Network Of Physicians Research Articles

Patient house calls in Attica and Thessaloniki, Greece (2005-2015): a model for out-of-hospital multispecialty emergency medicine

BackgroundThe SOS-doctors are a network of physicians who perform house-call visits in the areas of Attica and Thessaloniki, Greece.MethodsPatients requesting medical services by the SOS doctors during the period 1/1/2005 – 31/12/2015 were eligible for inclusion in this retrospective analysis.ResultsDuring this period 335, 212 home visits were performed. Females used this service more frequently compared to males (60.5% versus 39.5%). Among the age-groups, patients aged over 75 years made 56.6% of all house calls. Fewer phone requests were recorded during autumn than in winter (21.1% versus 29.1%). Infections were the most common cause of house-visits (29%), followed by cardiovascular diseases (10.3%), musculoskeletal (9.1%), gastrointestinal (6.3%) and neurological disorders (3.7%). An increasing demand for radiology at home was observed, starting at 352 calls in 2009 and reaching 2230 in 2015. Finally, 9.2% of patients were advised to be admitted into a hospital.ConclusionA shift towards older age, but not the oldest old (> 90 years), and acute conditions was observed during the study period. The study confirms that home visits retain a significant role in the modern health care systems.

Collaborative postgraduate training in family medicine and primary care: Reflections on my visit to South Africa.

This reflection describes my funded visit to South Africa to assist in primary care research capacity building as Chair, WONCA Working Party on Research (WP-R). The trip included time at the Universities of Walter Sisulu, Limpopo and Stellenbosch to mentor postgraduate students working on master’s and PhD theses. I held one-on-one and group sessions and ran interactive scientific writing workshops. I assisted with the establishment of a Stellenbosch University Family Physician Research Network of faculty academics and family physicians (FP) which will generate research questions from community stakeholders. I also ran a writing workshop at the Joint 5th WONCA Africa and 20th South African National Family Practitioners Conference in Pretoria attended by about 100 conference delegates, ranging from FP registrars to academics with PhDs and peer-reviewed publications. A WP-R panel presentation of international comparisons of primary care systems was also held at this conference, with the countries of Ghana, Malawi, Zimbabwe, Ethiopia and Nigeria presented. During my stay, I reflected on the differences between family medicine in South Africa and in my home country, New Zealand (NZ). In South Africa, there is high prevalence of HIV and tuberculosis, seldom seen in NZ. Donor-funded vertical programmes cause significant fragmentation of care. Family doctors generally work in district hospitals, providing consultancy support to nurse-led clinics. They have a laudable requirement to complete a Master’s in Medicine in conjunction with vocational training. Academic family medicine in South Africa is coming of age. I feel privileged to play a small part in its journey to maturity.

Treating Langerhans cell histiocytosis, globally.

Treating Langerhans cell histiocytosis, globally.

Revealing Physicians Referrals from Health Insurance Claims Data

Abstract Health insurance companies in Brazil have their data about claims organized having the view only for service providers. In this way, they lose the view of physicians' activity and how physicians share patients. Partnership between physicians can be seen as fruitful, when they team up to help a patient, but could represent an issue as well, when a recommendation to visit another physician occurs only because they work in same clinic. This work took place during a short-term project involving a partnership between our lab and a large health insurance company in Brazil. The goal of the project was to provide insights (with business impact) about physicians' activity from the analysis of the claims database. This work presents one of the outcomes of the project, i.e., a way of modeling the underlying referrals in the social network of physicians resulting from health insurance claims data. The approach considers the flow of patients through the physician–physician network, highlighting connections where referrals between physicians potentially occurred. We present the results from the analysis of a claims database (detailing 18 months of activity) from the health insurance company we partnered with. The main contribution presented in this paper is the model to reveal mutual referrals between physicians. Results show the proposed model reveals underlying characteristics of physicians' activity from real health insurance claims data with multiple business applications.

