Suicidal Ideation and Attitudes Regarding Help Seeking in US Physicians Relative to the US Working Population

ObjectiveTo evaluate the prevalence of suicidal ideation (SI) and attitudes regarding help seeking among US physicians relative to the general US working population.Participants and MethodsA secondary analysis of a cross-sectional survey of US physicians and a probability-based sample of the US working population was conducted between October 12, 2017, and March 15, 2018. Among 30,456 invited physicians, 5197 (17.1%) completed the primary survey. Suicidal ideation in the last year, attitudes regarding help seeking, symptoms of depression, and burnout were assessed by standardized questions.ResultsAmong the 4833 physicians who responded regarding SI, 316 (6.5%) reported having suicidal thoughts in the last 12 months. Most physicians (3527 [72.9%]) reported that they would seek professional help if they had a serious emotional problem. Physicians with SI were less likely to report that they would seek help (203/316 [64.2%]) than physicians without SI (3318/4517 [73.5%]; P=.001). On multivariable analysis, symptoms of depression (odds ratio [OR], 4.42; 95% CI, 1.89 to 11.52), emotional exhaustion (OR, 1.07 each 1-point increase; 95% CI, 1.03 to 1.11), and self-valuation (OR, 0.84 each 1-point increase; 95% CI, 0.70 to 0.99) were associated with SI. Among individuals aged 29 to 65 years, physicians were more likely than workers in other fields to report SI (7.1% vs 4.3%; P<.001), a finding that persisted on multivariable analysis.ConclusionIn this national study conducted before the COVID-19 pandemic, 1 in 15 US physicians had thoughts of taking their own life in the last year, which exceeded the prevalence of SI among US workers in other fields.     

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2020

ObjectiveTo evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) among physicians and US workers in 2020 relative to 2011, 2014, and 2017.MethodsBetween November 20, 2020, and March 23, 2021, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our prior studies. Burnout and WLI were measured using standard tools. Information about specific work-related COVID-19 experiences was collected.ResultsThere were 7510 physicians who participated in the survey. Nonresponder analysis suggested that participants were representative of US physicians. Mean emotional exhaustion and depersonalization scores were lower in 2020 than in 2017, 2014, and 2011 (all P<.001). However, emotional exhaustion and depersonalization scores did not improve in specialties most heavily affected by COVID-19. Overall, 38.2% of physicians reported 1 or more symptoms of burnout in 2020 compared with 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Providing care without adequate personal protective equipment (odds ratio [OR], 1.53; 95% CI, 1.35 to 1.72) and having suffered disruptive economic consequences due to COVID-19 (OR, 1.49; 95% CI, 1.32 to 1.69) were independently associated with risk of burnout. On multivariable analysis, physicians were at increased risk for burnout (OR, 1.41; 95% CI, 1.25 to 1.58) and were less likely to be satisfied with WLI (OR, 0.71; 95% CI, 0.64 to 0.79) than other working US adults.ConclusionBurnout and satisfaction with WLI among US physicians improved between 2017 and 2020. The impact of the COVID-19 pandemic on physicians varies on the basis of professional characteristics and experiences. Physicians remain at increased risk for burnout relative to workers in other fields.     

Self-Valuation Challenges in the Culture and Practice of Medicine and Physician Well-being

ObjectiveTo compare physicians with workers in other fields on measures of self-valuation (SV) and determine the effect of adjusting for SV on the relationship between being a physician and risk for burnout.Patients and MethodsA random sample of physicians from the American Medical Association Physician Masterfile and a probability sample from the general US population were used. Data were collected for this cross-sectional study between October 12, 2017 and March 15, 2018. Burnout was indicated by a score of 27 or higher on Emotional Exhaustion or 10 or higher on Depersonalization, using the Maslach Burnout Inventory. Self-valuation was measured with Self-valuation Scale items.ResultsPhysicians (248/832=29.8%) more than workers in other fields (1036/5182=20.0%) “often” or “always” felt more self-condemnation than self-encouragement to learn from the experience when they made a mistake. Physicians (435/832=52.3%) more than workers in other fields (771/5182=14.9%) “often” or “always” put off taking care of their own health due to time pressure. Physicians had greater odds of burnout before (odds ratio [OR], 1.51; 95% CI, 1.30 to 1.76) but not after adjusting for SV responses (OR, 0.93; 95% CI, 0.78 to 1.11). After adjustment for SV, work hours, sex, and age, physicians had lower odds of burnout than workers in other fields (OR, 0.82; 95% CI, 0.68 to 0.99).ConclusionSelf-valuation is lower in physicians compared with workers in other fields and adjusting for SV eliminated the association between being a physician and higher risk for burnout. Experimental design research is needed to determine whether the association of SV with burnout is causal and the degree to which SV is malleable to intervention at individual, organization, and professional culture levels.     

