Jane B Lemaire

Physician wellness: a missing quality indicator

When physicians are unwell, the performance of health-care systems can be suboptimum. Physician wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality health care. We review the work stresses faced by physicians, the barriers to attending to wellness, and the consequences of unwell physicians to the individual and to health-care systems. We show that health systems should routinely measure physician wellness, and discuss the challenges associated with implementation.

Burnout among doctors

A system level problem requiring a system level response

A real-time locating system observes physician time-motion patterns during walk-rounds: a pilot study

BackgroundWalk-rounds, a common component of medical education, usually consist of a combination of teaching outside the patient room as well as in the presence of the patient, known as bedside teaching. The proportion of time dedicated to bedside teaching has been declining despite research demonstrating its benefits. Increasing complexities of patient care and perceived impediments to workflow are cited as reasons for this declining use. Research using real-time locating systems (RTLS) has been purported to improve workflow through monitoring of patients and equipment. We used RTLS technology to observe and track patterns of movement of attending physicians during a mandatory once-weekly medical teaching team patient care rounding session endorsed as a walk-rounds format.MethodsDuring a project to assess the efficacy of RTLS technology to track equipment and patients in a clinical setting, we conducted a small-scale pilot study to observe attending physician walk-round patterns during a mandatory once-weekly team rounding session. A consecutive sample of attending physicians on the unit was targeted, eight agreed to participate. Data collected using the RTLS were pictorially represented as linked points overlaying a floor plan of the unit to represent each physician’s motion through time. Visual analysis of time-motion was independently performed by two researchers and disagreement resolved through consensus. Rounding events were described as a sequence of approximate proportions of time engaged within or outside patient rooms.ResultsThe patient care rounds varied in duration from 60 to 425 minutes. Median duration of rounds within patient rooms was approximately 33% of total time (range approximately 20-50%). Three general time-motion rounding patterns were observed: a first pattern that predominantly involved rounding in ward hallways and little time in patient rooms; a second pattern that predominantly involved time in a ward conference room; and a third balanced pattern characterized by equal proportions of time in patient rooms and in ward hallways.ConclusionsObservation using RTLS technology identified distinct time-motion rounding patterns that hint at differing rounding styles across physicians. Future studies using this technology could examine how the division of time during walk-rounds impacts outcomes such as patient satisfaction, learner satisfaction, and physician workflow.

How physicians identify with predetermined personalities and links to perceived performance and wellness outcomes: a cross-sectional study

BackgroundCertain personalities are ascribed to physicians. This research aims to measure the extent to which physicians identify with three predetermined personalities (workaholic, Type A and control freak) and to explore links to perceptions of professional performance, and wellness outcomes.MethodsThis is a cross-sectional study using a mail-out questionnaire sent to all practicing physicians (2957 eligible, 1178 responses, 40% response rate) in a geographical health region within a western Canadian province. Survey items were used to assess the extent to which participants felt they are somewhat of a workaholic, Type A and/or control freak, and if they believed that having these personalities makes one a better doctor. Participants’ wellness outcomes were also measured. Zero-order correlations were used to determine the relationships between physicians identifying with a personality and feeling it makes one a better doctor. T-tests were used to compare measures of physician wellness for those who identified with the personality versus those who did not.Results53% of participants identified with the workaholic personality, 62% with the Type A, and 36% with the control freak. Identifying with any one of the personalities was correlated with feeling it makes one a better physician. There were statistically significant differences in several wellness outcomes comparing participants who identified with the personalities versus those who did not. These included higher levels of emotional exhaustion (workaholic, Type A and control freak), higher levels of anxiety (Type A and control freak) and higher levels of depression, poorer mental health and lower levels of job satisfaction (control freak). Participants who identified with the workaholic personality versus those who did not reported higher levels of job satisfaction, rewarding patient experiences and career commitment.ConclusionsMost participants identified with at least one of the three personalities. The beliefs of some participants that these personalities enhance professional performance may reinforce the harmful behaviors associated with poor wellness outcomes. Future research should further explore links between physician personality, perceptions of performance and actual performance, and more definitively address whether the perceived benefits offered by identifying with the workaholic personality are enough to counter the potential costs to physician wellness.

