Burnout is an individual's specific, personal, and intimate stress reaction to the workplace, characterized by emotional exhaustion, depersonalization, and reduced self-efficacy. Even though it particularly affects the helping professions, there has been relatively little exploration into the causes and determinants of burnout among physicians; instead, the focus has been on documenting the prevalence and consequences of physician burnout. Furthermore, while the theory of burnout is based on the relationship between the individual and his or her workplace, interventions have focused on improving the resilience of an individual to withstand this imbalance rather than identifying and ameliorating the cause.This study observed a natural experiment to measure changes in primary care providers' burnout before and after the implementation of a workload intervention that changed the work process within primary care clinics. Four clinics received the intervention, while four others served as comparisons. Among physicians in clinics receiving the intervention, the results show significant impacts, with an improvement in workload of 0.61 units (p = 0.037) and a decrease in the emotional exhaustion dimension of burnout of 6.989 units (p = 0.039).Self-care interventions are inconsistent with the theory of burnout; success of such interventions may be due to participants self-selecting these interventions, and individuals' inability to change their workplace without management approval. Leaders need to consider the impact of the workplace itself on physicians, in addition to results or outcomes.

Policy Points:r The perioperative surgical home (PSH) is complementary to the patient-centered medical home (PCMH) and defines methods for improving the patient experience and clinical outcomes, and controlling costs for the care of surgical patients.r The PSH is a physician-led care delivery model that includes multispecialty care teams and cost-efficient use of resources at all levels through a patient-centered, continuity of care delivery model with shared decision making.r The PSH emphasizes "prehabilitation" of the patient before surgery, intraoperative optimization, improved return to function through follow-up, and effective transitions to home or post-acute care to reduce complications and readmissions. Context:The evolving concept of more rigorously coordinated and integrated perioperative management, often referred to as the perioperative surgical home (PSH), parallels the well-known concept of a patient-centered medical home (PCMH), as they share a vision of improved clinical outcomes and reductions in cost of care through patient engagement and care coordination. Elements of the PSH and similar surgical care coordination models have been studied in the United States and other countries. 796The Perioperative Surgical Home 797 results of studies of PSH elements in the United States and in other countries. We reviewed more than 250 potentially relevant studies. At the conclusion of the selection process, our search had yielded a total of 152 peer-reviewed articles published between 1980 and 2013. Findings:The literature reports consistent and significant positive findings related to PSH initiatives. Both US and non-US studies stress the role of anesthesiologists in perioperative patient management. The PSH may have the greatest impact on preparing patients for surgery and ensuring their safe and effective transition to home or other postoperative rehabilitation. There appear to be some subtle differences between US and non-US research on the PSH. The literature in non-US settings seems to focus strictly on the comparison of outcomes from changing policies or practices, whereas US research seems to be more focused on the discovery of innovative practice models and other less direct changes, for example, information technology, that may be contributing to the evolution toward the PSH model. Conclusions:The PSH model may have significant implications for policymakers, payers, administrators, clinicians, and patients. The potential for policy-relevant cost savings and quality improvement is apparent across the perioperative continuum of care, especially for integrated care organizations, bundled payment, and value-based purchasing.

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H igh-quality surgical outcomes require sound knowledge, communication skills, clinical judgment and technical proficiency. 1 Aging of the surgical workforce has been well recognized; however, the effect on patient outcomes is unclear. 2,3 The effect of aging, namely cognitive impairment, decline in visual acuity and worsening motor function, may negatively affect surgical ability. 4 However, age-related decline may be offset by the older surgeon's years of clinical acumen, surgical experience and clinical judgement. In addition, because surgeon volume is associated with improved surgical outcomes, 5,6 it is unclear whether surgical volume may offset age-related effects. Thus, surgical volume and age-related effects need to be evaluated concurrently. 7,8 Published evidence about the effect of physician age and experience on surgical outcomes shows mixed results. 9-11 Among Medicare beneficiaries undergoing pancreatectomy, coronary artery bypass grafting and carotid endarterectomy, mortality was higher among those treated by surgeons older than 60 years, especially those with low volumes. 12 This was corroborated in subsequent studies of particular surgical procedures. 13-15 In 2018, an observational study involving patients in the United States who were Medicare beneficiaries reported that patients who were treated by older surgeons had lower rates of mortality than those treated by younger surgeons. 16 However, these data lacked generalizability because the study included only a limited number of nonelective surgical procedures in patients 65 years and older and failed to inform the safety of older physicians performing most surgeries, elective procedures. We aimed to fill these knowledge gaps by assessing the association between surgeon age and outcomes across a broad range of patient age, surgical specialties and common procedures, while adjusting for surgeon volume.

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Inpatient portals may be an effective tool to improve the patient experience in the hospital. Moreover, making this technology available to inpatients may help to foster ongoing use of technology across the care continuum. However, deriving the benefits from the technology requires appropriate support. We identified multiple opportunities for hospital management to intervene. In particular, teaching patients to use the application by making a variety of instructional materials available could help to reduce several identified barriers to use. Additionally, hospitals should be prepared to manage patient anxiety and increased questioning arising from the availability of information in the inpatient portal application.

BackgroundCommunication is key in chronic disease management, and the internet has altered the manner in which patients and providers can exchange information. Adoption of secure messaging differs among patients due to the digital divide that keeps some populations from having effective access to online resources.ObjectiveThis study aimed to examine the current state of online patient-provider communication, exploring trends over time in the use of online patient-provider communication tools.MethodsA 3-part analytic process was used to study the following: (1) reanalysis, (2) close replication across years, and (3) trend analysis extension. During the reanalysis stage, the publicly available Health Information National Trends Survey (HINTS) 1 and 2 data were used with the goal of identifying the precise analytic methodology used in a prior study, published in 2007. The original analysis was extended to add 3 additional data years (ie, 2008, 2011, and 2013) using the original analytical approach with the purpose of identifying trends over time. Multivariate logistic regression was used to analyze pooled data across all years, with year as an added predictor, in addition to a model for each individual data year.ResultsThe odds of internet users to communicate online with health care providers was significantly and increasingly higher year-over-year, starting in 2003 (2005: odds ratio [OR] 1.31, 95% CI 1.03-1.68; 2008: OR 2.14, 95% CI 1.76-2.59; 2011: OR 2.92, 95% CI 2.33-3.66; and 2013: OR 5.77; 95% CI 4.62-7.20). Statistically significant socio-economic factors found to be associated with internet users communicating online with providers included age, having health insurance, having a history of cancer, and living in an urban area of residence.ConclusionsThe proportion of internet users communicating online with their health care providers has significantly increased since 2003. Although these trends are encouraging, access challenges still exist for some groups, potentially giving rise to a new set of health disparities related to communication.