Jasmine Nettiksimmons

Generational and Gender Perspectives on Career Flexibility: Ensuring the Faculty Workforce of the Future

There is growing national concern regarding the future adequacy of our physician workforce. The general population aged more than 65 years is predicted to double by 2030, and increased age is commonly accompanied by greater health care needs. The physician population also is aging; 1 in 3 active physicians is currently aged more than 55 years and likely to retire by 2020. A physician shortage is predicted by the Association of American Medical Colleges (AAMC).1 Further affecting the physician workforce is the observation that physicians are choosing to work differently. Many publications in both medical and popular literature describe generational differences toward work. They describe younger workers as placing a higher value on family, career flexibility, and work–life balance than their predecessors.2–10 This difference is likely based on the different roles both sexes assume at work and at home. The Families and Work Institute (FWI) reports that more young men are assuming household and childcare duties than their counterparts 30 years ago, and more women want jobs with responsibilities similar to those of men.11 The inherent challenges of balancing these demanding work and family roles create new stresses and conflicts for both sexes and provide insight into findings from the AAMC National Graduation Questionnaire, which shows a growing trend for medical graduates to choose specialties with more controllable work hours and little or no on-call duties. In addition, the questionnaire revealed more medical graduates opt for careers that do not involve the clinical practice of medicine at all, such as careers in the biotechnology and pharmaceutical industry or as consultants or entrepreneurs.12 Minimizing work–life conflict also is not limited to the younger generation of physicians. Many hospitals and physician practices are finding it difficult to motivate physicians of all ages to take night and weekend call, even when additional compensation is provided for on-call coverage.13,14 This trend among the older generation may reflect concerns about health, ability to meet changing family needs, burnout, or other changes in personal expectations as physicians mature and age. The emerging issues surrounding work and family compound academic medicine’s unique and long-standing challenges in recruitment and retention. In addition to the demands of patient care, which requires long work hours and on-call duties, a career in academic medicine includes considerable teaching demands and high expectations for research accomplishment and productivity. Economic pressures due to declining reimbursement for clinical services, increased competition for research funding, and minimal (if any) compensation for teaching have exacerbated faculty stress, making academic careers seem less appealing to younger generations. A study at a major academic health center found that the average annual turnover of new physician hires was 24%. Even more revealing were findings regarding retention: Only 55% of initial hires were still employed at this center 5 years later.15 Replacing academic physicians is costly. Recruitment, training, and cost of the learning curve as new recruits ramp up their practice over 1 year can total more than

Subgroup of ADNI Normal Controls Characterized by Atrophy and Cognitive Decline Associated With Vascular Damage

200,000 per physician.16 It is critical to identify better strategies to improve recruitment, retention, and satisfaction of academic faculty. Other industries and professions also are concerned about attracting and retaining talent. The generations following the baby boomers are smaller in number, and it is becoming harder to fill vacancies due to retirement. Career flexibility has become a common primary recruitment and retention strategy. The Radcliffe Public Policy Center found a work schedule that allows time with family is one of the most important job characteristics to men and women aged 20 to 50 years.17 At Deloitte & Touche, 86% of employees cited flexibility as the major reason for staying with the firm, leading to a savings of

Pediatric Obesity Management in Rural Clinics in California and the Role of Telehealth in Distance Education.

41.5 million in turnover costs alone.18 For many years, the Alfred P. Sloan Foundation has provided awards to business and industry to promote career flexibility in the workplace.19 Sloan’s perspective is that flexibility is not an accommodation, but a strategic tool in recruitment and retention. Career flexibility has not been a common strategic tool in academic medicine, but interest is growing. Flexibility policies are present at the majority of US medical schools,20 and a study of US News & World Report top 10-ranked medical schools shows that flexible career policies exist at each, but with considerable variation among the policies.21 A task force of the Association of Specialty Professors recommended increasing respect for work–life balance and allowing flexible time and part-time employment.22 An invitational conference on career flexibility sponsored by the Sloan Foundation in September 2010 demonstrated a keen interest among medical schools for help in enhancing career flexibility for their faculty. This report illuminates generational issues toward career flexibility in academic medicine. We share the University of California, Davis School of Medicine (UCDSOM) career flexibility policies, how these were developed, and the findings from our recent survey assessing faculty awareness of, attitudes to, and use of career flexibility policies. Our survey findings have uncovered vulnerable faculty groups who are at risk for work–life conflict. We highlight the impact that institutional policies can have in improving faculty satisfaction, recruitment, and retention for each generation. We believe that sharing our experience will allow departments and medical schools to create a more flexible work environment that will better meet recruitment and retention challenges, enhance faculty satisfaction, and more fully address the academic medical workforce needs of the future.

Targeted versus tailored multimedia patient engagement to enhance depression recognition and treatment in primary care: randomized controlled trial protocol for the AMEP2 study.