How Feedback Is Given Matters: A Cross-Sectional Survey of Patient Satisfaction Feedback Delivery and Physician Well-being

ObjectiveTo evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making.Participants and MethodsA cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates.ResultsOf 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P<.001). Physicians who received feedback that included one-on-one discussions (as opposed to feedback without this channel) held more positive perceptions of the feedback’s impact on patient care (OR, 2.0; 95% CI, 1.3 to 3.0; P=.003), whereas perceptions were less positive in physicians whose feedback included comparisons to named colleagues (OR, 0.5; 95% CI, 0.3 to 0.8; P=.003).ConclusionProviding patient satisfaction feedback to physicians was associated with mixed results, and physician perceptions of the impact of feedback depended on the characteristics of feedback delivery. Our findings suggest that feedback is viewed most constructively by physicians when delivered through one-on-one discussions and without comparison to peers.     

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic

ObjectiveTo evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) in US physicians at the end of 2021, roughly 21 months into the COVID-19 pandemic, with comparison to 2020, 2017, 2014, and 2011.MethodsBetween December 9, 2021, and January 24, 2022, we surveyed US physicians using methods similar to those of our prior studies. Burnout, WLI, depression, and professional fulfillment were assessed with standard instruments.ResultsThere were 2440 physicians who participated in the 2021 survey. Mean emotional exhaustion and depersonalization scores were higher in 2021 than those observed in 2020, 2017, 2014, and 2011 (all P<.001). Mean emotional exhaustion scores increased 38.6% (2020 mean, 21.0; 2021 mean, 29.1; P<.001), whereas mean depersonalization scores increased 60.7% (2020 mean, 6.1; 2021 mean, 9.8; P<.001). Overall, 62.8% of physicians had at least 1 manifestation of burnout in 2021 compared with 38.2% in 2020, 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Although these trends were consistent across nearly all specialties, substantial variability by specialty was observed. Satisfaction with WLI declined from 46.1% in 2020 to 30.2% in 2021 (P<.001). Mean scores for depression increased 6.1% (2020 mean, 49.54; 2021 mean, 52.59; P<.001).ConclusionA dramatic increase in burnout and decrease in satisfaction with WLI occurred in US physicians between 2020 and 2021. Differences in mean depression scores were modest, suggesting that the increase in physician distress was overwhelmingly work related. Given the association of physician burnout with quality of care, turnover, and reductions in work effort, these findings have profound implications for the US health care system.     

IMPACT: Evaluation of a Controlled Organizational Intervention Using Influential Peers to Promote Professional Fulfillment

ObjectiveTo determine the effects of a popular opinion leader (POL)-led organizational intervention targeting all physicians and advanced practice providers (APPs) working within clinic groups on professional fulfillment (primary outcome), gratitude, burnout, self-valuation, and turnover intent.Patients and MethodsAll 20 Stanford University HealthCare Alliance clinics with ≥5 physicians-APPs were matched by size and baseline gratitude scores and randomly assigned to immediate or delayed intervention (control). Between July 10, 2018, and March 15, 2019, trained POLs and a physician-PhD study investigator facilitated 4 interactive breakfast or lunch workshops at intervention clinics, where colleagues were invited to discuss and experience one evidence-based practice (gratitude, mindfulness, cognitive, and behavioral strategies). Participants in both groups completed incentivized annual assessments of professional fulfillment, workplace gratitude, burnout, self-valuation, and intent to leave as part of ongoing organizational program evaluation.ResultsEighty-four (75%) physicians-APPs at intervention clinics attended at least 1 workshop. Of all physicians-APPs, 236 of 251 (94%) completed assessments in 2018 and 254 of 263 (97%) in 2019. Of 264 physicians-APPs with 2018 or 2019 assessment data, 222 (84%) had completed 2017 assessments. Modal characteristics were 60% female, 46% White, 49% aged 40 to 59 years, 44% practicing family-internal medicine, 78% living with partners, and 53% with children. Change in professional fulfillment by 2019 relative to average 2017 to 2018 levels was more favorable (0.63 points; effect size = 0.35; P=.001) as were changes in gratitude and intent to leave among clinicians practicing at intervention clinics.ConclusionInterventions led by respected physicians-APPs can achieve high participation rates and have potential to promote well-being among their colleagues.     

