Internal Medicine Subspecialties Research Articles

Training in infectious diseases across Europe in 2021 – a survey on training delivery, content and assessment

ObjectivesTo define the status of infectious diseases (ID) as an approved specialty in Europe; to enumerate the number of specialists (in general and in relation to the overall population) and specialist trainees and describe the content, delivery and evaluation of postgraduate training in ID in different countries. MethodsStructured web-based questionnaire surveys in March 2021 of responsible national authorities, specialist societies and individual country representatives to the Section of Infectious Diseases of the European Union for Medical Specialties. Descriptive analysis of quantitative and qualitative responses. ResultsIn responses received from 33/35 (94.3%) countries, ID is recognized as a specialty in 24 and as a subspecialty of general internal medicine (GIM) in eight, but it is not recognized in Spain. The number of ID specialists per country varies from <5 per million inhabitants to 78 per million inhabitants. Median length of training is 5 years (interquartile range 4.0–6.0 years) with variable amounts of preceding and/or concurrent GIM. Only 21.2% of countries (7/33) provide the minimum recommended training of 6 months in microbiology and 30% cover competencies such as palliative care, team working and leadership, audit, and quality control. Training is monitored by personal logbook or e-portfolio in 75.8% (25/33) and assessed by final examinations in 69.7% (23/33) of countries, but yearly reviews with trainees only occur in 54.5% (18/33) of countries. ConclusionsThere are substantial gaps in modernization of ID training in many countries to match current European training requirements. Joint training with clinical microbiology (CM) and in multidisciplinary team working should be extended. Training/monitoring trainers should find greater focus, together with regular feedback to trainees within many national training programmes.

Physician Satisfaction With Telemedicine During the COVID-19 Pandemic: The Mayo Clinic Florida Experience.

ObjectiveTo evaluate physician perceptions and attitudes toward telemedicine use at a tertiary care academic institution in northeast Florida during the coronavirus disease 2019 pandemic.Patients and MethodsAn anonymous 38-question cross-sectional survey was developed using Qualtrics survey software (Qualtrics) and e-mailed to all staff physicians from all specialty disciplines at Mayo Clinic in Florida. The survey was open from August 17, 2020, through September 1, 2020. Collected data included general demographic characteristics and employment information, attitude and experience with telemedicine use before and during the coronavirus disease 2019 pandemic, perception of patients’ experience, and the effect of telemedicine on burnout.ResultsThe survey was distributed to 529 eligible physicians at our institution, with 103 physicians responding (20%). The distribution of specialties was 22% primary care specialties, 41% other internal medicine subspecialties, and 18% surgical specialties. Collectively, 63% found comparable quality of care when provided virtually (vs in-person) whereas 80% perceived telemedicine as cost-effective. A total of 76% of physicians felt that telemedicine increased flexibility and control over patient care activities, with 36% reporting improved work-life balance and 30% reporting improved burnout symptoms. Overall, 42% preferred using telemedicine over in-person visits when possible.ConclusionPhysicians generally had positive attitudes regarding the adoption of telemedicine and perceived that the quality of health care delivery as generally comparable to in-person care. Future studies are needed to explore attitudes regarding telemedicine after the pandemic and how this virtual technology may be further used to improve physicians’ professional and personal well-being.

A Scoping Review of Artificial Intelligence Algorithms in Clinical Decision Support Systems for Internal Medicine Subspecialties

