A Comparative Study of the Psychiatric Care between Locum Tenens and Staff Physicians in a State Hospltal

Abstract

Artificial neural networks (ANNs) were used to measure the quality of care (Q) at two admission units in a state psychiatric hospital, each unit having two treatment teams, one led by a permanent (PM) staff physician, and one led by various locum tenens (LT) physicians. An LT physician's tour of duty (TOD) averaged approximately 30 days. Over nearly a 2 1/2-year period the four treatment teams received 744 admissions. Our previous research has reported measuring Q using percent accurate prediction of hospital length-of-stay (LOS), divided by a measure of severity of patient illness. We calculated Q for each treatment team's test set of patients using a trained ANN for each team. All the teams' test sets were run through each of the trained ANNs resulting in a set of four Q values for each ANN. We defined the standard deviation of Qs resulting from a single team's test set run through it own as well as the other three teams' ANNs as representative of the "diversity" of the patients in that test set. We defined the reciprocal of the standard deviation of the Qs resulting from each of the teams' test sets run through a single team's ANN as that team's "robustness." The product of "robustness" times "diversity" was defined as the value (V) of the treatment team. The V of the PM physician-led teams was 1.9 times that of the LT physician-led teams. We normalized V for patient entropy (uncertainty) with a metric called the "risk ratio" (RR), derived from Boltzmann's law. This resulted in the V/RR of one PM physician-led team as superior, despite treating patients with the highest risk. The LT physician-led teams, despite having fewer patients afflicted with the more problematic diagnosis of schizophrenia, were handicapped by not having preexisting therapeutic relationships with their patients, giving both LT teams low robustness. There was no statistically significant difference in patient LOS between the teams. Because the greatest change in team composition was due to LT physicians, we assumed that the differences in V/RR were due to the short (30-day) TOD and not to any skill deficits in the LT physicians. This article explores a new paradigm which compares the value of patient care in separate delivery systems despite differences in severity of illness, case-mix, and uncertainty associated with an imperfect therapeutic environment.