Physician burnout, a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment, is prevalent internationally. Rates of burnout symptoms that have been associated with adverse effects on patients, the healthcare workforce, costs and physician health exceed 50% in studies of both physicians-in-training and practicing physicians. This problem represents a public health crisis with negative impacts on individual physicians, patients and healthcare organizations and systems. Drivers of this epidemic are largely rooted within healthcare organizations and systems and include excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, lack of input or control for physicians with respect to issues affecting their work lives, organizational support structures and leadership culture. Individual physician-level factors also play a role, with higher rates of burnout commonly reported in female and younger physicians. Effective solutions align with these drivers. For example, organizational efforts such as locally developed practice modifications and increased support for clinical work have demonstrated benefits in reducing burnout. Individually focused solutions such as mindfulness-based stress reduction and small-group programmes to promote community, connectedness and meaning have also been shown to be effective. Regardless of the specific approach taken, the problem of physician burnout is best addressed when viewed as a shared responsibility of both healthcare systems and individual physicians. Although our understanding of physician burnout has advanced considerably in recent years, many gaps in our knowledge remain. Longitudinal studies of burnout's effects and the impact of interventions on both burnout and its effects are needed, as are studies of effective solutions implemented in combination. For medicine to fulfil its mission for patients and for public health, all stakeholders in healthcare delivery must work together to develop and implement effective remedies for physician burnout.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/joim.12752

Physician burnout: contributors, consequences and solutions

Childhood obesity: a review of increased risk for physical and psychological comorbidities.

Discrete choice experiments (DCEs) are increasingly used in health economics to address a wide range of health policy-related concerns. Broadly adopting the methodology of an earlier systematic review of health-related DCEs, which covered the period 2001–2008, we report whether earlier trends continued during 2009–2012. This paper systematically reviews health-related DCEs published between 2009 and 2012, using the same database as the earlier published review (PubMed) to obtain citations, and the same range of search terms. A total of 179 health-related DCEs for 2009–2012 met the inclusion criteria for the review. We found a continuing trend towards conducting DCEs across a broader range of countries. However, the trend towards including fewer attributes was reversed, whilst the trend towards interview-based DCEs reversed because of increased computer administration. The trend towards using more flexible econometric models, including mixed logit and latent class, has also continued. Reporting of monetary values has fallen compared with earlier periods, but the proportion of studies estimating trade-offs between health outcomes and experience factors, or valuing outcomes in terms of utility scores, has increased, although use of odds ratios and probabilities has declined. The reassuring trend towards the use of more flexible and appropriate DCE designs and econometric methods has been reinforced by the increased use of qualitative methods to inform DCE processes and results. However, qualitative research methods are being used less often to inform attribute selection, which may make DCEs more susceptible to omitted variable bias if the decision framework is not known prior to the research project. The use of DCEs in healthcare continues to grow dramatically, as does the scope of applications across an expanding range of countries. There is increasing evidence that more sophisticated approaches to DCE design and analytical techniques are improving the quality of final outputs. That said, recent evidence that the use of qualitative methods to inform attribute selection has declined is of concern.

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Discrete Choice Experiments in Health Economics: A Review of the Literature

Lotte N. Dyrbye, MD, MHPE, Mayo Clinic; Tait D. Shanafelt, MD, Mayo Clinic; Christine A. Sinsky, MD, American Medical Association; Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, American Nurses Association; Jay Bhatt, DO, MPH, MPA, American Hospital Association; Alexander Ommaya, DSc, Association of American Medical Colleges; Colin P. West, MD, PhD, Mayo Clinic; David Meyers, MD, Agency for Healthcare Research and Quality

/pdf/burnout-among-health-care-professionals-a-call-to-explore-4xe27z2enb.pdf

Burnout Among Health Care Professionals: A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care

Although a prominent role for the brain in glucose homeostasis was proposed by scientists in the nineteenth century, research throughout most of the twentieth century focused on evidence that the function of pancreatic islets is both necessary and sufficient to explain glucose homeostasis, and that diabetes results from defects of insulin secretion, action or both. However, insulin-independent mechanisms, referred to as 'glucose effectiveness', account for roughly 50% of overall glucose disposal, and reduced glucose effectiveness also contributes importantly to diabetes pathogenesis. Although mechanisms underlying glucose effectiveness are poorly understood, growing evidence suggests that the brain can dynamically regulate this process in ways that improve or even normalize glycaemia in rodent models of diabetes. Here we present evidence of a brain-centred glucoregulatory system (BCGS) that can lower blood glucose levels via both insulin-dependent and -independent mechanisms, and propose a model in which complex and highly coordinated interactions between the BCGS and pancreatic islets promote normal glucose homeostasis. Because activation of either regulatory system can compensate for failure of the other, defects in both may be required for diabetes to develop. Consequently, therapies that target the BCGS in addition to conventional approaches based on enhancing insulin effects may have the potential to induce diabetes remission, whereas targeting just one typically does not.