Shifting perceptions: a pre-post study to assess the impact of a senior resident rotation bundle

BackgroundExtended duty hours for residents are associated with negative consequences. Strategies to accommodate duty hour restrictions may also have unintended impacts. To eliminate extended duty hours and potentially lessen these impacts, we developed a senior resident rotation bundle that integrates a night float system, educational sessions on sleep hygiene, an electronic handover tool, and a simulation-based medical education curriculum. The aim of this study was to assess internal medicine residents’ perceptions of the impact of the bundle on three domains: the senior residents’ wellness, ability to deliver quality health care, and medical education experience.MethodsThis prospective study compared eligible residents’ experiences (N = 67) before and after a six-month trial of the bundle at a training program in western Canada. Data was collected using an on-line survey. Pre- and post-intervention scores for the final sample (N = 50) were presented as means and compared using the t-test for paired samples.ResultsParticipants felt that most aspects of the three domains were unaffected by the introduction of the bundle. Four improved and two worsened perception shifts emerged post-intervention: less exposure to personal harm, reduced potential for medical error, more successful teaching, fewer disruptions to other rotations, increased conflicting role demands and less staff physician supervision.ConclusionsThe rotation bundle integrates components that potentially ease some of the perceived negative consequences of night float rotations and duty hour restrictions. Future areas of study should include objective measures of the three domains to validate our study participants’ perceptions.

Possible Celecoxib-Induced Gastroduodenal Ulceration:

TO THE EDITOR:Nonsteroidal antiinflammatory drugs (NSAIDs) are among the most commonly prescribed drugs in North America. At least 10–20% of patients experience dyspepsia while taking NSAIDs; 13 of every 1000 patients with rheumatoid arthritis who take NSAIDs for one year develop a serious gastrointestinal (GI) complication. 1 It has been estimated that 16 500 NSAID -related deaths occur in patients with rheumatoid arthritis or osteoarthritis every year in the US. This has led to the development of cyclooxygenase (COX)-2 inhibitors such as celecoxib and rofecoxib. This newer class of drugs is intended to have a better GI adverse effect profile than nonspecific COX inhibitors. 2-4 It has been suggested 4 that for every 100 patients treated with a COX-2 inhibitor instead of a nonspecific COX inhibitor, one symptomatic ulcer may be prevented during the first year of exposure. We report a case of possible celecoxib-induced gastric and duodenal ulcers. Case Report.A 57-year-old African-American man reported abdominal pain, bloating, and dizziness and was transported to the hospital by emergency medical services. He described four melena stools and two watery stools with frank blood, and one episode of hematemesis within the preceding 24 hours. His past medical history included coronary artery disease with angioplasty five years previously, hypertension, cardiomyopathy with left ventricular dysfunction (ejection fraction 25%), gastroesophageal reflux disease, dyslipidemia, and chronic left shoulder pain. The medications on admission included losartan 25 mg/d; carvedilol 12.5 mg twice daily; digoxin 0.25 mg/d; furosemide 40 mg/d; enteric-coated aspirin 325 mg/d, which he had been taking for three years; nitroglycerin patch 0.4 mg/h for 12 hours per day; atorvastatin 20 mg/d; and celecoxib 200 mg twice daily. His family physician had prescribed celecoxib 200 mg twice daily four months prior to this event for shoulder pain. Physical examination revealed a 5’7” obese man (91 kg). On admission, his BP was 80/60 mm Hg, HR 100 beats/min, RR 20 breaths/min, and an oxygen saturation of 93% on 4 L/min of oxygen. He received a 200-mL bolus of NaCl 0.9%, which increased his BP to 102/68 mm Hg. His cardiopulmonary examination revealed a grade I–II/VI pansystolic murmur and good breath sounds with fine crackles to both bases. A musculoskeletal examination showed decreased strength bilaterally in the upper extremities. His abdominal and central nervous system examinations were unremarkable. Laboratory parameters on admission included chloride 107 mEq/L (normal 98–111), carbon dioxide 28 mEq/L (21–31), potassium 4.1 mEq/L (3.5–5), sodium 142 mEq/L (135–145), creatinine 1.1 mg/dL (0.6–1.2), and BUN 33.1 mg/dL (8–18). Complete blood cell count revealed hemoglobin 12 g/dL (14–18), white blood cells 7.8 × 103/mm3 (3.8–11), and platelets 170 × 103/mm3 (150–400). The international normalized ratio was 1.0 (0.9–1.1). Liver function tests showed a bilirubin of 0.7 mg/dL (0.1–1), alkaline phosphatase 40 U/L (39–117), and alanine aminotransferase 40 U/L (1–60). Creatine kinase (CK) was elevated (303 IU/L, normal 40–200), with three normal CK-MB fractions. An electrocardiogram showed sinus bradycardia, left ventricular hypertrophy with QRS widening, and T-wave inversion consistent with ischemia. The patient did not complain of chest pain. A serum digoxin concentration was 1.3 ng/mL (0.9–2.2). The patient was cross-matched for four units of blood, but did not receive a transfusion. Endoscopy revealed a 1.5-cm duodenal ulcer and multiple small gastric ulcers. The duodenal ulcer was injected with 9 mL of epinephrine 1:10 000 and cauterized. The patient received an intravenous bolus of pantoprazole 40 mg, followed by a continuous infusion of 8 mg/h for 48 hours. Helicobacter pyloristatus was not tested; he was empirically started on eradication therapy with amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily for seven days. Pantoprazole was discontinued and oral omeprazole 40 mg twice daily was started after 48 hours. The omeprazole dose was to be decreased to 20 mg/d after seven days. The patient had one melena stool 24 hours after admission, and a small amount of frank blood in his stool on day 2. He was discharged after three days with a hemoglobin of 11 g/dL and was instructed not to restart atorvastatin until after the completion of clarithromycin therapy due to the risk of rhabdomyolysis. 5 The family physician was made aware that clarithromycin may increase digoxin concentrations. 6