Association between quality domains and health care spending across physician networks.

One of the more fundamental health policy questions is the relationship between health care quality and spending. A better understanding of these relationships is needed to inform health systems interventions aimed at increasing quality and efficiency of care. We measured 65 validated quality indicators (QI) across Ontario physician networks. QIs were aggregated into domains representing six dimensions of care: screening and prevention, evidence-based medications, hospital-community transitions (7-day post-discharge visit with a primary care physician; 30-day post-discharge visit with a primary care physician and specialist), potentially avoidable hospitalizations and emergency department (ED) visits, potentially avoidable readmissions and unplanned returns to the ED, and poor cancer end of life care. Each domain rate was computed as a weighted average of QI rates, weighting by network population at risk. We also measured overall and sector-specific per capita healthcare network spending. We evaluated the associations between domain rates, and between domain rates and spending using weighted correlations, weighting by network population at risk, using an ecological design. All indicators were measured using Ontario health administrative databases. Large variations were seen in timely hospital-community transitions and potentially avoidable hospitalizations. Networks with timely hospital-community transitions had lower rates of avoidable admissions and readmissions (r = -0.89, -0.58, respectively). Higher physician spending, especially outpatient primary care spending, was associated with lower rates of avoidable hospitalizations (r = -0.83) and higher rates of timely hospital-community transitions (r = 0.81) and moderately associated with lower readmission rates (r = -0.46). Investment in effective primary care services may help reduce burden on the acute care sector and associated expenditures.

Assessing Variation in Implantable Cardioverter Defibrillator Therapy Guideline Adherence With Physician and Hospital Patient-sharing Networks.

Implantable cardioverter defibrillator (ICD) therapy is used for primary prevention of death among people with heart failure, and new evidence in 2005 on its effectiveness changed practice guidelines in the United States. The objective of this study is to examine how the connectedness of physicians and hospitals, measured using network analysis, relates to guideline-consistent ICD implantation. We constructed physician and hospital networks for cardiovascular disease. Physicians were linked if they shared cardiovascular disease patients; these links were aggregated by hospital affiliation to construct a hospital network. Medicare beneficiaries who underwent ICD therapy for primary prevention from 2007 to 2011. The clinical outcome of interest was guideline-consistent ICD implantation, calculated using the National Cardiovascular Data Registry. The exposure variables of interest were the network measures of the ICD surgeon, the referring hospital, and the hospital where the ICD surgery occurred. We focused on patients who were referred between hospitals for ICD implantation because they were more likely influenced by the hospital network (n=28,179). Patients were less likely to meet guidelines if their referring hospital had more connections to other hospitals (OR, 0.49; 95% confidence interval, 0.25-0.96) and more likely to meet guidelines if their ICD surgery hospital had more connections (OR, 1.61; 95% confidence interval, 0.98-2.64). The ICD surgeon's network measures were not associated with guideline-consistent implantation. Associations between the hospital network measures and guideline adherence suggests new approaches to better disseminate clinical guidelines across health systems.

Deploying digital health data to optimize influenza surveillance at national and local scales.

The surveillance of influenza activity is critical to early detection of epidemics and pandemics and the design of disease control strategies. Case reporting through a voluntary network of sentinel physicians is a commonly used method of passive surveillance for monitoring rates of influenza-like illness (ILI) worldwide. Despite its ubiquity, little attention has been given to the processes underlying the observation, collection, and spatial aggregation of sentinel surveillance data, and its subsequent effects on epidemiological understanding. We harnessed the high specificity of diagnosis codes in medical claims from a database that represented 2.5 billion visits from upwards of 120,000 United States healthcare providers each year. Among influenza seasons from 2002-2009 and the 2009 pandemic, we simulated limitations of sentinel surveillance systems such as low coverage and coarse spatial resolution, and performed Bayesian inference to probe the robustness of ecological inference and spatial prediction of disease burden. Our models suggest that a number of socio-environmental factors, in addition to local population interactions, state-specific health policies, as well as sampling effort may be responsible for the spatial patterns in U.S. sentinel ILI surveillance. In addition, we find that biases related to spatial aggregation were accentuated among areas with more heterogeneous disease risk, and sentinel systems designed with fixed reporting locations across seasons provided robust inference and prediction. With the growing availability of health-associated big data worldwide, our results suggest mechanisms for optimizing digital data streams to complement traditional surveillance in developed settings and enhance surveillance opportunities in developing countries.

