family visitation, investigators relaxed family visitation hours to some intensive care units while other units continue to have their usual visitation hours. Overall, the number of hours a family member visited patient increased significantly in the intervention arm (4.8 hours versus 1.4 hours); almost three times increase.

Investigators did not find a statistically significant difference between the two groups although there appears to be a somewhat decreased incidence of delirium in patients admitted to ICUs in the intervention arm (18.9 vs 20.1%).

These findings are important and while do not reject the hypothesis that unfamiliar environment may play a causal role in delirium, it does question its validity. Future studies are likely to address this question further.

Suing Patients for Unpaid Hospital Medical Bills

Although published as a research letter, this study highlights a very important aspect of the business side of medicine in healthcare. Healthcare is very costly in the United States when compared to other countries. To collect revenue for the services provided, should hospitals pursue unpaid bills through all means including garnishing wages? If hospitals don’t do that then are they at risk of being in financial distress, particularly hospitals that are in poor areas? A larger question, that as a society needs an answer, is whether healthcare is a privilege or a right? Should an individuals be health responsible for healthcare expenses or society should collectively support healthcare costs of everyone? Blaming hospitals for pursuing unpaid bills is not going to fix the problem but may actually make it worse.

Anti-platelet Drugs after Coronary Intervention

The type and duration of anti-platelet therapy after cardiac catheterization and stent placement (also called percutaneous coronary intervention or PCI) is an ongoing debate.

There are two main groups of drugs. One is aspirin which is under use for over 100 years and we know a lot about it. The other group is P2Y12 blockers. P2Y12 is a receptor on the surface of platelets and these drugs block this receptor. The most well-known drug in this group is clopidogrel or Plavix.

A Japanese study examined the role of aspirin + clopidogrel for one month followed by 12-months of clopidogrel versus aspirin + clopidogrel for 12 months showed that the earlier strategy was superior. In contrast, a Korean study, also published in JAMA, found that there is no statistically significant difference between the two.

The results may appear different and the reason my be that the two studies were somewhat different. Below are some of the differences:

1. Korean study allowed the use of other P2Y12 inhibitors/blockers such as prasugrel or ticagrelor while Japanese study allowed on clopidogrel.

2. Korean study had lower adherence to drug therapy in the P2Y12 group as compared to combined group (79% vs. 95%).

3. P2Y12 inhibitors were given for 3-months in the first group in Korean study while Japanese study had for 1-month only.

Despite these somewhat difference results, the overall message is the same. Patients may have similar outcomes when given clopidogrel (or other P2Y12 inhibitors) alone after an initial period of combined therapy with aspirin. This may be a particularly good news for those patients who are at higher risk of bleeding.

Anti-platelet Therapy after Cardiac Stent Placement

The type and duration of anti-platelet therapy after cardiac catheterization and stent placement (also called percutaneous coronary intervention or PCI) is an ongoing debate. Aspirin is under use for over 100 years and we know a lot about it. Plus, it is a cheaper drug. Clopidogrel, better known by its market name Plavix, is now in marker for many years and its generic versions are available. Almost all studies have examined the use of additional anti-platelet drugs after PCI on top of aspirin use. What if we examine the use of anti-platelet drugs on top of clopidogrel use?

A study published in JAMA examined this question in a multi-center, open-label, randomized clinical trial conducted in Japan. They enrolled 3045 patients to either 1 month of aspirin + clopidogrel therapy followed by clopidogrel therapy alone versus 12 months of aspirin + clopidogrel therapy. The outcome they were looking at was a combined outcome of cardiovascular death, myocardial infarction, stroke (ischemic or hemorrhagic), stent thrombosis, or bleeding.

I am certain that authors were hoping for finding that the two treatments were similar. To their surprise, not only 1-month of aspirin + clopidogrel followed by clopidogrel alone was similar in efficacy but was superior to the 12-months of aspirin + clopidogrel (2.35% vs. 3.70%; P<0.001). In other words, a shorter duration of combined therapy followed by clopidogrel therapy is as effective, if not better, than 12-months of combined therapy. These findings are important especially for patients who are at high risk of bleeding.

Patient Satisfaction and Patient Psychological Well-being

Patient satisfaction with physician communication is part of the HCAHPS patient satisfaction survey. HCAHPS is a mandated survey of a sample of patients discharged from hospitals to assess their satsifaction with hospital, physicians, nurses, and discharge process. While CMS has advised not to use the individual domains of the survey as those individual domains are not tested (as compared to the whole survey which is tested), hospital administrators continue to use individuals domains to reward/punish physicians.

This recently published study shows that patient satisfaction strongly depends on patient’s psychological well-being. It is unlikely that a physician has any strong influence on a patient’s psychological well-being and hence on the patient satisfaction. Interesting study! We need more such studies to tease out what factors (patient level or healthcare level) that affect patient satisfaction so that we can adjust healthcare delivery accordingly.

Academic Center–Too Big to Fail?

A very interesting article published online in JAMA with a provacative title “Academic Medical Centers: Too Large for Their Own Health?”. The following few sentences are very telling “…. many of today’s AMCs are similar to huge tankers loaded with health care services, and research and education are merely passengers ……. the margins on clinical revenues are often used to cover deficits in budgets for research and education and from providing subsidized care ………. any changes threatening the margins from clinical care will affect the entire mission of an AMC. The AMC missions are not self-funded; the margins on clinical care are required at most AMCs …” (emphasis added).

Something for leaders in healthcare to think about and consider when planning for the future.