A Longitudinal Study Exploring Learning Environment Culture and Subsequent Risk of Burnout Among Resident Physicians Overall and by Gender

ObjectiveTo explore the relationship between learning environment culture and the subsequent risk of developing burnout in a national sample of residents overall and by gender.MethodsFrom April 7 to August 2, 2016, and May 26 to August 5, 2017, we surveyed residents in their second (R2) and third (R3) postgraduate year. The survey included a negative interpersonal experiences scale (score range 1 to 7 points, higher being worse) assessing psychological safety and bias, inclusion, respect, and justice; an unfair treatment scale (score range 1 to 5 points, higher being worse), and two items from the Maslach Burnout Inventory. Individual responses to the R2 and R3 surveys were linked.ResultsThe R2 survey was completed by 3588 of 4696 (76.4%) residents; 3058 of 3726 (82.1%) residents completed the R3 survey; and 2888 residents completed both surveys. Women reported more negative interpersonal experiences (mean [SD], 3.00 [0.83] vs 2.90 [0.85], P<.001) and unfair treatment (66.5% vs. 58.7%, P<.001) than men at R2. On multivariable analysis, women at R3 were more likely than their male counterparts to have burnout (odds ratio, 1.23; 95% CI, 1.02 to 1.48; P=.03). Both men and women who reported more negative interpersonal experiences at R2 were more likely to have burnout at R3 (odds ratio, 1.32; 95% CI, 1.14 to 1.52; P<.001). The factors contributing to burnout did not vary in effect magnitude by gender.ConclusionThese findings indicate women residents are more likely to have burnout relative to men in the third year of residency. Negative culture predicted subsequent burnout 1 year later among both men and women. Differences in burnout were at least partly due to differing levels of exposure to negative interactions for men versus women rather than a negative interaction having a differential impact on the well-being of men versus women.     

Cost-Related Nonadherence to Medications Among US Adults With Chronic Liver Diseases

ObjectiveTo estimate the prevalence, risk factors, and consequences of cost-related medication nonadherence (CRN) in individuals with chronic liver diseases (CLDs) in the United States.Patients and MethodsUsing the National Health Interview Survey from January 1, 2014, to December 31, 2018, we identified individuals with CLDs. Using complex weighted survey analysis, we obtained national estimates and risk factors for CRN and its association with cost-reducing behaviors and measures of financial toxicity. We evaluated the association of CRN with unplanned health care use, adjusting for age, sex, race/ethnicity, insurance, income, education, and comorbid conditions.ResultsOf 3237 respondents (representing 4.6 million) US adults with CLDs, 813 (representing 1.2 million adults, or 25%; 95% CI, 23% to 27%) reported CRN, of whom 68% (n=554/813) reported maladaptive cost-reducing behaviors. Younger age, female sex, low income, and multimorbidity were associated with a higher prevalence of CRN. Compared with patients without CRN, patients experiencing CRN had 5.1 times higher odds of financial hardship from medical bills (adjusted odds ratio [aOR], 5.05; 95% CI, 3.73 to 6.83) and 2.9 times higher odds of food insecurity (aOR, 2.85; 95% CI, 2.02 to 4.01). The CRN was also associated with 1.5 times higher odds of emergency department visits (aOR, 1.46; 95% CI, 1.11 to 1.94).ConclusionWe observed a high prevalence of CRN and associated consequences such as high financial distress, financial hardship from medical bills, food insecurity, engagement in maladaptive cost-reducing strategies, increased health care use, and work absenteeism among patients with CLD. These financial determinants of health have important implications in the context of value-based care.     

