The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system per- formance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.

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From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

1.22); HERS II, 1.00 (95% CI, 0.77-1.29); and overall, 0.99 (0.84-1.17). The overall RHs were similar after adjustment for potential confounders and differential use of statins between treatment groups (RH, 0.97; 95% CI, 0.82-1.14), and in analyses restricted to women who were adherent to randomized treatment assignment (RH, 0.96; 95% CI, 0.77-1.19). Conclusions Lower rates of CHD events among women in the hormone group in the final years of HERS did not persist during additional years of follow-up. After 6.8 years, hormone therapy did not reduce risk of cardiovascular events in women with CHD. Postmenopausal hormone therapy should not be used to reduce risk for CHD events in women with CHD.

https://jamanetwork.com/journals/jama/articlepdf/195080/joc20522.pdf

Cardiovascular Disease Outcomes During 6.8 Years of Hormone Therapy: Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II)

BIOMEDICAL RESEARCH POLICY COMMITTEE REPORT WAS PUBLISHED AS A SUPPLEMENT TO THE AUGUSTJOURNAL OF MEDICAL EDUCATION. A REPRINT IS ENCLOSED. REQUESTS FOR ADDITIONAL COPIES SHOULD BE ADDRESSED TO THISOFFICE. -COPIES ARE BEING SENT TO MEMBERS OF CONGRESS AND THE KEY MEMBERS OF THE ADMINISTRATION. CALLING UPON-YOUR SENATORSAND CONGRESSMEN TO TELL THE STORY OF THE ROLE. OF MEDICAL SCHOOLS IN BIOMEDICAL RESEARCH AND HEALTH CARE IS IMPORTANT.I STRONGLY URGE THAT YOU MAKE AN 411 APPOINTMENT TO SEE YOUR CONGRESSIONAL REPRESENTATIVES WHILE YOU ARE IN WASHINGTON FOR THE COUNCIL MEETINGON OCTOBER 29. UPON REQUEST WE CAN SUPPLY THE NAMES OF APPOINTMENT SECRETARIES AND PHONE NUMBERS OF YOUR SENATORS AND CONGRESSMEN. APPROPRIATIONS COMMITTEE ACTED WITH EXTRAORDINARY ALACRITY THIS YEAR. THE-NIH APPROPRIATION WAS INCREASED BY 242 MILLION DOLLARSOVER 1971, REPRESENTING A 142 MILLION DOLLAR INCREASE OVER. THE ADMINISTRATION BUDGET, THE BLUE SHEET ASCRIBES APPROPRIATIONS OUTCOME TO THE EFFECTIVENESS OF THE COALITION FOR HEALTH FUNDING UNDER THE LEADERSHIP OF JOHN A. D. COOPER.

The Association of American Medical Colleges

Purpose Empathy is a key element of patient– physician communication; it is relevant to and positively influences patients’ health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency. Method The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size 30 were excluded. Results Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the “hidden,” “formal,” and “informal” curricula as main reasons for empathy decline.

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Empathy decline and its reasons: a systematic review of studies with medical students and residents.

To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes.; Systematic review and meta-analysis.; Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews.; Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions.; Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = -.23 to .66. Using a random-effects model, the estimate of the overall effect size was small (d = .11), but statistically significant (p = .02).; This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic.

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The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials.

Purpose To test the hypothesis that physicians’ empathy is associated with positive clinical outcomes for diabetic patients. Method A correlational study design was used in a university-affiliated outpatient setting. Participants were 891 diabetic patients, treated between July 2006 and June 2009, by 29 family physicians. Results of the most recent hemoglobin A1c and LDL-C tests were extracted from the patients’ electronic records. The results of hemoglobin A1c tests were categorized into good control (7.0%) and poor control (9.0%). Similarly, the results of the LDL-C tests were grouped into good control (100) and poor control (130). The physicians, who completed the Jefferson Scale of Empathy in 2009, were grouped into high, moderate, and low empathy scorers. Associations between physicians’ level of empathy scores and patient outcomes were examined. Results Patients of physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy scores (40%, P .001). Similarly, the proportion of patients with good LDL-C control was significantly higher for physicians with high empathy scores (59%) than physicians with low scores (44%, P .001). Logistic regression analyses indicated that physicians’ empathy had a unique contribution to the prediction of optimal clinical outcomes after controlling for physicians’ and patients’ gender and age, and patients’ health insurance. Conclusions The hypothesis of a positive relationship between physicians’ empathy and patients’ clinical outcomes was confirmed, suggesting that physicians’ empathy is an important factor associated with clinical competence and patient outcomes. Empathy, an essential component of the physician–patient relationship, may be linked to positive patient outcomes. Although this notion is consistent with the conceptual view of physician–patient relationships, 1–3 empirical data supporting the association between physicians’ empathy and tangible clinical outcomes are difficult to find. Several studies generally support the notion that the quality of the physician–patient relationship (as a proxy for empathic engagement in patient care) has a positive influence on patient

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Physicians' Empathy and Clinical Outcomes for Diabetic Patients

