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Rising physician burnout has adverse effects on healthcare. This study aimed to identify remediable stressors associated with burnout using the 10-item Mini-Z and the Maslach Burnout Inventory (MBI), and to compare performance of the Mini-Z's single-item burnout metric against the 22-item MBI. Surveys were emailed to 4,118 clinicians affiliated with an academic health system; 1,252 clicked the link, and 557 responded (completion rate 44%). Four hundred seventy-five practicing physicians were included: academic faculty (372), hospital employed (52), and private practitioners (81). Prevalence of burnout via the MBI was 56.6%. Predictors of burnout were poor control over workload [OR = 8.24, 95% CI 4.(81, 14.11)], inefficient teamwork [OR = 7.61, 95% (CI 3.28, 17.67)], insufficient documentation time [OR = 5.83, 95% (CI 3.35, 10.15)], hectic-chaotic work atmosphere [OR = 3.49, 95% (CI 2.12, 5.74)], lack of value-alignment with leadership [OR = 3.27, 95% (CI 2.12, 5.74)], and excessive electronic medical record time at home [OR = 1.99, 95% CI (1.21, 3.27)]. Academic faculty experienced more burnout than private practitioners (59.9% vs. 42.0%, p = 0.013). Odds of burnout associated with stressors were generally concordant via Mini-Z's burnout metric versus the MBI. The Mini-Z is a brief, valid method to identify stressors associated with burnout and guide interventions.

Physicians “purchase” many health care services on behalf of patients yet remain largely unaware of the costs of these services. Electronic health record (EHR) cost displays may facilitate cost-conscious ordering of health services. To determine whether displaying hospital lab and imaging order costs is associated with changes in the number and costs of orders placed. Quasi-experimental study. All patients with inpatient or observation encounters across a multi-site health system from April 2013 to October 2015. Display of order costs, based on Medicare fee schedules, in the EHR for 1032 lab tests and 1329 imaging tests. Outcomes for both lab and imaging orders were (1) whether an order was placed during a hospital encounter, (2) whether an order was placed on a given patient-day, (3) number of orders placed per patient-day, and (4) cost of orders placed per patient-day. During the lab and imaging study periods, there were 248,214 and 258,267 encounters, respectively. Cost display implementation was associated with a decreased odds of any lab or imaging being ordered during the encounter (lab adjusted odds ratio [AOR] = 0.97, p = .01; imaging AOR = 0.97, p

Aim Cost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have had mixed results. We sought to assess resident physician cost awareness following sustained visual display of costs into electronic health record (EHR) order entry screens. Study Design We completed a preintervention and postintervention web-based survey. Participants were physicians in internal medicine, paediatrics, combined medicine and paediatrics, obstetrics and gynaecology, emergency medicine, and orthopaedic surgery at one tertiary co are academic medical centre. Costs were displayed in the EHR for 1032 unique laboratory orders. We measured attitudes towards costs and estimates of Medicare reimbursement rates for 11 common laboratory and imaging tests. Results We received 209 survey responses during the preintervention period (response rate 71.1%) and 194 responses during the postintervention period (response rate 66.0%). The proportion of residents that agreed/strongly agreed that they knew the costs of tests they ordered increased after the cost display (8.6% vs 38.2%; p Conclusions Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.

Phenomenon: As an impending shortage of primary care physicians is expected, understanding career trajectories of medical students will be useful in supporting interest in primary care fields and careers. The authors sought to characterize recent trends in primary care interest and career trajectories among medical students at an academic medical institution that did not have a family medicine department.Match data for 2,477 graduates who matched into resident training programs between 1989 and 2014 were analyzed to determine the proportion entering primary care residency programs. An online search and confirmatory phone call methodology was used to determine primary care career trajectories for the 795 graduates who matched into primary care residency programs between 1989 to 2010. Subanalyses were performed to characterize primary care career entrance among graduates who matched into the three primary care residency programs: Family Medicine, Categorical and Primary Care Internal Medicine, and Categorical and Primary Care Pediatrics.Between 1989 and 2014, 911 (37%) of all matched graduates matched into primary care residency programs. Of the 795 graduates who matched into these programs between 1989 and 2010, less than half (245; 31%) entered primary care careers. Of the graduates who ultimately entered primary care careers, 82% matched into either internal medicine or pediatrics residency programs and 18% matched into family medicine programs. Although there have been fluctuations in primary care interest that seem to parallel health care trends over the 26-year period, the overall percentage of graduates entering primary care residency programs and careers has remained fairly stable. Between 2006 and 2010, entrance into both primary care residency programs and primary care careers steadily increased. Despite this, the overall percentage of matched graduates who entered primary care careers over the 22-year study period (12%) was less than the national average (16%-18%). Insights: In the 26-year period between 1989 and 2014, primary care career interest increased slightly among medical students at this academic medical institution, with fluctuations that seem to coincide with national health care trends. Year-to-year fluctuations appear to be driven by rising numbers of Categorical Pediatrics and Categorical Internal Medicine matchers pursuing careers in primary care. There may be a need for specialized curricula and strategies to promote and retain interest in primary care at academic medical institutions, especially at institutions without family medicine training programs.

Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness.Background We sought to assess senior resident self-perceived cost awareness and cost knowledge.Objective In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale–New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price.Methods We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%.Results In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.Conclusions

Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. This was a qualitative study based on semi-structured, in-person interviews. Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27–39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents’ decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

“You don't know when the patient last ate?” Exasperated by another sloppy consult, my chief resident reminded me that, “they call because they need help. Remember, the patient really needs us.” Who said this? A chief on internal medicine? Or surgery? Can you tell? In truth, we have all felt this same sense of frustration with a late-night, seemingly incompetent consult. As residents, the intensity of training—and the pressure to complete ever-accumulating work—causes us to dread the shrill page portending another consult. Can't they figure out this question? Did they even look at the patient before calling? The frustration from poor consults, and the need for consult courtesy, has been well documented.1 As communication and teamwork break down, we take on tribal identities: the belief that they are different from us. And by different, we mean inferior. Other services don't work as hard or understand the patient the way we do. This lack of partnership and respect can lead to delays in providing care, an inefficient system, and more concerning, suboptimal patient care.2 Academic medicine is in the thick of a national dialogue on team-based approaches, with a focus on “interprofessionalism,” which examines the interactions between medicine, nursing, pharmacy, and other health professions.3 We suggest that something is missing in medical education—that it also must foster intra-professionalism. This concept is not new. More than 2 decades ago, surgeons began to discuss the need for modification of their own “ethic of rugged individualism,” realizing that the evolving health care system required “that we play as a team.”4 Residents should be learning not only to know when and how to consult other physicians and medical teams, but also to trust, depend on, and work in concert with other specialties. Currently, there is no formal graduate medical curriculum related to intra-professional teamwork. As residents from different specialties, we have common backgrounds in our dedication to quality and access to care, and 1 of us (M.D.S.) is a program director who enthusiastically supports intra-professional training. Despite that alignment, the pressures of residency training encourage us to silo ourselves into specialty-specific subcultures. Through our graduate medical training, we learn not only the intricacies of the human body, but also the culture of our new “in-crowd.” Through this, we have allowed ourselves to see specialties we interact with as the “other.” Whether or not the rationale is valid, all too often consulting specialties are not on the same page. Here, a crucial opportunity emerges: We must train intra-professional teams to examine, design, and deliver the medical care we all envision. Our inability as a house of medicine to optimally work alongside one another poses considerable risk—for our profession and for our patients. Teamwork training as a strategy for improving quality has been associated with substantially improved outcomes.5,6 For example, when the Veterans Health Administration implemented a formalized medical team training program for personnel in the surgical operating room, the result was an impressive 18% reduction in annual mortality among patients who were treated by teams that had undergone this training.7 Where team-based care and coordination among different services have been encouraged, there have been great strides in improving patient outcomes, and even evidence of sustained collaboration between different specialties.8–10 The promise of these findings is seen in emerging intra-professional models (t a b l e). An example is the University of California, San Fransisco's hospital-neurosurgery team-based approach. This combined service has led to decreased costs and increased physician perception of quality.11 For residents, there has been another benefit: learning from other services. As Dr Robert Wachter highlights in his online blog,8 the hospitalist who runs this service won a departmental teaching award last year from the Department of Neurosurgery. The lesson is clear: embracing intra-professional teams helps hospitals, patients, residents, and learning. TABLE Examples of Intra-Professional Teams Teams aren't just made; they require skills that can be taught. Team-based science teaches us that experienced teams are able to develop psychologically safe environments where team members can make better use of each other's knowledge, skills, and abilities.12 Residency programs should embrace this, and begin to teach with this approach. These team science lessons include the cultivation of psychological safety, enabling the development of transactive memory—a group-level memory system, and the recognition that the leader's behavior matters.12 Structured programming engaging intra-professional teams in health care and health care delivery improvement should happen through purposeful reorganization of teams into shared intern rotations, or collective research opportunities. Having met beyond the wards through a mutual interest in health policy, the authors have repeatedly found that high-quality care emerges from cross-specialty efforts around a common goal. To that end, the collective impact amassed will not be additive—it will be exponential. In an era where the medical education community, including the Accreditation Council for Graduate Medical Education, strives to meaningfully engage trainees to lead change in quality and safety,13 substantive intra-professional training may provide a compelling solution. As our health care delivery system shifts toward new collaborative payment models, such as bundled payment models and Accountable Care Organizations, specialties will no longer be stand-alone silos. We will need to work together to enhance and support high-quality care, and to continue to innovate in medicine. By being part of these types of teams during training, residents will be less likely to hide in the shelter of their own tribal identity. They will be better prepared to work together through mutual respect and understanding, which will lead to improved patient outcomes and efficiency of the health care system as a whole.

