Safety and Effectiveness of Large-Bore Percutaneous Cholangioscopy-Assisted Gallstone Retrieval for Inoperable Calculous Cholecystitis: A Multi-Institutional Retrospective Study.

PURPOSE: To evaluate the safety and effectiveness of large-bore percutaneous biliary access techniques for cholangioscopy-assisted gallstone extraction in patients with a history of acute calculous cholecystitis who are poor surgical candidates. MATERIALS AND METHODS: A retrospective analysis was conducted on patients who underwent percutaneous cholangioscopy for gallstone extraction using large-bore access (24 or 30 French) at two large academic centers from September 2020 and August 2022. Technical success, procedure duration, fluoroscopy time, immediate post-procedure symptom reduction, 3-month symptom-free outcomes, and adverse effects were assessed. RESULTS: Thirty consecutive patients were included. Gallstone removal in a single cholangioscopy session was successful in 93.3% of cases. Large-bore access facilitated the removal of gallstones ranging from 0.5 to 4 cm in diameter, with mean procedure and fluoroscopy times of 105.4 mins 21.7 mins, respectively. This compares to a previous small cholangioscopy study of 13 patients demonstrating mean procedure and fluoroscopy times of 164 mins and 30 mins, respectively. All patients who presented for 3-month follow-up remained symptom-free without gallstone recurrence on imaging. The overall adverse event rate was 6.7%, one Grade C and one Grade D based on the SIR adverse events grading system, both managed appropriately, leading to patient discharge home. CONCLUSION: Large-bore percutaneous biliary access for cholangioscopy-assisted gallstone extraction is a safe and effective technique for managing symptomatic cholelithiasis in poor surgical candidates. Further prospective studies are warranted to validate these findings and evaluate long-term treatment outcomes.

Accounting for taste: preferences mediate the relationship between documentation time and ambulatory physician burnout.

OBJECTIVES: Physician burnout in the US has reached crisis levels, with one source identified as extensive after-hours documentation work in the electronic health record (EHR). Evidence has illustrated that physician preferences for after-hours work vary, such that after-hours work may not be universally burdensome. Our objectives were to analyze variation in preferences for after-hours documentation and assess if preferences mediate the relationship between after-hours documentation time and burnout. MATERIALS AND METHODS: We combined EHR active use data capturing physicians' hourly documentation work with survey data capturing documentation preferences and burnout. Our sample included 318 ambulatory physicians at MedStar Health. We conducted a mediation analysis to estimate if and how preferences mediated the relationship between after-hours documentation time and burnout. Our primary outcome was physician-reported burnout. We measured preferences for after-hours documentation work via a novel survey instrument (Burden Scenarios Assessment). We measured after-hours documentation time in the EHR as the total active time respondents spent documenting between 7 pm and 3 am. RESULTS: Physician preferences varied, with completing clinical documentation after clinic hours while at home the scenario rated most burdensome (52.8% of physicians), followed by dealing with prior authorization (49.5% of physicians). In mediation analyses, preferences partially mediated the relationship between after-hours documentation time and burnout. DISCUSSION: Physician preferences regarding EHR-based work play an important role in the relationship between after-hours documentation time and burnout. CONCLUSION: Studies of EHR work and burnout should incorporate preferences, and operational leaders should assess preferences to better target interventions aimed at EHR-based contributors to burnout.

Multi-institutional Retrospective Study of Percutaneous Cholangioscopy-Assisted Lithotripsy for Inoperable Calculous Cholecystitis.

PURPOSE: This study aimed to assess the safety and efficacy of percutaneous lithotripsy for gallstone eradication in patients with calculous cholecystitis with stones >1 cm. MATERIALS AND METHODS: Multi-institutional institutional review board approved retrospective review of patients who presented with calculous cholecystitis and were not determined to be surgical candidates. All patients underwent percutaneous cholecystostomy tube placement for acute infection, which was later exchanged for a large sheath for ShockPulse (Olympus, Tokyo, Japan) lithotripsy and stone destruction. Review parameters included procedural technical and clinical data, including clinical presentation, mean length of hospital stay, and postintervention symptom reduction. RESULTS: Twelve patients (mean age, 74.6 years; range, 52-94 years; 6 men and 6 women) underwent large-bore sheath (24-30 F) cholangioscopy-assisted gallstone destruction via rigid lithotripsy. The size of the gallstones ranged from 1.2 to 4.0 cm. All patients had prior cholecystostomy access for a mean of 25 weeks before gallstone extraction to ensure tract maturation via transhepatic or transperitoneal access. The technical success rate in single-session stone removal was 100%, with no major procedure-related adverse events. All patients were symptom- and pain-free after the procedure. The mean procedure time was 111.5 minutes, and the mean fluoroscopy time was 19.2 minutes. The median length of hospital stay was 1 day after the procedure. The mean time from percutaneous lithotripsy to biliary tube removal was 35 days (range, 17-45 days). CONCLUSIONS: Fluoroscopy-guided percutaneous rigid lithotripsy is a safe and effective procedure for gallstone destruction and extraction in patients who are poor surgical candidates with large lumen-occupying cholelithiasis.