Evaluation of a hands-free communication device in an acute care setting: a study of healthcare providers' perceptions of its performance.

Quality medical care hinges on healthcare providers being able to communicate effectively and efficiently. In this study, we examine if healthcare providers’ perceptions of the performance of a wireless communication device are consistent with what it is claimed the technology can offer, namely, improved patient safety and quality of care. We used a mixed-methods design where we collected data from a single medical unit. During the qualitative component of the study, we conducted face-to-face interviews to explore healthcare team members’ perceptions of the impact of a wireless communication device on their day-to-day patient care activities. Three major improvements were identified from the interview data: more direct and effective communication, improved work efficiency, and enhanced continuity of patient care. The quantitative component consisted of a questionnaire constructed from the major themes extracted from the interviews. Many of the healthcare team members reported that the wireless communication device improved their communication and allowed them to complete their work more efficiently. In addition, the questionnaire findings suggest that both improved communication and work efficiency are correlated with perceptions of improved quality of patient care. Based on the results of this study, this wireless communication device does live up to its aims of enhancing communication, staff efficiency, and improving perceived patient safety.

Hands-free communication technology: a benefit for nursing?

The introduction of mobile communication devices (MCDs) has dramatically altered how nurses communicate. It is critical to assess whether these technologies contribute to stress and complicate the work of the nurse or if the devices are perceived as assisting in the provision of efficient and higher-quality patient care. The authors discuss a study that assessed the perceptions of nurses on a medical unit after MCDs were implemented.

How evidence from observing attending physicians links to a competency-based framework

Competency‐based medical education frameworks are often founded on a combination of existing research, educational principles and expert consensus. Our objective was to examine how components of the attending physician role, as determined by observing preceptors during their real‐world work, link to the CanMEDS Physician Competency Framework.

An orientation to wellness for new faculty of medicine members: meeting a need in faculty development.

Objectives To evaluate the format, content, and effectiveness of a newly developed orientation to wellness workshop, and to explore participants’ overall perceptions. Methods This was a mixed methods study. Participants consisted of 47 new faculty of medicine members who attended one of the four workshops held between 2011 and 2013. Questionnaires were used to evaluate workshop characteristics (10 survey items; response scale 1=unacceptable to 7=outstanding), intention to change behavior (yes/no), and retrospective pre/post workshop self-efficacy (4 survey items; response scale 1=no confidence to 6=absolute confidence). Mean scores and standard deviations were calculated for the workshop characteristics. Pre/post workshop self-efficacy scores were compared using a Wilcoxon signed-rank test. Participants’ written qualitative feedback was coded using an inductive strategy to identify themes. Results There was strong support for the workshop characteristics with mean scores entirely above 6.00 (N=42). Thirty-one of 34 respondents (91%) expressed intention to change their behavior as a result of participating in the workshop. The post workshop self-efficacy scores (N=38 respondents) increased significantly for all four items (p<0.0001) compared to pre workshop ratings. Participants perceived the key workshop elements as the evidence-based content relevant to academic physicians, incorporation of practical tips and strategies, and an atmosphere conducive to discussion and experience sharing. Conclusions Participants welcomed wellness as a focus of faculty development. Enhancing instruction around wellness has the potential to contribute positively to the professional competency and overall functioning of faculty of medicine members.