Burnout, Cognitive Overload, and Metacognition in Medicine

The number of physicians reportedly suffering from burnout, a phenomenon where the individual appears overwhelmed by tasks usually within their competence, has been increasing internationally. Burnout represents a large burden for the medical profession, from undergraduate training to the postgraduate world. The impact of burnout has effects on physician productivity, although the exact effect remain difficult to quantify. By extension, a physician suffering from burnout is likely to have ramifications to the wider team of colleagues. Evidence suggests that, independent to level of experience, the extent of the relationship between burnout and work extends beyond total capacity and directly affects patient safety. The widespread impact on burnout on both the providers and recipients of healthcare is therefore a critical aspect of clinical practice.

Factors affecting the phenomenon of physician burnout have been considered in literature, with reported risk factors being younger age, longer working hours with high workload, low job satisfaction, negative or poor personal relationships and interpersonal demands, job insecurity, and female gender, as well as a weak association with specialty. These findings place physicians in common with other healthcare professions. However, healthcare professions as a group stand apart as particularly prone to burnout. The implication of this suggests that risk factors are shared within the healthcare professions. This may also imply that risk reduction and prevention strategies can be applied across the spectrum. Prior to considering the prevention, it is invaluable to evaluate the stressors associated with healthcare that serve to predispose these professions to burnout.

The full commentary can be downloaded below.  

Using Aggregate Data on Health Goals, Not Disease Diagnoses, to Develop and Implement a Healthy Aging Group Education Series

The Healthy Aging Group Education Series was developed by interprofessional primary healthcare team members and researchers to address the health needs and goals of nutrition, fitness and function, and advance care planning identified using data from a randomized controlled trial. Older adults from one family practice were invited to attend the series and participate in the descriptive evaluation. The series was developed based on aggregated patient-reported data on health goals, risks, and needs gathered using a structured process. Surveys which included open-ended feedback and rated items of content and delivery evaluated the series. Program delivery expenses were itemized. Of 69 people invited, a range of 26 to 37 people attended sessions. The overall series was rated positively with respect to meeting attendees’ expectations and being well-organized; 69.2% and 76.9% of attendees gave a positive rating respectively. Individual session feedback indicated a range of positive ratings (82.8-100%) for categories of effective and engaging presenters and providing new and relevant information. The majority of attendees (76.9%) indicated they would recommend the series to friends. The series continues to be offered regularly in the family practice. The health goal information (and not disease diagnosis) that was used to develop and deliver the program resulted in a program that was well received by participants and sustainable in the family practice.

The full article can be downloaded below.  

Primary care physicians’ attitudes to the adoption of electronic medical records: a systematic review and evidence synthesis using the clinical adoption framework

Recent decades have seen rapid growth in the implementation of Electronic Medical Records (EMRs) in healthcare settings in both developed regions as well as low and middle income countries. Yet despite substantial investment, the implementation of EMRs in some primary care systems has lagged behind other settings, with piecemeal adoption of EMR functionality by primary care physicians (PCPs) themselves. We aimed to review and synthesise international literature on the attitudes of PCPs to EMR adoption using the Clinical Adoption (CA) Framework. MEDLINE, PsycINFO, and EMBASE were searched from 1st January 1996 to 1st August 2017 for studies investigating PCP attitudes towards EMR adoption. Papers were screened by two independent reviewers, and eligible studies selected for further assessment. Findings were categorised against the CA Framework and the quality of studies assessed against one of three appropriate tools. Out of 2263 potential articles, 33 were included, based in North and South America, Europe, Middle East and Hong Kong. Concerns about the accessibility, reliability and EMR utility exerted an adverse influence on PCPs’ attitudes to adoption. However many were positive about their potential to improve clinical productivity, patient safety and care quality. Younger, computer-literate PCPs, based in large/multi-group practices, were more likely to be positively inclined to EMR use than older physicians, less-skilled in technology use, based in solo practices. Adequate training, policies and procedures favourably impacted on PCPs’ views on EMR implementation. Financial factors were common system level influencers shaping EMR adoption, from start-up costs to the resources required by ongoing use. By using the CA Framework to synthesise the evidence, we identified a linked series of factors influencing PCPs attitudes to EMR adoption. Findings underline the need to involve end-users in future implementation programmes from the outset, to avoid the development of an EMR which is neither feasible nor acceptable for use in practice.

