In the Limelight: March 2023

Casting a long and ominous shadow on health care, burnout impairs the professional and personal well-being of physicians, their commitment to and care of patients they serve, and the mission of health care systems now and well into the future. Understandably, considerable attention is directed to the causes of burnout, with the electronic health record (EHR) increasingly regarded as a significant contributor. In the present issue of Mayo Clinic Proceedings, Dyrbye, West, and colleagues examined the relationship between EHR-based audit log data and physician burnout. Their study involved physicians in an academic department of medicine who had completed an annual Program on Physician Well-being survey; this study matched these responses to EHR-based audit log data obtained between August 1, 2019, through October 31, 2019. The survey response was 77.5% with some 39% of physicians exhibiting high emotional exhaustion, 22% high depersonalization, and 40% of physicians with overall burnout. Broadly considered, the mean number of In Basket messages received per day were 26, with 4 messages for each appointment per scheduled day in the clinic. The salient finding of this study was that, after adjusting for relevant factors (gender, age, specialty, number of daily appointments, and working hours of physicians), burnout and turnaround time to In Basket messages independently associated with the number of and the time spent in addressing In Basket messages and the time spent in the EHR beyond the time committed to scheduled patient care. Another notable finding in this study was that primary care physicians received twice as many messages as compared with non-primary care physicians, many of these messages involving the returning of patient calls. Response to patient calls is critically important and needs to be done in a timely manner, and as pointed out by the authors, is “often unaccounted for by health care organizations and traditionally not reimbursed, leaving it as an add-on activity after a busy clinical day.” This study also demonstrated that a larger volume of patient calls was associated with less timeliness in response to other In Basket messages and with burnout itself. The patient-physician interaction is an inviolate cornerstone in the edifice of health care, and advancements in the digital age, in particular the EHR, should strengthen this interaction, and not, as is the case of aspects of In Basket, detract from and burden it. Solutions are clearly needed, and in this regard, the authors point out the need for “new reimbursement models that enable replacement of traditional face-to-face clinic visits with blocked time during the clinical workday for In Basket work” and “new approaches to reduce the volume of In Basket messages received by physicians.” Dyrbye, West, and colleagues are to be highly commended for their numerous and seminal contributions to the field of physician burnout, and, as exemplified by the present studies, for uncovering significant determinants of this tragic and growing phenomenon.

Dyrbye LN, Gordon J, O’Horo J, et al. Relationships between EHR-based audit log data and physician burnout and clinical practice process measures. Mayo Clin Proc. 2023;98(3):398-409. https://doi.org/10.1016/j.mayocp.2022.10.027

Hypertrophic cardiomyopathy (HCM) imposes a risk of sudden cardiac death (SCD) that may approach 1% in referral populations, with lower rates in unselected populations. Risks for SCD include, among others, a relevant family history; patient age; a personal history of syncope, arrhythmias, or cardiac arrest; wall thickness; ventricular dysfunction; ventricular aneurysm; and myocardial fibrosis. As pointed out by Burczak et al, biomarker data have yet to be incorporated in such risk assessment, and while a limited number of studies suggest that biomarkers such as high sensitivity cardiac troponin T (hs-cTnT) may correlate with certain SCD risk factors, such studies generally exclude relevant subsets of HCM patients and do not adhere to sex-specific hs-cTnT cutoff values in their analysis. In a referral HCM population with hs-cTnT levels prospectively determined between March 2018 and April 2020, Burczak et al correlated such hs-cTnT levels with clinical characteristics, comorbidities, HCM-associated risk factors, prior cardiac events, and findings from relevant evaluations. The population included patients who underwent prior septal myectomy and those with coronary artery disease. The majority (62%) of patients in this study (totalling 112 patients) had elevated hs-cTnT, and elevated hs-cTnT correlated with such SCD risk factors as septal thickness and nonsustained ventricular tachycardia. Patients with elevated hs-cTnT levels were at risk for cardiac events, the latter based on a composite index encompassing appropriate ICD discharge, unstable ventricular arrhythmia, and cardiac arrest. This association was no longer discernible when sex-specific cutoff values were not utilized in data analysis. As there are recognized sex differences in outcomes in HCM, with worse survival in women, Burczak et al emphasize the need to employ sex-specific cutoff values for hs-cTnT levels in studies of HCM. An intriguing question is why does hs-cTnT correlate with ventricular arrhythmias and other cardiac events in HCM. In this regard, Burczak et al point out that the variable in HCM studies to-date that most frequently associates with hs-cTnT is ventricular thickness. Certain pathophysiologic processes - oxygen demand-supply mismatch, microvascular dysfunction, and cell death and attendant fibrosis - underpin both increased hs-cTnT levels and ventricular hypertrophy; cardiac fibrosis is recognized as a driver of ventricular arrhythmias, thereby offering a linkage between elevated hs-cTnT levels and cardiac events in HCM. This timely study by Burczak et al significantly advances the field of hs-cTnT as a biomarker for cardiac events in HCM and uniquely underscores the application of sex-specific cutoff values for hs-cTnT in such studies of HCM.

Burczak DR, Newman DB, Jaffe AS, Ackerman MJ, Ommen SR, Geske JB. High-sensitivity cardiac troponin T elevation in hypertrophic cardiomyopathy is associated with ventricular arrhythmias. Mayo Clin Proc. 2023;98(3):410-418. https://doi.org/10.1016/j.mayocp.2022.08.010

The gut-brain interaction (GBI) - a bidirectional one involving, on the one hand, the gut wall and luminal contents with, on the other, the central and peripheral nervous systems – is a salient determinant of physiologic functioning of the gastrointestinal tract. This interaction can be perturbed by diverse stressors including, notably, psychosocial stress, and may lead to disorders of the GBI (DGBI). DGBI, previously termed functional gastrointestinal disorders, are common in clinical practice, not infrequently distressing to the patient, and can be challenging to effectively manage. Tome et al provide a superb review of DGBI, outlining their approach and key considerations by an appealing mnemonic of the 5 Es: Exclusion of organic/structural conditions; Empathy for the patient; Education of the patient; Expectations of management; and Establishing appropriate management. The authors emphasize the importance of the history and physical examination (H&P) as the foundational step in diagnostic evaluation, a major objective being the exclusion of an underlying organic/structural condition. Certain “alarm” symptoms and “red flag” signs from the H&P may point to organic/structural diseases and the need for appropriate evaluation. While there are no definitive tests for DGBI, the Rome IV criteria lend support for such diagnoses. Empathy, listening, and validation of the patient’s symptoms promote a trusting patient-physician relationship, in the course of which the physician should be cognizant of the triggering events that provoke or exacerbate symptoms, the risks of medicalization and fragmentation of care, and the adverse effects of DGBI on the patient’s work and personal life. Appropriate education by the provider enables the patient to gain insight into her/his condition and the feasible expectations of management. The latter includes pharmacologic approaches, non-pharmacologic approaches (dietary, avoiding triggers, physical therapy, cognitive behavior therapy), and perhaps alternative medicine. This review by Tome et al expertly addresses the challenges and management of DGBI and provides certain concepts that may be broadly applicable to functional disorders involving systems other than the gastrointestinal tract.

Tome J, Kamboj AK, Loftus CG. Approach to disorders of gut-brain interaction. Mayo Clin Proc. 2023;98(3):458-467. https://doi.org/10.1016/j.mayocp.2022.11.001