Trends in Metabolic Phenotypes According to Body Mass Index Among US Adults, 1999-2018

ObjectiveTo examine the prevalence, distribution, and temporal trends of metabolic phenotypes that are jointly determined by obesity and metabolic health status among US adults, overall and in key population subgroups.Participants and MethodsA nationally representative sample of civilian, noninstitutionalized US adults aged 20 years and older from the National Health and Nutrition Examination Survey between 1999-2000 and 2017-2018 were included. Metabolic phenotypes were characterized jointly by body mass index and metabolic health: metabolically healthy underweight, normal weight, overweight, and obese (MH-OB); and metabolically unhealthy underweight, normal weight, overweight, and obese (MU-OB). Metabolic health was defined using the 2009 joint scientific statement for metabolic syndrome from the International Diabetes Federation Task Force on Epidemiology and Prevention, National Heart, Lung, and Blood Institute, American Heart Association, World Heart Federation, International Atherosclerosis Society, and International Association for the Study of Obesity as having 2 or less components (primary analysis) or no components (secondary analysis) of the following: waist circumference of 102 cm or greater in men and 88 cm or greater in women, fasting plasma glucose level of 100 mg/dL or greater, blood pressure of 130/85 mm Hg or greater, triglyceride level of 150 mg/dL or greater, and high-density lipoprotein cholesterol level of less than 40 mg/dL in men and less than 50 mg/dL in women.ResultsOf 19,941 adults, the mean age was 46.9 years; 10,005 (50.6%) were female. From 1999 to 2018, the prevalence in primary analysis declined from 33.2% (465465 of 1646) to 25.1% (454454 of 2058) (difference, ?8.09%; 95% CI, ?12.5% to ?3.70%) for metabolically healthy normal weight, whereas it increased from 9.92% (178178 of 1646) to 14.1% (277277 of 2058) (difference, 4.17%; 95% CI, 1.13% to 7.21%) for MH-OB (both P<.001 for trend). The prevalence of metabolically healthy underweight and overweight remained stable at about 1.62% (298298 of 19,94119,941) (95% CI, 1.38% to 1.89%; P=.34 for trend) and 22.2% (4,275 of 19,941) (95% CI, 21.4% to 23.0%; P=.14 for trend), respectively. The prevalence declined from 3.77% (72 of 1646) to 2.10% (68 of 2058) (difference, ?1.67%; 95% CI, ?3.22% to ?0.12%; P=.006 for trend) for metabolically unhealthy normal weight, whereas it increased from 19.0% (343 of 1646) to 26.4% (574 of 2058) (difference, 7.41%; 95% CI, 2.67% to 12.2%; P<.001 for trend) for MU-OB. The prevalence of metabolically unhealthy underweight and overweight remained stable at 0.06% (11 of 19,941) (95% CI, 0.03% to 0.15%; P=.84 for trend) and 11.2% (2528 of 19,941) (95% CI, 10.6% to 11.8%; P=.29 for trend), respectively. Persistent differences in the prevalence of metabolic phenotypes were identified across multiple sociodemographic subgroups. For example, the prevalence of MH-OB increased from 7.58% (53 of 754) to 12.0% (79 of 694) (P<.001 for trend) for non-Hispanic Whites and 12.2% (60 of 567) to 18.4% (76 of 493) for Hispanics (P=.01 for trend) and remained stable at 22.6% (756 of 3,825) for non-Hispanic Blacks (P=.62 for trend and P=.05 for interaction). Results in secondary analyses revealed similar patterns.ConclusionFrom 1999 to 2018, US adults experienced major increases in the prevalence of both MH-OB and MU-OB, largely due to decreases in MH-N. The prevalence of MU-OB increased across all subgroups, with higher values observed in older adults and those with lower education and income levels.     