ContextThe Physician Shortage Area Program (PSAP) of Jefferson Medical College
(Philadelphia, Pa) is one of a small number of medical school programs that
addresses the shortage of rural primary care physicians. However, little is
known regarding why these programs work.ObjectivesTo identify factors independently predictive of rural primary care supply
and retention and to determine which components of the PSAP lead to its outcomes.DesignRetrospective cohort study.Setting and ParticipantsA total of 3414 Jefferson Medical College graduates from the classes
of 1978-1993, including 220 PSAP graduates.Main Outcome MeasuresRural primary care practice and retention in 1999 as predicted by 19
previously collected variables. Twelve variables were available for all classes;
7 variables were collected only for 1978-1982 graduates.ResultsFreshman-year plan for family practice, being in the PSAP, having a
National Health Service Corps scholarship, male sex, and taking an elective
senior family practice rural preceptorship (the only factor not available
at entrance to medical school) were independently predictive of physicians
practicing rural primary care. For 1978-1982 graduates, growing up in a rural
area was the only additionally collected independent predictor of rural primary
care (odds ratio [OR], 4.0; 95% CI, 2.1-7.6; P<.001).
Participation in the PSAP was the only independent predictive factor of retention
for all classes (OR, 4.7; 95% CI, 2.0-11.2; P<.001).
Among PSAP graduates, taking a senior rural preceptorship was independently
predictive of rural primary care (OR, 2.5; 95% CI, 1.3-4.7; P = .004). However, non-PSAP graduates with 2 key selection characteristics
of PSAP students (having grown up in a rural area and freshman-year plans
for family practice) were 78% as likely as PSAP graduates to be rural primary
care physicians, and 75% as likely to remain, suggesting that the admissions
component of the PSAP is the most important reason for its success. In fact,
few graduates without either of these factors were rural primary care physicians
(1.8%).ConclusionsMedical educators and policy makers can have the greatest impact on
the supply and retention of rural primary care physicians by developing programs
to increase the number of medical school matriculants with background and
career plans that make them most likely to pursue these career goals. Curricular
experiences and other factors can further increase these outcomes, especially
by supporting those already likely to become rural primary care physicians.

https://jamanetwork.com/journals/jama/articlepdf/194154/joc11016.pdf

Critical factors for designing programs to increase the supply and retention of rural primary care physicians.

ContextThe shortage of physicians in rural areas is a
longstanding and serious problem, and national and state policymakers
and educators continue to face the challenge of finding effective ways
to increase the supply of rural physicians.ObjectiveTo determine the direct and long-term impact of
the Physician Shortage Area Program (PSAP) of Jefferson Medical College
(JMC) on the rural physician workforce.DesignRetrospective cohort study.Participants and SettingA total of 206 PSAP graduates from the
classes of 1978 to 1991.Main Outcome MeasuresThe PSAP graduates currently practicing
family medicine in rural and underserved areas of Pennsylvania,
compared with all allopathic medical school graduates in the state, and
with all US and international allopathic graduates. All PSAP graduates
were also compared with their non-PSAP peers at JMC regarding their US
practice location, medical specialty, and retention for the past 5 to
10 years.ResultsThe PSAP graduates account for 21% (32/150) of family
physicians practicing in rural Pennsylvania who graduated from one of
the state's 7 medical schools, even though they represent only 1%
(206/14,710) of graduates from those schools (relative risk
[RR], 19.1). Among all US and international medical school graduates,
PSAP graduates represent 12% of all family physicians in rural
Pennsylvania. Results were similar for PSAP graduates practicing in
underserved areas. Overall, PSAP graduates were much more likely than
their non-PSAP classmates at JMC to practice in a rural area of the
United States (34% vs 11%; RR, 3.0), to practice in an underserved
area (30% vs 9%; RR, 3.2), to practice family medicine (52% vs 13%;
RR, 4.0), and to have combined a career in family practice with
practice in a rural area (21% vs 2%; RR, 8.5). Of PSAP graduates,
84% were practicing in either a rural or small metropolitan area, or
one of the primary care specialties. Program retention has remained
high, with the number of PSAP graduates currently practicing rural
family medicine equal to 87% of those practicing between 5 and 10
years ago, and the number practicing in underserved areas, 94%.ConclusionsThe PSAP, after more than 22 years, has had a
disproportionately large impact on the rural physician workforce, and
this effect has persisted over time. Based on these program results,
policymakers and medical schools can have a substantial impact on the
shortage of physicians in rural areas.

https://jamanetwork.com/journals/jama/articlepdf/188379/joc80057.pdf

A Program to Increase the Number of Family Physicians in Rural and Underserved Areas: Impact After 22 Years

Purpose To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication. Method Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed. Results

http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/79edbd02248881d486257402005295c7/$FILE/Medical%20Schools%20and%20Rural%20Physicians.pdf

Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication.

Background: Empathy is the backbone of a positive physician-patient relationship. Physician einpathy and the patient's awareness of the physician's empathic concern can lead to a more positive clinical outcome. Material/Methods: The Jefferson Scale of Physician Empathy (JSPE) was completed by 36 physicians in the Family Medicine residency program at Thomas Jefferson University Hospital, and 90 patients evaluated these physicians by completing the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE), and a survey about physicians' humanistic approaches to patient care. Results: A statistically significant correlation was found between scores of the JSPE and JSPPPE (r=0.48, p<0.05). Significant correlations were also obtained between scores of the JSPE and patients' assessments that their physician was concerned about their feelings (r= 0.55, p<0.01), and that the physician took their wishes into account in making treatment decisions (r=0.48, p<0.05). A negative correlation was observed between scores of the JSPE and patient's perception that their physician was in hurry (r=-0.50, p<0.01). Conclusions: These findings provide further support for the validity of the JSPE. Implications for the assessments of empathy in the physician-patient relationship as related to clinical outcomes are discussed.

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Relationships between scores on the Jefferson Scale of physician empathy, patient perceptions of physician empathy, and humanistic approaches to patient care: a validity study.

Fred W. Markham

Papers

Physicians' Empathy and Clinical Outcomes for Diabetic Patients

Critical factors for designing programs to increase the supply and retention of rural primary care physicians.

A Program to Increase the Number of Family Physicians in Rural and Underserved Areas: Impact After 22 Years

Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication.

Relationships between scores on the Jefferson Scale of physician empathy, patient perceptions of physician empathy, and humanistic approaches to patient care: a validity study.