This cohort study evaluates postoperative adherence to venous thromboembolism prophylaxis guidelines among US adults with pancreatic cancer using a national population sample drawn from Surveillance, Epidemiology, and End Results–Medicare data.
Public reporting of individual physician patient experience scores is becoming widespread on hospital websites and may be included on the Centers for Medicare and Medicaid Services Physician Compare website in the future.1 2 Moreover, physician groups can submit patient experience scores for incentive compensation through the Merit-based Incentive Payment System, and many groups are including patient experience scores in the allocation of incentive compensation.3 However, there is concern that certain physician characteristics (eg, gender, age, training) may unduly influence these scores and may merit consideration of adjustment when used in these ways. It is important to understand whether uncontrollable factors beyond the patient–physician encounter may influence patients’ scores regarding a physician. It was our hypothesis that physician factors such as age, sex and aspects of his or her medical training significantly influence patient experience scores. Therefore, our objective was to assess the association between physician characteristics and patient experience scores from a diverse group of hospitals and medical groups.
Patient experience survey data were acquired for all physicians from a large, diverse, six-hospital (one academic medical centre, one large community hospital, four small community hospitals) health system consisting of 252 outpatient clinic locations for fiscal years (FY) 2013–2017. Only the outpatient survey (Consumer Assessment of Healthcare Providers and Systems, Clinican and Group (CG-CAHPS)) was examined as the inpatient survey (Consumer Assessment of Healthcare Providers and Systems, Hospital (HCAHPS)) is not attributable to a single physician. Delivered nationally by a commercial third-party vendor, the survey contains 10 unique questions specifically addressing the …
Using a mul -ins tu onal database, this study found that for pa ents with func onal neuroendocrine tumors, the failure to achieve symptom improvement a er the resec on is associated with earlier disease recurrence even when accoun ng for histological type, the presence of gene c syndromes, R1 resec on margin, and lymph node involvement.
Curative intent therapy is the standard of care for early-stage hepatocellular carcinoma (HCC). However, these therapies are under-utilized, with several treatment and survival disparities. We sought to demonstrate whether the type of facility and distance from treatment center (with transplant capabilities) contributed to disparities in curative-intent treatment and survival for early-stage HCC in California.
In academic medicine, value has traditionally been placed on faculty considered the “triple threat”—excellent clinicians, outstanding educators, and impactful researchers. However, many questions whether academic clinicians can maintain simultaneous excellence in all these domains and if the “triple threat” should remain the gold standard of academic success. One reason is the complexity and rigor by which excellence is contemporaneously defined. For example, federal research funding has become highly competitive with a halving of the award rate across the National Institutes of Health over the past 2 decades (∼30% in the late 1990s; ∼16% in 2014).1 However, a more existential threat is the financial demands placed on academic faculty by their departments, hospitals, and health systems. Academic surgery departments are generally considered revenue centers for hospitals with surgical admissions accounting for a quarter of all hospital admissions and approximately half of all health care costs.2 As our healthcare landscape continues its shift toward integration of local and regional health systems, there will be added pressure on member hospitals to increase financial productivity. This productivity burden will be borne by all specialties, but particularly among those with the greatest potential to impact hospital revenue—like surgery. The fundamental issue then becomes how this emphasis on financial productivity is currently impacting, and will further impact in the future, the educational and research missions of academic departments and their faculty. POTENTIAL CONSEQUENCES OF FOCUSING ON CLINICAL PRODUCTIVITY Faculty in many academic settings already feel the result of these financial pressures with decreases in their protected base salaries in favor of compensation plans more heavily weighted toward individual clinical productivity targets. These types of salary models can be a significant problem for several important reasons. First, faculty interested in developing educational or research programs may become increasingly dispirited as they face the conundrum of balancing the hospital's need for clinical productivity (on which a significant portion of their salary may be based) relative to the time needed for professional development in the other 2 domains. This in turn could impact physician wellness and burnout, which are currently major problems.3 While academic surgeons generally have a lower risk of burnout and higher job satisfaction compared with surgeons in private practice, many of the factors associated with higher job satisfaction among academicians are directly affected by this tension between the clinical and financial needs of the hospital relative to the need for support and development by the individual.4,5 An important additional issue is that it can often be difficult to separate feelings of professional wellness or burnout/fatigue at work from a sense of personal happiness outside of work. This can create an equally important tension between the clinical pressure of work and life at home. If academic clinicians are provided neither a venue nor opportunity to pursue nonclinical interests, there could be an exacerbation of job dissatisfaction resulting in increased faculty burnout. Second, these salary models could erode at the nature and mission of academic surgery departments. Academic surgery departments should strive to have a strong culture and an identity that binds faculty (who may have wide ranging individual interests) around a common purpose. An overemphasis on financial gains can dilute this culture and obscure this common sense of mission. If hospitals primarily hire faculty to meet clinical need, this could result in fewer opportunities to hire young faculty with aspirations to conduct research along more traditional career development routes. Because most K-awards explicitly