Health Care Expenditures Attributable to Primary Care Physician Overall and Burnout-Related Turnover: A Cross-sectional Analysis

ObjectiveTo estimate the excess health care expenditures due to US primary care physician (PCP) turnover, both overall and specific to burnout.MethodsWe estimated the excess health care expenditures attributable to PCP turnover using published data for Medicare patients, calculated estimates for non-Medicare patients, and the American Medical Association Masterfile. We used published data from a cross-sectional survey of US physicians conducted between October 12, 2017, and March 15, 2018, of burnout and intention to leave one’s current practice within 2 years by primary care specialty to estimate excess expenditures attributable to PCP turnover due to burnout. A conservative estimate from the literature was used for actual turnover based on intention to leave. Additional publicly available data were used to estimate the average PCP panel size and the composition of Medicare and non-Medicare patients within a PCP’s panel.ResultsTurnover of PCPs results in approximately $979 million in excess health care expenditures for public and private payers annually, with $260 million attributable to PCP burnout-related turnover.ConclusionTurnover of PCPs, including that due to burnout, is costly to public and private payers. Efforts to reduce physician burnout may be considered as one approach to decrease US health care expenditures.     

The Natural History of Chronic Unexplained Gastrointestinal Disorders and Gastroesophageal Reflux During 20 Years: A US Population-Based Study

ObjectiveTo explore the natural history of chronic unexplained gastrointestinal (GI) symptoms and to determine the longitudinal trends of prevalence during a 20-year period in a single US community.MethodsBetween January 1, 1990, and December 31, 2009, valid self-report questionnaires of GI symptoms were mailed to randomly selected cohorts of a community. The study used respondents who answered questions on 1 or more of 3 surveys (initial, 1990-1992; second, 2003-2004; and third, 2008-2009). The trends of prevalence of GI symptoms over time were analyzed in responders who completed 3 surveys, and the natural history or transition was evaluated.ResultsThe overall prevalence of major symptom groupings including gastroesophageal reflux disease was consistent among residents in a community on 3 survey time points (1990-1992, 2003-2004, and 2008-2009). The transitions of GI symptoms were common in 228 patients who responded to all 3 surveys; only 29% had the same symptom category in 3 surveys; otherwise, symptoms changed over time, resolving, recurring, or transitioning to another disorder. Observed proportions of symptom transitions were significantly different from expected during 20 years (P<.001). Higher non-GI somatic symptom scores were significantly associated with both symptom transitions (odds ratio, 3.9; 95% CI, 1.38 to 10.77) and having sustained symptoms (odds ratio, 12.7; 95% CI, 4.62 to 34.90).ConclusionThe overall population prevalence of chronic unexplained GI symptoms is stable, but in individuals, transitions seem to be the rule. As these various GI syndromes appear to be so intimately interconnected, the common underlying pathogenesis may account for a major subgroup of chronic unexplained GI disorders.     

Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center

ObjectiveTo assess changes in inpatient transfusion utilization and patient outcomes with implementation of a comprehensive patient blood management (PBM) program at a large US medical center.Patients and MethodsThis is an observational study of graduated PBM implementation for hospitalized adults (age ≥18 years) from January 1, 2010, through December 31, 2017, at two integrated hospital campuses at a major academic US medical center. Allogeneic transfusion utilization and clinical outcomes were assessed over time through segmented regression with multivariable adjustment comparing observed outcomes against projected outcomes in the absence of PBM activities.ResultsIn total, 400,998 admissions were included. Total allogeneic transfusions per 1000 admissions decreased from 607 to 405 over the study time frame, corresponding to an absolute risk reduction for transfusion of 6.0% (95% confidence interval [CI]: 3.6%, 8.3%; P<.001) and a 22% (95% CI: 6%, 37%; P=.006) decrease in the rate of transfusions over projected. The risk of transfusion decreased for all blood components except cryoprecipitate. Transfusion reductions were experienced for all major surgery types except liver transplantation, which remained stable over time. Hospital length of stay (multiplicative increase in geometric mean 0.85 [95% CI: 0.81, 0.89]; P<.001) and incident in-hospital adverse events (absolute risk reduction: 1.5% [95% CI: 0.1%, 3.0%]; P=.04) were lower than projected at the end of the study time frame.ConclusionPatient blood management implementation for hospitalized patients in a large academic center was associated with substantial reductions in transfusion utilization and improved clinical outcomes. Broad-scale implementation of PBM in US hospitals is feasible without signal for patient harm.     