A Pilot Study to Understand the Role of Medical Humanities in Medical Education.

Over the past 20 years, the number of colleges offering programs in medical humanities has increased, and through the Medical Humanities Initiative at Georgetown University, this pilot study sought to understand students perceived benefits of a medical humanities curriculum. Based on a qualitative thematic analysis of free-response survey reflections from students enrolled in three unique medical humanities courses, six themes emerged. The themes help capture the role that a medical humanities education can play in shaping future clinicians and demonstrate that these courses not only provided a distinct teaching methodology from the scientific classroom but also appeared to deepen the students' understanding of the humanistic aspects of medicine and its many facets.

A Multinational Study of The Impact of Covid-19 On Urologic Surgery Residency and Wellbeing.

OBJECTIVE: To assess changes to the experiences and wellbeing of urology trainees in the United States (US) and European Union (EU) during the COVID-19 pandemic. METHODS: A 72-item anonymous online survey was distributed September 2020 to urology residents of Italy, France, Portugal, and the US. The survey assessed burnout, professional fulfillment, loneliness, depression and anxiety as well as 38 COVID specific questions. RESULTS: Two hundred twenty-three urology residents responded to the survey. Surgical exposure was the main educational concern for 81% of US and 48% of EU residents. E-learning was utilized by 100% of US and 57% of EU residents with two-thirds finding it equally or more useful than traditional didactics. No significant differences were seen comparing burnout, professional fulfillment, depression, anxiety, or loneliness among US or EU residents, 73% of US and 71% of EU residents reported good to excellent quality of life during the pandemic. In the US and EU, significantly less time was spent in the hospital, clinic, and operating room (P <.001) and residents spent more time using telehealth and working from home during the pandemic and on research projects, didactic lectures, non-medical hobbies and reading. The majority of residents reported benefit from more schedule flexibility, improved work life balance, and increased time for family, hobbies, education, and research. CONCLUSION: The COVID-19 pandemic has resulted in significant restructuring of residents' educational experience around the globe. Preservation of beneficial changes such as reduction of work hours and online learning should be pursued within this pandemic and beyond it.

Burnout, Professional Fulfillment, Intention to Leave, and Sleep-Related Impairment among Radiology Trainees across the United States (US): A Multisite Epidemiologic Study.

OBJECTIVE: To examine the prevalence of burnout among radiology trainees in the United States, and to study the relationships between burnout and professional fulfillment (PF), intent-to-leave (ITL), sleep-related impairment and self-compassion by gender. METHODS: This cross-sectional study was conducted via an anonymous electronic survey sent to 11 large academic medical centers (Physician Wellness Academic Consortium) between January 2017 and September 2018. The survey included the Professional Fulfillment Index (PFI) and an abbreviated form of the PROMIS Sleep-related impairment (SRI) scale. Two-sample t-tests and chi-square exact tests were used for analysis (p < 0.05). RESULTS: Two hundred forty-seven radiology residents responded to the survey. Out of these, 36.2% reported burnout, 37.4% endorsed PF, 64.8% reported sleep-related impairment, 7.6% expressed ITL. There were no significant differences between genders. Burnout was associated with reduced PF, increased sleep-impairment (p < 0.001 for both) and increased ITL (p = 0.02). Lower PF, peer support, perceived appreciation for and meaningfulness in work, alignment of organizational and personal values, self-compassion, and higher sleep impairment were associated with burnout (p < 0.001 for all). Burnout was associated with perceptions of less support from department leaders (p = 0.003), control over schedules (p = 0.001) and helpfulness of electronic health record systems (p = 0.01). ITL was associated with reduced PF, perceived work appreciation, and leadership support (p = 0.03, p = 0.04, and p = 0.007, respectively). DISCUSSION: Burnout is prevalent among radiology residents. Many demonstrate sleep-impairment and reduced professional fulfillment, with a lesser fraction desiring to leave their institution. Key factors to burnout included peer and organizational support, electronic health record systems helpfulness, and personal factors like self-compassion and work appreciation.