Social media in the mentorship and networking of physicians: Important role for women in surgical specialties

BackgroundSocial media may be a useful supplement to physician and trainee interactions; however, its role in enhancing mentorship has not been described. MethodsA 35-item survey investigating trainee and physician social media use was distributed. Responses were analyzed using descriptive statistics. Results282 respondents completed the survey, among whom 136 (48.2%) reported careers in surgical specialties. Women in surgical specialties were more likely to describe the specialty as being dominated by the opposite sex (p < 0.001) and to be mentored by the opposite sex though wish to be mentored by individuals of the same sex (p < 0.001). Respondents in surgical specialties were also more likely to report using social media to build a network of same-sex mentorship (p = 0.031). ConclusionsSocial media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution.

Incidence and costs of herpes zoster and postherpetic neuralgia in German adults aged ≥50 years: A prospective study

ObjectivesHerpes zoster (HZ) mainly affects elderly people and immunocompromised individuals. HZ is usually characterized by a unilateral painful skin rash. Its most common complication, postherpetic neuralgia (PHN), may cause chronic debilitating pain. This study aimed to estimate the HZ incidence in individuals aged ≥50 years in Germany, the proportion of PHN and the economic burden. MethodsFrom 2010 to 2014, HZ patients were recruited when consulting physicians in physician networks covering about 157,000 persons aged ≥50 years. PHN was defined as “worst pain” rated ≥3 on the zoster brief pain inventory persisting or appearing over 90 days after rash onset. Costs were calculated based on medical resource utilization and lost working time. ResultsHZ incidence was estimated as 6.7/1000 person-years, increasing with age to 9.4/1000 in ≥80 year-olds. Among 513 HZ patients enrolled, the proportion of PHN was 11.9%, rising with age to 14.3% in HZ patients ≥80 years. Estimated total cost per HZ patient was €156 from the healthcare system perspective and €311 from the societal perspective. ConclusionsThe study confirmed previous findings that HZ causes a substantial clinical and economic burden in older German adults. It also confirmed the age-related increasing risk of HZ and PHN.

Aspiring Pain Practitioners in India: Assessing Challenges and Building Opportunities.

Background:Pain medicine is a developing specialty, aimed at relieving pain and suffering, enhancing function, and improving the quality of life of patients. Pain is often ignored, under-reported and mismanaged by health-care providers. Aspiring pain physicians in India face many challenges and barriers in advancing their specialty.Objectives:The objective of this study is to determine the challenges in establishing a pain practice in India and to discuss the opportunities and strategies to overcome these barriers.Subjects and Methods:Face-to-face interactive sessions were held with 60 aspiring pain physicians of India who were chosen as registrants to an International Association for the Study of Pain-Indian Society for Study of Pain multidisciplinary evidence-based pain management program conducted at Delhi and Mumbai. The available opportunities, practical issues and the hurdles in becoming a pain specialist were analyzed and summarized in this commentary.Results:The major barriers identified were: (1) Inadequate knowledge and absence of structured, educational and training courses, (2) bureaucratic hurdles, and (3) concerns of opioid misuse and addiction. The opportunities for personal growth and that of the specialty that could be utilized include the creation of a pain resource team, increasing community awareness, changing attitudes of other physicians toward pain specialty, and research and evidence building of the effectiveness of pain management strategies.Conclusion:India needs a structured teaching and training program in the area of pain medicine that is affiliated by the Medical Council of India or other reputed boards of medical education and certification. There is an urgent need to include pain management in the undergraduate and postgraduate medical curriculum. Enhancing community level awareness by public health education campaigns, developing networks of pain physicians, and appropriate marketing of the specialty is needed to make pain medicine recognized and utilized as a valuable specialty.