Previous work examining Alzheimers Disease Neuroimaging Initiative (ADNI) normal controls using cluster analysis identified a subgroup characterized by substantial brain atrophy and white matter hyperintensities (WMH). We hypothesized that these effects could be related to vascular damage. Fifty-three individuals in the suspected vascular cluster (Normal 2) were compared with 31 individuals from the cluster characterized as healthy/typical (Normal 1) on a variety of outcomes, including magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) biomarkers, vascular risk factors and outcomes, cognitive trajectory, and medications for vascular conditions. Normal 2 was significantly older but did not differ on ApoE4+ prevalence. Normal 2 differed significantly from Normal 1 on all MRI measures but not on Amyloid-Beta1-42 or total tau protein. Normal 2 had significantly higher body mass index (BMI), Hachinksi score, and creatinine levels, and took significantly more medications for vascular conditions. Normal 2 had marginally significantly higher triglycerides and blood glucose. Normal 2 had a worse cognitive trajectory on the Reys Auditory Verbal Learning Test (RAVLT) 30-min delay test and the Functional Activity Questionnaire (FAQ). Cerebral atrophy associated with multiple vascular risks is common among cognitively normal individuals, forming a distinct subgroup with significantly increased cognitive decline. Further studies are needed to determine the clinical impact of these findings.

Telemedicine and Face-to-Face Care for Pediatric Obesity

OBJECTIVE To determine health care provider needs related to pediatric obesity management in rural California and to explore strategies to improve care through telehealth. METHODS Cross-sectional survey of health care providers who treated children and adolescents at 41 rural clinics with existing telehealth connectivity. RESULTS Most of the 135 respondents were family physicians at designated rural health clinics serving low-income families. Respondents had practiced in rural areas for an average of 10 years. Most providers rated their self-efficacy in managing pediatric obesity as 2 or 3 on a 5-point scale. The barriers most frequently reported by health care providers were lack of local weight management programs, lack of patient motivation, and lack of family involvement in treatment. Providers reported that the resources they would find most helpful were readily accessible patient education materials, strategies to link patients with community treatment programs and training in brief, focused counseling skills. Three-quarters of providers already used telehealth for distance learning. Providers reported very high interest in participating in continuing education on pediatric obesity delivered by telehealth, specifically Internet communication with specialists, web-based education, and interactive video case-conferencing. CONCLUSIONS Rural health care providers face several barriers related to pediatric obesity management. Targeted interventions provided via telehealth to rural health care providers may enhance the care of obese children and adolescents. The results of this study provide directions and priorities for the design of appropriate interventions.

Impact of Electronic Health Record Clinical Decision Support on the Management of Pediatric Obesity

BackgroundDepression in primary care is common, yet this costly and disabling condition remains underdiagnosed and undertreated. Persisting gaps in the primary care of depression are due in part to patients’ reluctance to bring depressive symptoms to the attention of their primary care clinician and, when depression is diagnosed, to accept initial treatment for the condition. Both targeted and tailored communication strategies offer promise for fomenting discussion and reducing barriers to appropriate initial treatment of depression.Methods/designThe Activating Messages to Enhance Primary Care Practice (AMEP2) Study is a stratified randomized controlled trial comparing two computerized multimedia patient interventions --- one targeted (to patient gender and income level) and one tailored (to level of depressive symptoms, visit agenda, treatment preferences, depression causal attributions, communication self-efficacy and stigma)--- and an attention control. AMEP2 consists of two linked sub-studies, one focusing on patients with significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] scores ≥ 5), the other on patients with few or no depressive symptoms (PHQ-9 < 5). The first sub-study examined effectiveness of the interventions; key outcomes included delivery of components of initial depression care (antidepressant prescription or mental health referral). The second sub-study tracked potential hazards (clinical distraction and overtreatment). A telephone interview screening procedure assessed patients for eligibility and oversampled patients with significant depressive symptoms. Sampled, consenting patients used computers to answer survey questions, be randomized, and view assigned interventions just before scheduled primary care office visits. Patient surveys were also collected immediately post-visit and 12 weeks later. Physicians completed brief reporting forms after each patient’s index visit. Additional data were obtained from medical record abstraction and visit audio recordings. Of 6,191 patients assessed, 867 were randomized and included in analysis, with 559 in the first sub-study and 308 in the second.DiscussionBased on formative research, we developed two novel multimedia programs for encouraging patients to discuss depressive symptoms with their primary care clinicians. Our computer-based enrollment and randomization procedures ensured that randomization was fully concealed and data missingness minimized. Analyses will focus on the interventions’ potential benefits among depressed persons, and the potential hazards among the non-depressed.Trial registrationClinicialTrials.gov Identifier: http:www.//NCT01144104