Clinical Characteristics and Outcomes of Patients With Primary Plasma Cell Leukemia in the Era of Novel Agent Therapy

ObjectiveTo evaluate the clinical outcomes of patients with primary plasma cell leukemia (pPCL) defined by 5% or greater clonal circulating plasma cells on peripheral blood smear and treated with novel agent induction therapies.Patients and MethodsA cohort of 68 patients with pPCL diagnosed at the Mayo Clinic in Rochester, Minnesota, from January 1, 2000, to December 31, 2019, and treated with novel agent induction therapies was evaluated.ResultsThe median follow-up was 46 (95% CI, 41 to 90) months. The median bone marrow plasma cell content was 85% (range, 10% to 100%) and median clonal circulaitng plasma cell percentage on the peripheral blood smear was 26% (range, 5% to 93%). There was a preponderance of t(11;14) primary cytogenetic abnormality in this cohort. The median time to next therapy (TTNT) and overall survival (OS) for all patients with pPCL patients in this cohort was 13 (95% CI, 9 to 17) and 23 (95% CI, 19 to 38) months, respectively. However, when stratified by cytogenetic risk, the median TTNT and OS were 16 and 51 months for standard risk vs 9 and 19 months for high risk (P=.01 for OS).ConclusionPrimary plasma cell leukemia remains an aggressive disease with poor prognosis despite novel agent–based therapies. Some patients have better than expected survival and this phenomenon may be influenced by the absence of high-risk cytogenetics. Newer treatment regimens are needed to improve the prognosis of this devastating disease.     

Healing the Professional Culture of Medicine

The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.     

Colleagues Meeting to Promote and Sustain Satisfaction (COMPASS) Groups for Physician Well-Being: A Randomized Clinical Trial

ObjectiveTo evaluate physician small groups to promote physician well-being in a scenario with provided discussion topics but without trained facilitators, and for which protected time was not provided but meal expenses were compensated.Participants and MethodsWe conducted a randomized controlled trial of 125 practicing physicians in the Department of Medicine, Mayo Clinic, Rochester, Minnesota, between October 2013 and October 2014 with subsequent assessment of organizational program implementation. Twelve biweekly self-facilitated discussion groups involving reflection, shared experience, and small-group learning took place over 6 months. Main outcome measures included meaning in work, burnout, symptoms of depression, quality of life, social support, and job satisfaction assessed using validated metrics.ResultsAt 6 months after completion of the intervention (12 months from baseline), the rate of overall burnout had decreased by 12.7% (31/62 to 19/51) in the intervention arm versus a 1.9% increase (25/61 to 24/56) in the control arm (P<.001). The rate of depressive symptoms had decreased by 12.8% (29/62 to 17/50) in the intervention arm versus a 1.1% increase (20/61 to 19/56) in the control arm (P<.001). The proportion of physicians endorsing at least moderate self-reported likelihood of leaving their current practice in the subsequent 2 years had decreased by 1.9% (17/62 to 13/51) in the intervention arm and increased by 6.1% (14/61 to 16/55) in the control arm (P<.001). No statistically significant differences were seen in mean changes in burnout scale scores, meaning, or social support, although numeric differences generally favored the intervention.ConclusionSelf-facilitated physician small-group meetings improved burnout, depressive symptoms, and job satisfaction. This intervention represents a low-cost strategy to promote important dimensions of physician well-being.Trial Registrationclinicaltrials.gov Identifier: NCT04466423     

In-Hospital Complications in Pregnant Women With Current or Historical Cancer Diagnoses

ObjectiveTo assess the temporal trends, characteristics and comorbidities, and in-hospital cardiovascular and obstetric complications and outcomes of pregnant women with current or historical cancer diagnosis at the time of admission for delivery.MethodsWe analyzed delivery hospitalizations with or without current or historical cancer between January 1, 2004, and December 31, 2014, from the US National Inpatient Sample database.ResultsWe included 43,132,097 delivery hospitalizations with no cancer, 39,118 with current cancer, and 67,336 with historical diagnosis of cancer. The 5 most common types of current cancer were hematologic, thyroid, cervical, skin, and breast cancer. Women with current and historical cancer were older (29 years and 32 years vs 27 years) and incurred higher hospital costs ($4131 and $4078 vs $3521) compared with women without cancer. Most of the cancer types were associated with preterm birth (hematologic: adjusted odds ratio [aOR], 1.48 [95% CI, 1.35 to 1.62]; cervical: aOR, 1.47 [95% CI, 1.32 to 1.63]; breast: aOR, 1.93 [95% CI, 1.72 to 2.16]). Current hematologic cancer was associated with the highest risk of peripartum cardiomyopathy (aOR, 12.19 [95% CI, 7.75 to 19.19]), all-cause mortality (aOR, 6.50 [95% CI, 2.22 to 19.07]), arrhythmia (aOR, 3.82 [95% CI, 2.04 to 7.15]), and postpartum hemorrhage (aOR, 1.31 [95% CI, 1.11 to 1.54]). Having a current or historical cancer diagnosis did not confer additional risk for stillbirth; however, metastases increased the risk of maternal mortality and preterm birth.ConclusionWomen with a current or historical diagnosis of cancer at delivery have more comorbidities compared with women without cancer. Clinicians should communicate the risks of multisystem complications to these complex patients.     