Medical Diaspora: An Underused Entity in Low- and Middle- Income Countries' Health System Development

Background: At present, over 215 million people live outside their countries of birth, many of which are referred to as diaspora - those that live in host countries but maintain strong sentimental and material links with their countries of origin, their homelands. A growing number of policy-makers have come to acknowledge that medical diaspora can play a vital role in the development of their homelands health workforce capacity. However, there is lack of coordination among diasporic organizations, donors and homeland governments that make sustainable systematic engagement a challenge. Methods: A literature search and manual internet search were conducted. Findings: In total, the authors found 95 medical diaspora organizations in 4 main countries (the United States: 65, the United Kingdom: 25, Australia: 3, and Canada: 2). These organizations all collaborate with health professionals in their home country to provide a pathway for the exchange of information between the countries, provide medical education resources and develop research exchange relationships. Many organizations are also investing in building medical facilities in their home country. Interpretation: Medical diaspora organizations tend to have three main focuses, which are present or prioritized differently depending on the migrant community. These focuses are (1) the creation of a social or professional network of migrant physicians (i.e. simply to bring together people with an ethnic and professional commonality), (2) a desire to provide improved and specific healthcare to the migrant population within the host country and (3) providing some form of health-related humanitarian aid to their home country. As a means to institutionalize relationships with diaspora, several Low- and Middle-Income Countries (LMIC) countries are establishing diaspora offices to facilitate ties with diaspora. Recognizing, diaspora as a key underutilized resource, the international community has also begun to invest in enhancing the governance structures needed to capitalize on the potential of the diaspora to solve development challenges. Funding Statement: Milken Institute School of Public Health, The George Washington University Declaration of Interests: The authors state: None.

The CCPZ rabies surveillance program: an inclusive learning model for addressing one-health educational challenge in West African sub-region

Introduction : one-health action against rabies can be driven by training programmes geared towards knowledge and skills in zoonosis surveillance and prevention in West Africa. Rabies surveillance programmes are relatively few and inadequate in higher education in the sub-region; hence require critical review. A systematic review was sponsored by the Centre for Control and Prevention of Zoonoses (CCPZ), University of Ibadan, Nigeria, for certificate of participation in rabies surveillance program. Since community participation is fundamental to effectively implement rabies surveillance, two lead questions were posed, namely: How can trained lay persons be better utilized to facilitate rabies surveillance program at the community level? And how can inclusive learning in one-health mode be applied to post-graduate programmes for surveillance of rabies in West Africa? Method : data were collected from 4 major specialised data base search engines on liberal art and science approaches to rabies surveillance education. One thousand, one hundred and eighty-nine papers were retrieved. Predefined selection criteria on teaching outcome and nature of collaboration were used to select 7 of these papers for review, using systematic analysis of the literature. Results : revised curriculum enlists experiential learning about epidemiologic networking of physicians, veterinarians, geographers, laboratorians, statisticians, sociologists and lay persons; eliciting care seeking preferences of animal bite victims (ABVs); categorizing ABVs into suspected, probable and confirmed rabies exposures; converting ABVs’ geographic locations to map points; estimating annual human death, associated spatial cluster, time-trend model, vaccination status and involved virus molecules. Conclusion : an inclusive one-health curriculum is developed for rabies surveillance in West African sub-region.