The full article can be downloaded below.  

How can technology enhance elderly adherence to self-managed treatment plan?

Patient non-compliance with treatment care is one of the leading causes of increasing healthcare costs and hospital readmissions. Elderly patients, those 65 years and older, are especially prone to losing motivation to adhere to treatment, particularly when self-management is required and they are infrequently checked by providers. This study investigates the effect of information systems on retaining motivation to adhere to self-management and satisfaction with treatment. Drawing upon goal-setting and control theories, we found that clearly defined and revisited goals are more likely to be followed by elderly patients if progress is monitored and regular and timely feedback is provided by their provider.

The full pdf can be downloaded below.  

What's Needed to Develop Strategic Purchasing in Healthcare?

In the context of serious concerns over the affordability of healthcare, various authors and international policy bodies advise that strategic purchasing is a key means of improving health system performance. Such advice is typically informed by theories from the economics of organization (EOO). This paper proposes that these theories are insufficient for a full understanding of strategic purchasing in healthcare, because they focus on safeguarding against poor performance and ignore the coordination and adaptation needed to improve performance. We suggest that insights from other, complementary theories are needed. A realist review method was adopted involving three steps: first, drawing upon complementary theories from the EOO and inter-organizational relationships (IOR) perspectives, a theoretical interpretation framework was developed to guide the review; second, a purposive search of scholarly databases to find relevant literature addressing healthcare purchasing; and third, qualitative analysis of the selected texts and thematic synthesis of the results focusing on lessons relevant to three key policy objectives taken from the international health policy literature. Texts were included if they provided relevant empirical data and met specified standards of rigour and robustness. A total of 58 texts were included in the final analysis. Lessons for patient empowerment included: the need for clearly defined rights for patients and responsibilities for purchasers, and for these to be enacted through regular patient-purchaser interaction. Lessons for government stewardship included: the need for health strategy to contain specific targets to incentivise purchasers to align with national policy objectives, and for national government actors to build close, trusting relationships with purchasers to facilitate access to local knowledge about needs and priorities. Lessons for provider performance included: provider decision autonomy may drive innovation and efficient resource use, but may also create scope for opportunism, and interdependence likely to be the best power structure to incentivise collaboration needed to drive performance improvement. Using complementary theories suggests a range of general policy lessons for strategic purchasing in healthcare, but further empirical work is needed to explore how far these lessons are a practically useful guide to policy in a variety of healthcare systems, country settings and purchasing process phases.

The full article can be downloaded below.  

Professional culture, information security and healthcare quality—an interview study of physicians’ and nurses’ perspectives on value conflicts in the use of electronic medical records

Digital healthcare information systems impose new demands on healthcare professionals, and information security rules may induce stressful value conflicts, which the professional culture may help professionals to handle. The aim of the study was to elucidate physicians’ and registered nurses’ shared professional assumptions and values, grounded in their professional cultures, and how these assumptions and values explain and guide healthcare professionals’ handling of value conflicts involving rules regulating the use of electronic medical records. Healthcare professionals in five organisations in two Swedish healthcare regions were interviewed. The study identified ensuring the patients’ physical health and well-being as the overarching value and a shared basic assumption among physicians and registered nurses. A range of essential professional and organisational values were identified to help attain this goal. In value conflicts, different values were weighted in relation to each other and to the electronic information security rules. The results can be used to guide effective design and implementation of electronic medical records and information security regulations in healthcare.

The full pdf can be downloaded below.  

How health insurance companies use AI to make consumers healthier

Health insurance companies today are using artificial intelligence and machine learning in ways not possible just five years ago to better pinpoint at-risk individuals and to reduce costs.

