How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care

Abstract

ObjectivesThe quest to measure and improve diagnosis has proven challenging; new approaches are needed to better understand and measure key elements of the diagnostic process in clinical encounters. The aim of this study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters’ recorded transcripts. Additionally, we aimed to correlate and contextualise these findings with measures of encounter time and physician burnout.DesignWe audio-recorded encounters, reviewed their transcripts and associated them with their clinical notes and findings were correlated with concurrent Mini Z Worklife measures and physician burnout.SettingThree primary urgent-care settings.ParticipantsWe conducted in-depth evaluations of 28 clinical encounters delivered by seven physicians.ResultsComparing encounter transcripts with clinical notes, in 24 of 28 (86%) there was high note/transcript concordance for the diagnostic elements on our tool. Reliably included elements were red flags (92% of notes/encounters), aetiologies (88%), likelihood/uncertainties (71%) and follow-up contingencies (71%), whereas psychosocial/contextual information (35%) and mentioning common pitfalls (7%) were often missing. In 22% of encounters, follow-up contingencies were in the note, but absent from the recorded encounter. There was a trend for higher burnout scores being associated with physicians less likely to address key diagnosis items, such as psychosocial history/context.ConclusionsA new tool shows promise as a means of assessing key elements of diagnostic quality in clinical encounters. Work conditions and physician reactions appear to correlate with diagnostic behaviours. Future research should continue to assess relationships between time pressure and diagnostic quality.

Overlooking the obvious: the importance of communicating safety and risks of opioids-the Israeli context

“…Failure to communicate opioid risks might be attributed to workloads and maintaining the workflow, when clinicians feel beleaguered in their jobs as is, leaving less room to converse with patients. A hectic work environment and heavy workloads can hinder the communication process, add to clinician burnout, and result in less attentiveness to pain experienced by the patient (Khazen et al, 2023). Thus, healthcare systems should advance regulations for additional allotted time during clinical visits that involve opioid prescribing.…”