Patient-sharing physician networks increase spending

Patient-sharing physician networks increase spending

Engaging the Transgender Community to Improve Medical Education and Prioritize Healthcare Initiatives

ABSTRACTPhenomenon: Transgender patients experience discrimination, limited access to care, and inadequate provider knowledge in healthcare settings. Medical education to address transgender-specific disparities is lacking. Research that engages transgender community members may help address health disparities by empowering patients, increasing trust, and informing medical curricula to increase competence. Approach: A 2015 Community Forum on Transgender Health Care was hosted at the University of Louisville School of Medicine, which included healthcare professionals and transgender community members to facilitate dialogue among mixed-participant groups using a World Café model. Fifty-nine participants discussed the status of transgender healthcare and made recommendations for local improvements. A follow-up survey was administered to 100 individuals, including forum participants and their referrals. The forum discussion and survey responses were analyzed to determine common perceptions of transgender healthcare, priorities for improvement interventions, and themes to inform curriculum. Findings: The community forum discussion showed that local transgender care is overwhelmingly underdeveloped and unresponsive to the needs of the transgender community. The follow-up survey revealed that priorities to improve transgender care included a multidisciplinary clinic for lesbian, gay, bisexual, and transgender (LGBT) patients, an LGBT-friendly network of physicians, and more training for providers and support staff. This mutually constructive engagement experience influenced reform in undergraduate curricula and continuing education opportunities. Insights: Community engagement in healthcare disparities research can cultivate improbable discussions, yield innovative insight from marginalized populations, and build relationships with community members for future collaborations and interventions. Societal acceptance of transgender identities, which could be promoted through healthcare providers, could stimulate significant progress in transgender healthcare. Supplemental educational interventions for practicing physicians will improve the current conditions of transgender healthcare, but a comprehensive medical school curriculum specifically for transgender health that includes interactions between the transgender community and medical students could be particularly impactful.

Patient-Sharing Networks of Physicians and Health Care Utilization and Spending Among Medicare Beneficiaries

Physicians are embedded in informal networks in which they share patients, information, and behaviors. We examined the association between physician network properties and health care spending, utilization, and quality of care among Medicare beneficiaries. In this cross-sectional study, we applied methods from social network analysis to Medicare administrative data from 2006 to 2010 for an average of 3 761 223 Medicare beneficiaries per year seen by 40 241 physicians practicing in 51 hospital referral regions (HRRs) to identify networks of physicians linked by shared patients. We improved on prior methods by restricting links to physicians who shared patients for distinct episodes of care, thereby excluding potentially spurious linkages between physicians treating common patients but for unrelated reasons. We also identified naturally occurring communities of more tightly linked physicians in each region. We examined the relationship between network properties measured in the prior year and outcomes in the subsequent year using regression models. Spending on total medical services, hospital, physician, and other services, use of services, and quality of care. The mean patient age across the 5 years of study was 72.3 years and 58.5% of the participants were women. The mean age across communities of included physicians was 49 years and approximately 78% were men. Mean total annual spending per patient was $10 051. Total spending was higher for patients of physicians with more connections to other physicians ($1009 for a 1-standard deviation increase, P < .001) and more shared care outside of their community ($172, P < .001). Spending on inpatient care was slightly lower for patients of physicians whose communities had higher proportions of primary care physicians (-$38, P < .001). Patients cared for by physicians linked to more physicians also had more hospital admissions and days (0.02 and 0.18, respectively; both P < .001 for a 1-standard deviation increase in the number of connected physicians), more emergency visits (0.02, P < .001), more visits to specialists (0.37, P < .001), and more primary care visits (0.11, P < .001). Patients whose physicians' networks had more primary care physicians had more primary care visits (0.44, P < .001) and fewer specialist and emergency visits (-0.33 [P < .001] and -0.008 [P = .008], respectively). The various measures of quality were inconsistently related to the network measures. Characteristics of physicians' networks and the position of physicians in the network were associated with overall spending and utilization of services for Medicare beneficiaries.