"The applicability and opportunity on the insurers side is fantastic," said Mark Morsch, vice president of Technology for Optum360. "AI has gotten hot in the last few years.

The biggest breakthroughs are in more sophisticated machine learning. Being able to take that data and leverage it to drive algorithms and move towards being more predictive."

The full Healthcare Finance article can be found at this link.  

AI Doesn't Ask Why -- But Physicians And Drug Developers Want To Know

Both physicians and drug developers draw much of their authority from their ability to leverage mechanistic understanding to move from observation to insight. This ability is likely both better and worse than we typically recognize. Our mechanistic understanding is often far less robust than we appreciate, but we bring a sense of intuition and a wealth of tacit knowledge to these domains, enabling us to notice that a patient just doesn’t seem himself, or that a cell culture or chemical reaction is behaving in a curious way. Humble physicians and drug developers will seek ways to embrace (as well as critically verify) the mechanistically unmoored insights offered by ever more sophisticated algorithms. At the same time, engineers seeking to disrupt medicine and pharma would do well to temper their messianic vigor with a healthy appreciation for the lived experience and hard-won-wisdom of many incumbent practitioners.

The full Forbes article can be found at this link.  

THE FOOD AND DRUG ADMINISTRATION’S POLICIES AND PROCEDURES SHOULD BETTER ADDRESS POSTMARKET CYBERSECURITY RISK TO MEDICAL DEVICES 

FDA had plans and processes for addressing certain medical device problems in the postmarket phase, but its plans and processes were deficient for addressing medical device cybersecurity compromises. Specifically, FDA's policies and procedures were insufficient for handling postmarket medical device cybersecurity events; FDA had not adequately tested its ability to respond to emergencies resulting from cybersecurity events in medical devices; and, in 2 of 19 district offices, FDA had not established written standard operating procedures to address recalls of medical devices vulnerable to cyber threats. These weaknesses existed because, at the time of our fieldwork, FDA had not sufficiently assessed medical device cybersecurity, an emerging risk to public health and to FDA's mission, as part of an enterprise risk management process. We shared our preliminary findings with FDA in advance of issuing our draft report. Before we issued our draft report, FDA implemented some of our recommendations. Accordingly, we kept our original findings in the report, but, in some instances, removed our recommendations.

We recommend that FDA do the following: (1) continually assess the cybersecurity risks to medical devices and update, as appropriate, its plans and strategies; (2) establish written procedures and practices for securely sharing sensitive information about cybersecurity events with key stakeholders who have a “need to know”; (3) enter into a formal agreement with Federal agency partners, namely the Department of Homeland Security's Industrial Control Systems Cyber Emergency Response Team, establishing roles and responsibilities as well as the support those agencies will provide to further FDA's mission related to medical device cybersecurity; and (4) ensure the establishment and maintenance of procedures for handling recalls of medical devices vulnerable to cybersecurity threats. FDA agreed with our recommendations and said it had already implemented many of them during the audit and would continue working to implement the recommendations in the report. However, FDA disagreed with our conclusions that it had not assessed medical device cybersecurity at an enterprise or component level and that its preexisting policies and procedures were insufficient. We appreciate the efforts FDA has taken and plans to take in response to our findings and recommendations, but we maintain that our findings and recommendations are valid.

The full Office of Inspector General report can be downloaded below.  

America's Obesity Crisis: The Health and Economic Costs of Excess Weight

This study calculates the prevalence and economic effects of diseases related to obesity and overweight in the United States. These costs are paid by individuals and their households, employers, government, and society. The study uses a range of data sources to comprehensively establish the prevalence of conditions related to obesity, as well as the costs. To capture all costs, this study evaluated the direct costs of health care services to treat these diseases—costs paid by individuals, families, insurance companies, and employers—as well as indirect costs that relate to work absences, lost wages, and reduced economic productivity for the individuals suffering from the conditions and their family caregivers.  For each condition, the direct health care costs and the indirect costs are calculated and presented separately.

The full pdf from the Milken Institute can be downloaded below.