Improving Pediatric Health Care Delivery by Engaging Residents in Team-Based Quality Improvement Projects

The University of California Davis Medical Center (Sacramento, CA) has pioneered the use of telemedicine in its approach to childhood obesity to cover more than 20 rural clinics in California. In our study, we compared the outcomes of the Telemedicine Weight Management Clinic (TM) with those of its face-to-face (FTF) Weight Management Clinic counterpart over the last 5 years, predicting the results to be equivalent or in favor of TM. All children seen in the TM from June 2006 to June 2011 were included (n=121), and encounter notes in medical records were reviewed. For comparison, an equivalent sample of FTF patients was selected from that time frame (n=122). Data that were also abstracted from the medical record included age at first visit, gender, race, referral site, and comorbid diagnoses. Forty-two percent of TM patients compared with 52% of FTF patients received a change in diagnosis. Thirty-nine percent of TM patients received a change in diagnostic evaluation compared with 67% of patients in FTF. When comparing patients who received more than one visit with either form of consultation, the TM group demonstrated substantially more improvement than the FTF group in improving nutrition (88% versus 65%), increasing activity (76% versus 49%), and decreasing screen time (33% versus 8%). Substantially more TM patients were successful with a combined outcome of any one of the weight parameters that included weight loss, weight maintenance, or slowing of weight gain (69% TM versus 44% FTF). Our study suggests that telemedicine can serve as a feasible strategy to increase access to medical care for childhood obesity in rural communities and promote changes in lifestyle with the goal of maintaining a healthy weight.

Improving Knowledge, Awareness, and Use of Flexible Career Policies through an Accelerator Intervention at the University of California, Davis, School of Medicine

Clinicians vary significantly in their adherence to clinical guidelines for overweight/obesity. This study assessed the impact of electronic health record–based clinical decision support in improving the diagnosis and management of pediatric obesity. The study team programmed a point-of-care alert linked to a checklist and standardized documentation templates to appear during health maintenance visits for overweight/obese children in an outpatient teaching clinic and compared outcomes through medical record reviews of 574 (287 control and 287 intervention) visits. The results demonstrated a statistically significant increase in the diagnosis of overweight/obesity, scheduling of follow-up appointments, frequency of ordering recommended laboratory investigations, and assessment and counseling for nutrition and physical activity. Although clinical guideline adherence increased significantly, it was far from universal. It is unknown if modest improvements in adherence to clinical guidelines translate to improvements in children’s health. However, this intervention was relatively easy to implement and produced measurable improvements in health care delivery.

Do Family Responsibilities and a Clinical Versus Research Faculty Position Affect Satisfaction with Career and Work–Life Balance for Medical School Faculty?

The goal was to implement and evaluate an experimental and longitudinal team-based curriculum in quality improvement (QI) for pediatric residents that would increase their ability to apply QI methodology while improving clinical processes and outcomes. The curriculum evolved over 3 years based on resident feedback. Working in teams, residents and faculty apply QI principles to systematically design and implement QI projects. Residents increased their level of comfort with key QI concepts. They showed an increase in QI skills by meaningful integration of the following QI concepts into their projects: establishing the magnitude of the problem, developing focused aims for improvement, identifying areas to change, using QI tools, collecting data, and assessing if changes were successful. The 10 resident-led projects conducted over the past 3 years also resulted in improvements in measures of multiple clinical processes and outcomes. This curriculum was effective and feasible within the constraints of residency work hours.

Collaborative Practice Improvement for Childhood Obesity in Rural Clinics: The Healthy Eating Active Living Telehealth Community of Practice (HEALTH COP)

The challenges of balancing a career and family life disproportionately affect women in academic health sciences and medicine, contributing to their slower career advancement and/or their attrition from academia. In this article, the authors first describe their experiences at the University of California, Davis, School of Medicine developing and implementing an innovative accelerator intervention designed to promote faculty work–life balance by improving knowledge, awareness, and access to comprehensive flexible career policies. They then summarize the results of two faculty surveys—one conducted before the implementation of their intervention and the second conducted one year into their three-year intervention—designed to assess faculty’s use and intention to use the flexible career policies, their awareness of available options, barriers to their use of the policies, and their career satisfaction. The authors found that the intervention significantly increased awareness of the policies and attendance at related educational activities, improved attitudes toward the policies, and decreased perceived barriers to use. These results, however, were most pronounced for female faculty and faculty under the age of 50. The authors next discuss areas for future research on faculty use of flexible career policies and offer recommendations for other institutions of higher education—not just those in academic medicine—interested in implementing a similar intervention. They conclude that having flexible career policies alone is not enough to stem the attrition of female faculty. Such policies must be fully integrated into an institution’s culture such that faculty are both aware of them and willing to use them.