Evolving Delivery System and Market Factors and Their Influence on Physician Networks and Patient Care

Evolving Delivery System and Market Factors and Their Influence on Physician Networks and Patient Care

Impact of Establishing a Communication Network of Family Physicians on Level of Hba1c and FBS in Patients With Diabetes: A Randomized Clinical Trial

Background: Diabetes could be especially difficult for females. The burden of diabetes on females is unique because the disease could affect both mothers and their unborn children. Objectives: The aim of this study was to determine the effect of developing a communication network among physicians on the level of HbA(1C) and Fasting Blood Sugar (FBS) in patients with diabetes in Iran. Methods: This study was a randomized clinical trial performed with 100 patients, who were randomly divided to experimental and control groups. The study was conducted from 20/11/2015 to 15/1/2016. A communication network was established among the physicians at health centers, to which patients in the intervention group were referred. The data were collected using a checklist of demographic information of patients. Laboratory results regarding the level of Glycated Hemoglobin (HbA(1C)) and Fasting Blood Sugar (FBS) of patients were gathered at baseline and 4 months after the establishment of the communication network. Results: After the development of the communication network, HbA(1C) levels had reduced from 8.14 +/- 2.08 to 7.90 +/- 2.01 in the intervention group (P < 0.001), while in the control group HbA(1C) levels had increased from 8.98 +/- 2.20 to 9.09 +/- 2.21 (P < 0.001). Conclusions: The results showed that for successful control of diabetes, physicians need to communicate with each other and share information and experiences. Furthermore, establishing a communication network among physicians could be effective to control diabetes.

Exploring Attributes of High-Value Primary Care.

Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers. To help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 high-value sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value. Thirteen attributes of care delivery distinguished sites in the high-value cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.

Performance Management in Accountable Care Organizations in the U.S. and Germany: From external reporting requirements to enabling internal performance management in physician practices

Background : USA: Performance management systems (PMSYSs) are an important tool for increasing the performance (quality, efficiency, effectiveness) of accountable care organizations (ACOs), and enable continuous improvement in affiliated physician practices. So far, there is limited knowledge about the extent of their implementation in US physician practices and about factors associated with their implementation. In addition, although performance measurement is seen as a core element of ACOs and is externally enforced, sparse information exists as to the interplay of external reporting requirements and incentives for internal PMSYSs. Germany: Whereas there are currently over 800 ACOs in the USA, Germany has only a few comparable ACO flagship projects. Also external financial and non-financial performance measurement requirements are, in comparison to the US, in an early stage. However, accountable, integrated care and performance measurement initiatives have moved up the political agenda. There may arise important insights for policy makers and health care managers from the experiences in the USA. Methods : A mixed-method approach using survey data analyses of a nationally representative sample of US physician practices (total n = 1,328; ACO practices n = 316) and case studies in the US (n=3) and Germany (n=1, Gesundes Kinzigtal) was used. Results : On average, practices affiliated with an ACO (24%) used only approximately half (53.1 points out of 100) of the measured PMSYS processes, whereas practices not participating in ACOs (76%) used even fewer PMSYS processes on average (22.6 points). Participating in an ACO was one of the strongest differentiators of US physician organizations with robust PMSYSs versus those with underdeveloped PMSYSs. Also participation in other forms of networks, such as Independent Physician Associations or Physician Hospital Organizations, and greater health information technology (HIT) capabilities and chronic disease registries were factors associated with a greater implementation of PMSYS. The use of financial and non-financial incentives offered mixed results in the survey analysis. The case studies indicate that a culture of quality drives the internal implementation and use of PMSYSs. Financial incentives play a minor role, and nonfinancial external incentives, such as public reporting, are secondary in the studied organizations. External incentives may even compete for internal PMSYS resources. Implications for the US : These findings highlight that policies to further strengthen ACOs or other networks could be a viable strategy to help physician practices strengthen their internal organizational capabilities and prepare for the new performance measurement requirements, such as the MACRA value-based payment models. External requirements have to be balanced with the strengthening of internal capabilities, such as HIT functionality. Cultural aspects and potential adverse effects of financial incentives (e.g. on intrinsic motivation) have to be considered. Implications for Germany : Although the quantitative findings are based in the US, the findings may generalize to physician practices and networks in other countries, as indicated by the German ACO case. For the advancement of performance measurement in Germany external requirements should be simplified by synchronizing initiatives and eliminating unnecessary, invalid demands, to free resources for internal PMSYS. In addition, further strengthening of networks could facilitate PMSYS implementation.