In the USA, the politics around healthcare reform have created polarised views of the Affordable Care Act (ACA), but underlying these views is a disquieting lack of knowledge that could have harmful consequences for patients. Recently, television host Jimmy Kimmel interviewed a series of citizens on the street, all of whom vehemently stated their objections to Obamacare but were supportive of the ACA, suggesting misperceptions and lack of knowledge about the legislation among the public. But this is not just a case of late-night comedy. A recent Commonwealth Fund Health Insurance Marketplace Survey found that only two out of five adults in the USA were aware of health insurance exchanges or that there might be financial assistance to purchase plans.1 Even among childhood cancer survivors with substantial long-term healthcare needs, almost all participants surveyed did not have knowledge about health-insurance related laws.2 Physicians, who are experts in practicing medicine, are often assumed by patients to be experts in the legal changes affecting healthcare delivery. However, the reality is that most physicians are not experts in health policy,3 and it is not only the public that lacks knowledge about the ACA. In a recent survey of 2958 physicians in the USA, 45% did not know what an accountable care organisation was, but 65% felt that healthcare will deteriorate over the next 5 years after passage of the ACA, while only 27% believed the ACA will have a positive effect on patients.4 Furthermore, despite the ACA increasing Medicare and Medicaid reimbursement to …

Background One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED). Objective To characterize continuity under the Veterans Health Administration’s PCMH model – the Patient Aligned Care Team (PACT), at one large Veterans Affair’s (VA’s) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits. Design Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012. Patients The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011. Main Measures Our exposure variable was continuity of care –a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit. Results The patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care – at least one visit with their assigned PCP – had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (p = 0.001). Compared to patients with low continuity (50%) continuity were less likely to utilize the ED. Conclusions Strong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services.

Background Education in health policy and advocacy is recognized as an important component of health professional training. To date, curricula have only been assessed at the medical school level. Objective We sought to address the gap in these curricula for residents and other health professionals in primary care. Innovation We created a health policy and advocacy curriculum for the VA Connecticut Healthcare System, Center of Excellence in Primary Care Education, an interprofessional, ambulatory-based, training program that includes internal medicine residents, nurse practitioner fellows, health psychology fellows, and pharmacy residents. The policy module focuses on health care finance and delivery, and the advocacy module emphasizes negotiation skills and opinion-based writing. Trainee attitudes were surveyed before and after the course, and using the Wilcoxon signed rank test, relative change was determined. Knowledge acquisition was evaluated with precourse and postcourse examinations using a paired sample t test. Results From July 2011 through June 2013, 16 trainees completed the course. In the postcourse survey, trainees demonstrated improved comfort with understanding health law and the American health care system (Likert mean increased from 2.1 to 3.0, P = .01), as well as with associated advocacy skills (Likert mean increased from 2.0 to 2.9, P = .04). Knowledge-based test scores also showed significant improvement (increasing from 55% to 78% correct, P ≤ .001). Conclusions Our curriculum integrating core health policy knowledge with advocacy skills represents a novel approach in postgraduate health professional education and resulted in sustained improvement in knowledge and comfort with health policy and advocacy.

Whether in the USA or UK, the resounding question in the health sphere is: How do we achieve better value in healthcare? The answer to date has been simple: get bigger, merge administrative departments, get more managerialised, and so cut costs. But none of this represents real change: just some tinkering of the current hospital-centric system. In order to find a sustainable and effective solution, we must consider value and not cost while focusing on what contributes to better health. This means becoming serious about caring for people beyond a hospital's walls. Population health, which links health outcomes for a population to the context of medical system and social determinants of health,1 offers the promise of dramatic improvement in value and personalisation for patients. This is not to diminish or downgrade the importance of continuing to improve healthcare for the individual, but rather to link that with an active approach to improving health. Doctors and other healthcare professionals will need to refocus their roles and renegotiate their relationships across the healthcare sector. Health systems across the globe are pressured to derive greater value in healthcare, which in the context of the continuing groundbreaking developments in medical technology must now centre on becoming serious about population health. The Institute for Healthcare Improvement's triple aim sets out the laudable ambition for all health systems: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of healthcare to ensure benefits can be applied across communities. It is the first of these, improving the health of the population, that is the most difficult and which seems out of the scope of healthcare. Delivering on this promise will not happen without clear leadership. Primary care—which assumes nearly 60% of all US patient visits and 90% of …