Pulling our lens backwards to move forward: an integrated approach to physician distress

The medical community has recently acknowledged physician stress as a leading issue for individual wellness and healthcare system functioning. Unprecedented levels of stress contribute to physician burnout, leaves of absence and early retirement. Although recommendations have been made, we continue to struggle with addressing stress. One challenge is a lack of a shared definition for what we mean by ‘stress’, which is a complex and idiosyncratic phenomenon that may be examined from a myriad of angles. As such, research on stress has traditionally taken a reductionist approach, parsing out one aspect to investigate, such as stress physiology. In the medical domain, we have traditionally underappreciated other dimensions of stress, including emotion and the role of the environmental and sociocultural context in which providers are embedded. Taking a complementary, holistic approach to stress and focusing on the composite, subjective individual experience may provide a deeper understanding of the phenomenon and help to illuminate paths towards wellness. In this review article, we first examine contributions from unidimensional approaches to stress, and then outline a complementary, integrated approach. We describe how complex phenomena have been tackled in other domains and discuss how holistic theory and the humanities may help in studying and addressing physician stress, with the ultimate goal of improving physician well-being and consequently patient care.

Physician Stress During Electronic Health Record Inbox Work: In Situ Measurement With Wearable Sensors

Background Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day. Objective The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress. Methods Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model. Results Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2=98%). Conclusions This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours.

A Multi-Layered LSTM for Predicting Physician Stress During an ED Shift

Emergency Department (ED) physicians are faced with complex care settings, including a high level of uncertainty and intensity. Burnout among physicians is increasing every year, and ED physicians are one of the groups most prone to burnouts and work-related stress in the US. This research focused on developing a supervised Long Short-Term Memory (LSTM) artificial neural network model to predict a physician’s stress level based on their physiological data. Twelve attending physicians working a 3:00 pm - 11:00 pm shift at Greenville Memorial Hospital (GMH) in Greenville, SC, participated in the study. Stress levels were estimated using physiological measures, including heart rate and electrodermal activity. Over 100 hours of physiological data were collected from 12 eight-hour shifts. Initially, an 80:20 split was used on the 12 individual datasets for training and testing the model. Further, to develop a generalizable model, the data were merged, and a 60:20:20 split was used for training, validating, and testing the model. On the test set, the model achieved values of 0.98, 0.17, and 0.005 as the R-squared, RMSE, and loss for EDA data and 0.99, 0.41, and 0.002 for HR data.

An Exploration of Pediatricians’ Personal Value on Mental Health: Experience with Integrated Healthcare and its Impact on Physicians’ Lives

An integrated healthcare model incorporates behavioral health services into a medical setting to address patients’ physical, emotional, and behavioral healthcare concerns. The integrated healthcare model has been associated with positive patient satisfaction and health outcomes, yet limited studies have examined, using qualitative methods, physicians’ experiences of working alongside behavioral health consultants (BHCs) in integrated healthcare settings. Data was gathered through semi-structured interviews with pediatricians (N=4) working in an integrated healthcare model. Participants shared that as pediatricians they received personal, educational, and organizational benefits from an integrated healthcare model. Pediatricians also reported increased knowledge in effectively addressing mental health concerns for their patients and decreased physician stress-levels. Results of pediatricians’ experiences working in an integrated healthcare setting are discussed with regard to their implications for clinical practice and research.

Physician Stress During Electronic Health Record Inbox Work: In Situ Measurement With Wearable Sensors (Preprint)

BACKGROUND Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day. OBJECTIVE The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress. METHODS Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model. RESULTS Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; <i>P</i>=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal <i>R²</i>=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional <i>R²</i>=98%). CONCLUSIONS This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours. CLINICALTRIAL