Effect of Omega-3 Dosage on Cardiovascular Outcomes: An Updated Meta-Analysis and Meta-Regression of Interventional Trials

ObjectivesTo quantify the effect of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids on cardiovascular disease (CVD) prevention and the effect of dosage.MethodsThis study is designed as a random effects meta-analysis and meta-regression of randomized control trials with EPA/DHA supplementation. This is an update and expanded analysis of a previously published meta-analysis which covers all randomized control trials with EPA/DHA interventions and cardiovascular outcomes published before August 2019. The outcomes included are myocardial infarction (MI), coronary heart disease (CHD) events, CVD events (a composite of MI, angina, stroke, heart failure, peripheral arterial disease, sudden death, and non-scheduled cardiovascular surgical interventions), CHD mortality and fatal MI. The strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework.ResultsA total of 40 studies with a combined 135,267 participants were included. Supplementation was associated with reduced risk of MI (relative risk [RR], 0.87; 95% CI, 0.80 to 0.96), high certainty number needed to treat (NNT) of 272; CHD events (RR, 0.90; 95% CI, 0.84 to 0.97), high certainty NNT of 192; fatal MI (RR, 0.65; 95% CI, 0.46 to 0.91]), moderate certainty NNT = 128; and CHD mortality (RR, 0.91; 95% CI, 0.85 to 0.98), low certainty NNT = 431, but not CVD events (RR, 0.95; 95% CI, 0.90 to 1.00). The effect is dose dependent for CVD events and MI.ConclusionCardiovascular disease remains the leading cause of death worldwide. Supplementation with EPA and DHA is an effective lifestyle strategy for CVD prevention, and the protective effect probably increases with dosage.     

Outcomes Following Percutaneous Coronary Intervention in Renal Transplant Recipients: A Binational Collaborative Analysis

ObjectiveTo investigate the clinical and procedural characteristics in patients with a history of renal transplant (RT) and compare the outcomes with patients without RT in 2 national cohorts of patients undergoing percutaneous coronary intervention (PCI).Patients and MethodsData from the National Inpatient Sample (NIS) and British Cardiovascular Intervention Society (BCIS) were used to compare the clinical and procedural characteristics and outcomes of patients undergoing PCI who had RT with those who did not have RT. The primary outcome of interest was in-hospital mortality.ResultsOf the PCI procedures performed in 2004-2014 (NIS) and 2007-2014 (BCIS), 12,529 of 6,601,526 (0.2%) and 1521 of 512,356 (0.3%), respectively, were undertaken in patients with a history of RT. Patients with RT were younger and had a higher prevalence of congestive cardiac failure, hypertension, and diabetes but similar use of drug-eluting stents, intracoronary imaging, and pressure wire studies compared with patients who did not have RT. In the adjusted analysis, patients with RT had increased odds of in-hospital mortality (NIS: odds ratio [OR], 1.90; 95% CI, 1.41-2.57; BCIS: OR, 1.60; 95% CI, 1.05-2.46) compared with patients who did not have RT but no difference in vascular or bleeding events. Meta-analysis of the 2 data sets suggested an increase in in-hospital mortality (OR, 1.79; 95% CI, 1.40-2.29) but no difference in vascular (OR, 1.24; 95% CI, 0.77-2.00) or bleeding (OR, 1.21; 95% CI, 0.86-1.68) events.ConclusionThis large collaborative analysis of 2 national databases revealed that patients with RT undergoing PCI are younger, have more comorbidities, and have increased mortality risk compared with the general population undergoing PCI.