Editors' Note

Editors' Note: In a survey of US American Academy of Neurology member neurologists who had finished training, Busis et al. found that approximately 60% had at least one symptom of burnout. Burnout was strongly associated with decreased career satisfaction, while meaningful work and job autonomy were associated with increased satisfaction. Several of our readers commented on the study. Bagot et al. note that the practice settings in the report did not specifically reference telemedicine. They suggest that additional telemedicine responsibilities may cause more burnout, but can also moderate burnout risk and augment professional satisfaction via meaningful work. Dr. Giannouli worries that the choice of binary logistic regressions with only individual-level variables neglects the importance of working group dynamics. Dr. Yanofsky opposes the use of the word burnout, finding it demeaning. He argues that the term physician dissatisfaction syndrome should be used instead. Dr. Berger mentions Dr. Cascino's 2017 Presidential Plenary Address, in which he presented a figure from a larger survey of US physicians in general that correlated the percentage of physicians with burnout identified by specialty with the percentage satisfied with their work–life balance. In his presentation, Dr. Cascino suggested that there was nothing unique about neurologists that predisposed them to burnout, but Dr. Berger proposes otherwise. He explains that neurologists tend to have a unique personality predisposing them to burnout. He further adds that neurologists spend a great deal of time eliciting patient histories and performing detailed examinations, which work against demands for more relative value units, time to input information in the electronic medical record, and fighting with insurance companies, which can lower job satisfaction. Finally, Dr. Sethi mentions 2 additional factors contributing to burnout. One is the electronization of medicine, which makes doctors always reachable electronically to patients. The other is the increasing mandatory continuing medical education requirements and maintenance of certification (MOC) requirements. In response to the telemedicine issue, Busis et al., authors of the study, explain that they surveyed neurologists who mostly practice fee-for-service face-to-face medicine and that telemedicine was not a choice for their questions on primary work setting and primary types of patients seen. Their survey can be adapted to study neurologists practicing under newer health care delivery and payment models, including telemedicine. In response to the issues with the neurologists' practice context that may influence burnout, they agree that there is an effect of the practice environment on individual physicians and networks of physicians; they suggest that future studies exploring the effects of neurologists' practice frameworks on burnout, career satisfaction, and well-being using multilevel analyses may yield valuable insights. In response to using the term physician dissatisfaction syndrome instead of burnout, Busis et al. disagree, stating that burnout has been a well-defined construct for more than 40 years and is evaluated in all types of workers, including extensive research in physicians. In response to the idea that neurologist personality type plays a role in burnout, they also disagree, stating that psychiatrists overlap with neurologists in their personality type, yet psychiatrists are among the specialties with the highest work–life balance satisfaction and the lowest burnout rates. However, the authors point out that the high prevalence of neurologist burnout may be due to misalignment of the neurologic method with the current health care environment. Finally, in response to the electronization of medicine and MOC requirements issues, Busis et al. explain that they did study those variables in their surveys. They add that clerical burden, electronic health records, and computerized order entry are associated with physician burnout, but there is no association between attitudes toward MOC and burnout. They conclude that there is a need for evidence-based health care policies, jettisoning administrative tasks that do not add value. —Chafic Karam, MD, and Steven Galetta, MD Editors' Note: In a survey of US American Academy of Neurology member neurologists who had finished training, Busis et al. found that approximately 60% had at least one symptom of burnout. Burnout was strongly associated with decreased career satisfaction, while meaningful work and job autonomy were associated with increased satisfaction.