Beyond burnout: Understanding the well-being gender gap in general surgery by examining professional fulfillment and control over schedule.

BACKGROUND: Prior research has revealed a gender gap in physician burnout. Our study attempts to elucidate the cause for the differences in burnout among male and female general surgeons (GS). METHODS: The study is based on a sample of 431 GS from 11 healthcare organizations participating in the Physician Wellness Academic Consortium. RESULTS: Female (N = 154) and male (N = 277) GS significantly differed in burnout (46% vs 33%, p = 0.008) and professional fulfillment (PF), (37% vs 56% p < 0.001). Male surgeons reported a higher sense of control over their schedule (COS) (5.0 vs 4.2, p = 0.001). Mediation analyses showed that the gender effect on burnout was fully mediated through PF and COS. CONCLUSIONS: This study demonstrates that the observed differences in burnout between female and male GS are due to their differences in PF and COS. Longitudinal research is needed to determine whether interventions targeting PF and COS may mitigate burnout among female GS.

Impact of leadership behaviour on physician well-being, burnout, professional fulfilment and intent to leave: a multicentre cross-sectional survey study.

OBJECTIVE: To examine how perceived leadership behaviours affect burnout, professional fulfilment and intent to leave the organisation among physicians. DESIGN: Anonymous cross-sectional survey study from November 2016 to October 2018. SETTING: 12 036 attending and resident physicians at 11 healthcare organisations participating in the Physician Wellness Academic Consortium (PWAC) were surveyed to assess burnout and professional fulfilment and their drivers. PARTICIPANTS: A sample of 5416 attending physicians with complete data on gender, specialty, leadership, burnout and professional fulfilment. MAIN OUTCOMES AND MEASURES: The leadership behaviour of each physician's supervisor was assessed using the Mayo Clinic Participatory Management Leadership Index and categorised in tertiles. Multivariable logistic regression analyses examined the effect of leadership behaviour rating of each physician's supervisor on burnout, professional fulfilment and intent to leave controlling for gender and specialty. RESULTS: The response rate was 45% across 11 institutions. Half of the respondents were female. Professional fulfilment increased with increasing tertiles of leadership behaviour rating (19%, 34%, 47%, p<0.001). The odds of professional fulfilment were 5.8 times higher (OR=5.8, 95% CI: 5.1 to 6.59) for physicians in the top tertile compared with those in the lowest tertile. Physicians in the top tertile were also 48% less likely to be burned out (OR=0.52, 95% CI: 0.45 to 0.61) and reported 66% lower intent to leave (OR=0.34, 95% CI: 0.26 to 0.44). Individuals who rated their supervisor's leadership in upper tertiles relative to lower tertiles exhibited lower levels of burnout (18% vs 35% vs 47%, p<0.001), and intent to leave (16% vs 24% vs 50% p<0.001). CONCLUSION: Perceived leadership behaviours have a strong relationship with burnout, professional fulfilment and intent to leave among physicians. Organisations should consider leadership development as a potential vehicle to improve physician wellness and prevent costly physician departures.

Analysis of Electronic Health Record Use and Clinical Productivity and Their Association With Physician Turnover.

Importance: Physician turnover takes a heavy toll on patients, physicians, and health care organizations. Survey research has established associations of electronic health record (EHR) use with professional burnout and reduction in professional effort, but these findings are subject to response fatigue and bias. Objective: To evaluate the association of physician productivity and EHR use patterns, as determined by vendor-derived EHR use data platforms, with physician turnover. Design, Setting, and Participants: This retrospective cohort study was conducted among nonteaching ambulatory physicians at a large ambulatory practice network based in New England. Data were collected from March 2018 to February 2020. Main Outcomes and Measures: Physician departure from the practice network; 4 time-based core measures of EHR use, normalized to 8 hours of scheduled clinical time; teamwork, percentage of a physician's orders that are placed by other members of the care team; and productivity measures of patient volume, intensity, and demand. Results: Among 335 physicians assessed for eligibility, 314 unique physicians (89.2%) were included in the analysis (123 [39%] women; 100 [32%] aged 45-54 years), with 5663 physician-months of data. The turnover rate was 5.1%/year (32 of 314 physicians). Physicians completed a mean 2.6 appointments/hour (95% CI, 2.5-2.6 appointments/hour) and 206 appointments/month (95% CI, 197-215 appointments/month) with 5.5 hours (95% CI, 5.3-5.8 hours) of EHR time for every 8 hours of scheduled patient time. After controlling for gender, medical specialty, and time, the following variables were associated with turnover: inbox time (odds ratio [OR], 0.70; 95% CI, 0.61-0.82; P < .001), teamwork (OR, 0.68; 95% CI, 0.52-0.87; P = .003), demand (ie, proportion of available appointments filled: OR, 0.49; 95% CI, 0.35-0.70; P < .001), and age 45 to 54 years vs 25 to 34 years (OR, 0.19; 95% CI, 0.04-0.93; P = .04). Conclusions and Relevance: In this study, physician productivity and EHR use metrics were associated with physician departure. Prospectively tracking these metrics could identify physicians at high risk of departure who would benefit from early, team-based, targeted interventions. The counterintuitive finding that less time spent on the EHR (in particular inbox management) was associated with physician departure warrants further investigation.

