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Original Investigation
Physician Work Environment and Well-Being
September 13, 2021

Association Between Physician Part-time Clinical Work and Patient Outcomes

Author Affiliations
  • 1Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
  • 2Graduate School of Business Administration, Keio University, Yokohama, Japan
  • 3Graduate School of Health Management, Keio University, Tokyo, Japan
  • 4Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 5Department of Medicine, Massachusetts General Hospital, Boston
  • 6National Bureau of Economic Research, Cambridge, Massachusetts
  • 7Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 8Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 9Department of Medicine, Harvard Medical School, Boston, Massachusetts
  • 10Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
JAMA Intern Med. Published online September 13, 2021. doi:10.1001/jamainternmed.2021.5247
Key Points

Question  Do patient outcomes differ between physicians who work part time clinically vs full-time clinicians?

Findings  In this cross-sectional study of nationally representative data of 392 797 Medicare beneficiaries admitted to hospitals and treated by 19 170 hospitalists, patients treated by hospitalists who worked more clinical days per year had statistically significantly lower 30-day mortality compared with patients treated by hospitalists working fewer clinical days, after adjusting for potential confounders (adjusted 30-day mortality for physicians in the bottom quartile of days worked clinically per year vs top quartile, 10.5% vs 9.6%).

Meaning  These findings suggest that clinical care by physicians working part time clinically in the inpatient setting may be associated with worse patient outcomes.

Abstract

Importance  Despite the growing number of physicians who reduce clinical time owing to research, administrative work, and family responsibilities, the quality of care provided by these physicians remains unclear.

Objective  To examine the association between the number of days worked clinically per year by physicians and patient mortality.

Design, Setting, and Participants  This cross-sectional analysis was completed on a 20% random sample of Medicare fee-for-service beneficiaries 65 years and older who were admitted to the hospital with an emergency medical condition and treated by a hospitalist in 2011 through 2016. Because hospitalists typically work in shifts, hospitalists’ patients are plausibly quasirandomized to hospitalists based on the hospitalists’ work schedules (natural experiment). The associations between hospitalists’ number of days worked clinically per year and 30-day patient mortality and readmission rates were examined, adjusting for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). Data analysis was conducted from July 1, 2020, to July 2, 2021.

Exposures  Physicians’ number of days worked clinically per year.

Main Outcomes and Measures  The primary outcome was 30-day patient mortality, and the secondary outcome was 30-day patient readmission.

Results  Among 392 797 hospitalizations of patients treated by 19 170 hospitalists (7482 female [39.0%], 11 688 male [61.0%]; mean [SD] age, 41.1 [8.8] years), patients treated by physicians with more days worked clinically exhibited lower mortality. Adjusted 30-day mortality rates were 10.5% (reference), 10.0% (adjusted risk difference [aRD], −0.5%; 95% CI, −0.8% to −0.2%; P = .002), 9.5% (aRD, −0.9%; 95% CI, −1.2% to −0.6%; P < .001), and 9.6% (aRD, −0.9%; 95% CI, −1.2% to −0.6%; P < .001) for physicians in the first (bottom), second, third, and fourth (top) quartile of days worked clinically, respectively. Readmission rates were not associated with the numbers of days a physician worked clinically (adjusted 30-day readmissions for physicians in the bottom quartile of days worked clinically per year vs those in the top quartile, 15.3% vs 15.2%; aRD, −0.1%; 95% CI, −0.5% to 0.3%; P = .61).

Conclusions and Relevance  In this cross-sectional study, hospitalized Medicare patients treated by physicians who worked more clinical days had lower 30-day mortality. Given that physicians with reduced clinical time must often balance clinical and nonclinical obligations, improved support by institutions may be necessary to maintain the clinical performance of these physicians.

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    1 Comment for this article
    Attributing Outcome
    Joseph Rosin, D.O. | Community Hospital
    How were patient mortalities attributed to individual physicians? Typically patients are cared for by more than one hospitalist per admission.
    CONFLICT OF INTEREST: None Reported
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