/pdf/cooperation-between-brain-and-islet-in-glucose-homeostasis-49id9ebwdx.pdf

Cooperation between brain and islet in glucose homeostasis and diabetes

Objective: This study assessed the associations between obesity and dental caries in young children participating in a national survey. Methods: Participants included 1,507 children aged 2-6 years who received dental examinations and had at least 10 primary teeth in the National Health and Nutrition Examination Survey 1999-2002. Decayed/filled teeth (dft) counts of primary dentition were obtained, and weight and height were measured. Body mass index (BMI; kg/m2) was calculated, and participants were categorized using age- and gender-specific criteria as underweight ( 85th and 5 dft. When caries experience was compared across BMI categories stratified by age and race characteristics, statistically significant association between caries and obesity was found only for 60- <72-month age group. In the comparison between children with normal and at-risk BMI only, significant associations were also found in the Hispanic and non-Hispanic Black strata. In multivariable logistic regression models to predict caries experience, family income and age were statistically significant predictors for severe early childhood caries only. Conclusions: There appears to be no significant association between childhood obesity and caries experience after controlling for age, race, and poverty/income ratio. However, further studies are needed to better understand this relationship.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1752-7325.2008.00083.x

Obesity and dental caries in children aged 2-6 years in the United States: National Health and Nutrition Examination Survey 1999-2002.

There is no question of the need for advocacy within pharmacy and the health professions. Collective voices need to be heard, and those for whom pharmacists provide care and services need others to advocate for them simply because they have no voice in many discussions. Currently in pharmacy and the wider health professions, there are many points of contention and debate. This is not a new phenomenon; it has existed for decades. In 2010, the American Pharmacists Association and the American Society of Health-System Pharmacists (1) collaborated on a discussion paper that suggests that the rapid expansion of pharmacy schools' satellite campuses and the increasing class sizes enrolled in pharmacy colleges and schools needs to be thoughtfully reconsidered. Voices within the academy have also called for careful consideration of expansion plans for programs. These arguments are juxtaposed with suggestions that there are too many health care institutions or affiliated clinics in North America, some of which are an easy stroll across the street from one another. Some believe there are too many pharmacy organizations as well, all of which were under one umbrella before being split up decades ago. The point of this editorial is not to take sides in the debate over supply of health professionals and services or to criticize any entity, but rather to lament the lack of cohesion among all affinity groups in advocating for one special interest above all else: the graduates of pharmacy education programs. Regardless of vested interests, all pharmacy educators should hold the practice options available to graduates and future graduates in the highest importance of all that we represent, advocate for, or suggest allegiance to. Other Professions Filling the Expanding Need for Physician Extender Services Nurse practitioners (NP) and physician assistants (PA) have worked hard to take advantage of the tenets behind much of the Patient Protection and Affordable Care Act passed in 2010. Despite political posturing, many provisions of this health reform legislation have been implemented and experts believe that many of the preventive health services components put in play by this legislation will not be reversed in the future regardless of the fate of the overall Act. In mid-December 2011, the components dealing with payment and service provision for preventive obesity counseling and services imbedded in the legislation began to be operationalized for enrollees of Medicare. Physician extenders will provide many of these and other types of future needed services. Our previous research (2,3) found that consumers are willing to use physician extenders (eg, NPs) when seeking care for acute conditions requiring medical care services. Many if not all of these retail clinic-based physician extenders are located within pharmacies. There are numerous opportunities for professional collaboration between pharmacists and other physician extenders (NPs and PAs). The health professions striving to avail the opportunities presented by disruptive innovations such as retail clinic and the increasing demand for primary health care services do not need to do so at the expense of each other. There are tremendous opportunities for outreach and collaborative efforts, many in place already, that need expansion for the benefit of all--most importantly the patients served. These professions (NPs, PAs) have achieved tremendous success by working within and across their specific professional associations, practitioner groups, and health professional schools, and with colleagues to advocate for the benefits of PA- and NP-provided health care services. This has not been achieved without tremendous organizational and collaborative synergy uniting segments within these professions that may not always agree with all aspects of what disparate affinity groups might advocate for. These processes have been documented extensively in the literature, and most certainly provide blueprints for the pharmacy profession's future advocacy and cooperation with physician extender groups and physicians. …

Dramatic need for cooperation and advocacy within the academy and beyond.

PURPOSE Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices. METHODS As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting–clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews. RESULTS The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (β =−0.149; P = .008); preferred to seek care from a physician (β =1.067; P CONCLUSIONS Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices.

https://www.annfammed.org/content/annalsfm/8/2/117.full.pdf

Physician Office vs Retail Clinic: Patient Preferences in Care Seeking for Minor Illnesses

Results. We found a significant increasing trend in dental complaint visits dur ing the six-year period (from 13.1% to 19.0%, p0.01). Dental caries accounted for 20.4%, pulpitis or periapical abscess accounted for 14.8%, dental injury accounted for 8.7%, temporomandibular joint (TMJ) disorders accounted for 1.5%, and all other unspecified dental diseases accounted for 54.6% of the ED visits for dental complaints. The mean charge was approximately $360 per visit and was highest for TMJ disorders ($747) and lowest for unspecified other dental diseases ($277). Self-pay (38.3%) and Medicaid (32.3%) constituted the majority of the payment sources. Multivariable regression analysis indicated that self-payers, nonwhite people, adults, people with lower family income, and weekends were associated with increased use of ED visits for dental complaints.

/pdf/secular-trends-in-hospital-emergency-department-visits-for-2emjodg7e9.pdf

Arif Ahmed

Papers

Obesity and dental caries in children aged 2-6 years in the United States: National Health and Nutrition Examination Survey 1999-2002.

Dramatic need for cooperation and advocacy within the academy and beyond.

Physician Office vs Retail Clinic: Patient Preferences in Care Seeking for Minor Illnesses

Secular trends in hospital emergency department visits for dental care in Kansas City, Missouri, 2001-2006.

Physician turnover: a costly problem.