Challenges in management of nephrolithiasis in a patient with class III obesity (BMI 97).

Patients with severe obesity have an increased risk of renal and ureteral calculi formation, and therefore, increased risk of associated complications. Despite the expanding number of people with obesity, there remains a dearth of scientific literature and training in navigating the associated limitations of our healthcare system. We present a case of a patient with severe, class III obesity (BMI 97) who was transferred to our tertiary care center for treatment of obstructive kidney stone disease. We highlight challenges in caring for our patient and discuss our approach and lessons learned for care of this vulnerable bariatric population.

Burnout, Professional Fulfillment, Intention to Leave, and Sleep-Related Impairment Among Faculty Radiologists in the United States: An Epidemiologic Study.

OBJECTIVE: To examine the prevalence of burnout in faculty radiologists in the United States and to explore the relationship between burnout and professional fulfillment (PF), intention to leave (ITL), and sleep-related impairment by gender. METHODS: This cross-sectional study was conducted through a voluntary anonymous, electronic survey of radiologists at 11 academic medical institutions participating in the Physician Wellness Academic Consortium between January 2017 and September 2018. Faculty radiologists who completed the survey were included in the study. The survey contained the validated professional fulfillment index and National Institute of Health Patient Reported Outcomes Measurement Information System sleep-related impairment scale. Demographics of participants only included gender to protect anonymity. Sample t tests and χ2 exact tests were used for analysis with significance level set at P < .05. RESULTS: In all, 456 faculty radiologists (171 women) answered the survey. The overall prevalence of burnout was 37.4%, PF was 35.6%, ITL was 33.3%, and sleep-related impairment was 45.3%. Burnout was higher in female versus male respondents (44% versus 31%, P < .05), and PF and ITL were lower (30% versus 42%, P < .05, 26% versus 38%, P < .05, respectively). When faculty were stratified into burned out versus not burned out, PF was significantly lower in those with burnout (12% versus 52%, P < .05), and ITL and sleep-related impairment was higher (51% versus 24%, P < .05 and 75% versus 30%, P < .05, respectively). DISCUSSION: Higher burnout was associated with reports of greater ITL and sleep-related impairment and lower PF. Female radiologists experience more burnout but less ITL than their male counterparts.

Characterizing physician EHR use with vendor derived data: a feasibility study and cross-sectional analysis.

OBJECTIVE: To derive 7 proposed core electronic health record (EHR) use metrics across 2 healthcare systems with different EHR vendor product installations and examine factors associated with EHR time. MATERIALS AND METHODS: A cross-sectional analysis of ambulatory physicians EHR use across the Yale-New Haven and MedStar Health systems was performed for August 2019 using 7 proposed core EHR use metrics normalized to 8 hours of patient scheduled time. RESULTS: Five out of 7 proposed metrics could be measured in a population of nonteaching, exclusively ambulatory physicians. Among 573 physicians (Yale-New Haven N = 290, MedStar N = 283) in the analysis, median EHR-Time8 was 5.23 hours. Gender, additional clinical hours scheduled, and certain medical specialties were associated with EHR-Time8 after adjusting for age and health system on multivariable analysis. For every 8 hours of scheduled patient time, the model predicted these differences in EHR time (P < .001, unless otherwise indicated): female physicians +0.58 hours; each additional clinical hour scheduled per month -0.01 hours; practicing cardiology -1.30 hours; medical subspecialties -0.89 hours (except gastroenterology, P = .002); neurology/psychiatry -2.60 hours; obstetrics/gynecology -1.88 hours; pediatrics -1.05 hours (P = .001); sports/physical medicine and rehabilitation -3.25 hours; and surgical specialties -3.65 hours. CONCLUSIONS: For every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours on the EHR. Physician gender, specialty, and number of clinical hours practicing are associated with differences in EHR time. While audit logs remain a powerful tool for understanding physician EHR use, additional transparency, granularity, and standardization of vendor-derived EHR use data definitions are still necessary to standardize EHR use measurement.