require 75% effort dedicated to research, they are often associated with a significant upfront investment by the department and institution. As such, it is incumbent on academic departments to thoughtfully consider how this will affect their ability to develop the next generation of clinician-scientists. Third, these financial pressures could leave faculty with less time for educational, academic, and career mentorship of students and trainees. Similarly, established faculty may feel competing demands and commit less effort to helping junior partners develop their own practices. These same pressures could become a significant impediment to intradepartmental or cross-disciplinary collaboration. Within departments, this could certainly limit institutional and programmatic growth. With regard to research, this could take time away from surgical investigators pursuing interests in developing, participating in, or leading multidisciplinary research teams. POTENTIAL SOLUTIONS Because each individual institution has a distinct culture and may value different things, there is unlikely to be a single, generalizable solution to address the existing tension between clinical productivity and academic success. Nevertheless, there are several options to consider. First, novel compensation models that not only consider clinical productivity, but simultaneously support efforts directed at trainee education both within and outside the operating room as well as incentivize research productivity and successful grant funding should be developed, implemented, and prioritized.6 Rather than fostering a culture in which compensation is driven primarily (or only) by the individual surgeon's clinical work, these models should strive to encourage collaboration, teamwork, and success of the group as a whole. A practice plan model based principally on the success of the division or department with a guaranteed proportion of salary (as long as minimum thresholds are met) could help to enhance intradepartmental collaboration. These models should continue to reward individual clinicians for high performance if they achieve or exceed threshold benchmarks for clinical productivity; however, they should also incentivize and offer similarly significant salary support for education and academic success. For academic programs to sustain high-quality residency training activities, clinicians must continue to be supported and valued for their nonclinical efforts. Second, in our current healthcare environment, the focus should shift from recruiting and developing individual “triple threat” academic surgeons in favor of creating “triple threat” departments. In addition to clinical care, research, and education, value is also placed on the contribution surgeons can make in departmental, hospital, and health system administrative leadership. Surgeons should be hired to fit a niche within this framework and everyone's efforts in their specified role (s) should be valued equally toward the common goal of supporting the department's overall academic mission. For example, junior faculty hired to help the department fulfill its research mission should be provided adequate mentorship and support while simultaneously finding ways to de-emphasize their role in the department's clinical mission to afford them the best chance for success. Importantly, in addition to requiring a shift in recruitment strategy, this approach also necessitates a shift in culture toward one in which each member of the department—including those who focus primarily on clinical productivity—is valued for their contributions toward the academic mission. Faculty who primarily fill roles in research and/or education should seek to engage and collaborate with those who fill the role of “master clinician” so that they too participate in the department's overall academic mission—those who primarily fill a clinical niche are likely to have insights into evolving patient care issues (that can help to inform research) and the most contact with residents in patient care settings. Moreover, there should be the opportunity for fluidity between roles so individuals have the chance to pursue and explore their current, burgeoning, and future interests. Third, academic surgery departments should consider building interinstitutional collaborations and exchanges. This could help to address the fact that at any individual institution there may be limited resources to support a department's academic mission. For example, the department of surgery at the University of Michigan has developed a junior faculty exchange program to allow interinstitutional networking and mentorship.7 These types of interinstitutional collaborations could be an excellent model for fostering the mission of academic surgical departments. They can help scientific advancement through collaboration and clinical advancement through observation of faculty in other departments. Visiting individuals can in turn share new perspectives with residents and faculty. Perhaps most importantly, it can help to build a positive culture by clearly demonstrating the department's commitment to the growth and development of its member faculty. Perhaps infrastructure used in the creation and implementation of regional collaboratives could further support these types of programs. Finally, academic surgeons are well positioned to take roles at their respective institutions in quality, innovation, and administrative leadership.8 In these roles, surgeons need to have an active voice in shaping major decisions affecting clinical workflow and how this may impact the department and its faculty members. Furthermore, because surgery departments are hospital revenue centers, departmental leadership should continue to emphasize the advantages of maintaining an engaged faculty by offering opportunities and support for nonclinical activities. Faculty who feel valued and believe the institution supports their personal growth and development may in turn be more likely to take a vested interest in ensuring the financial health and solvency of their division, department, and hospital. In conclusion, the landscape of academic surgery has changed over the past several decades. Although the tension generated between the for-profit corporate model of success and the support for academic achievement is not new, several unique challenges will need to be addressed going forward. Opportunities offered by a career in academic surgery should not be taken for granted. Academic surgery departments, hospitals, and health systems should work collaboratively toward the common goal of supporting a unified mission of innovation, creativity, and clinical excellence.