AbstractObjectives Artificial intelligence (AI)-based clinical decision support systems (CDSS) have been developed to solve medical problems and enhance health care management. We aimed to review the literature to identify trends and applications of AI algorithms in CDSS for internal medicine subspecialties.Methods A scoping review was conducted in PubMed, IEEE Xplore, and Scopus to determine articles related to CDSS using AI algorithms that use deep learning, machine learning, and pattern recognition. This review synthesized the main purposes of CDSS, types of AI algorithms, and overall accuracy of algorithms. We searched the original research published in English between 2009 and 2019.Results Given the volume of articles meeting inclusion criteria, the results of 218 of the 3,467 articles were analyzed and presented in this review. These 218 articles were related to AI-based CDSS for internal medicine subspecialties: neurocritical care (n = 89), cardiovascular disease (n = 79), and medical oncology (n = 50). We found that the main purposes of CDSS were prediction (48.4%) and diagnosis (47.1%). The five most common algorithms include: support vector machine (20.9%), neural network (14.6%), random forest (10.5%), deep learning (9.2%), and decision tree (8.8%). The accuracy ranges of algorithms were 61.8 to 100% in neurocritical care, 61.6 to 100% in cardiovascular disease, and 54 to 100% in medical oncology. Only 20.1% of those algorithms had an explainability of AI, which provides the results of the solution that humans can understand.Conclusion More AI algorithms are applied in CDSS and are important in improving clinical practice. Supervised learning still accounts for a majority of AI applications in internal medicine. This study identified four potential gaps: the need for AI explainability, the lack of ubiquity of CDSS, the narrow scope of target users of CDSS, and the need for AI in health care report standards.

Combined Medicine-Pediatrics Fellowships: A Guide for Fellowship Directors and Residents.

Dual training in Internal Medicine-Pediatrics (MedPeds) was recognized by the American Board of Medical Specialties in 1967. Residents complete 24 months each in Internal Medicine and Pediatrics and are board-eligible for both at the conclusion of training. Graduates are eligible for fellowships in either or both fields. Many graduates pursue fellowship training. A small absolute number of graduates apply for dual training in adult and pediatric subspecialties, but those that do bring direct, in-depth clinical experience across the lifespan, and familiarity with care in both pediatric and adult settings. As such, they contribute unique perspectives and capabilities to their fellowship and future practice. This includes the ability to provide subspecialty care in settings with limited resources, where they are able to address needs without age restrictions, and in the transition of subspecialty care for emerging adults with childhood-onset conditions.Due to the small number of applicants pursuing joint adult and pediatric fellowships, many fellowship directors may have limited experience with dual fellowships but may want to create opportunities for these unique trainees. This summary was developed jointly by residents, fellows, MedPeds program directors, and fellowship directors in Pediatrics and Internal Medicine subspecialties, and approved by their respective leadership councils to offer some key points on common questions, suggest additional resources, and share best practices, with a goal of facilitating this process for fellowship programs and residents alike.

Core Cardiology Training Symposium (COCATS) Standards and Board Certifications: Implications for Fellows-in-Training Seeking Employment.

The Core Cardiology Training Symposium (COCATS) standards are recommendations endorsed by the American College of Cardiology to assist cardiology fellowship program training directors in curricular design. In addition to seeking COCATS standards as evidence of proficiency in cardiovascular skills, Fellows-In-Training (FITs) often pursue board certifications to maximize their hiring potential. The costs and barriers with COCATS standards and board certification processes are not insignificant, however the degree to which the job marketplace demands them has not been well characterized. The intent of this investigation study was to estimate the demand for COCATS standards and board certification in cardiology job advertisements. We conducted a cross-sectional survey of job listings on the American College of Cardiology's "Cardiology Careers" page, to establish how often advanced COCATS standards and certifications are requested. Of a total of 314 total cardiology job postings (including 133 academic positions), only eight (2.5%) job postings explicitly noted COCATS standards. Aside from American Board of Internal Medicine subspecialty certification, only 8.60% required certification in another cardiology related board certification. Despite the perception that COCATS standards and subspecialty certifications are vital to the cardiology job application process, our analysis suggests that few job postings require them. Concern regarding COCATS standards and subspecialty certification of FITs may be out of proportion to the relevance of these achievements on the current job market.

Analysis of hematology and oncology fellowship website content and diversity representation.

11004 Background: Fellowship in hematology and oncology (HO) is widely sought after but lags behind all other internal medicine subspecialties in attracting applicants underrepresented in medicine (URM). An approach to appealing to URMs involves preexisting in-person strategies but also adapting virtual tools to promote inclusion. Specifically, program websites serve as the first impressions of a program, as well as influence the perception of diversity and inclusion. We evaluated the content and diversity representation of HO program websites to facilitate a generally more informed and URM-considerate recruitment. Methods: The websites of 2019-2020 ACGME accredited HO programs were assessed between June 1st to July 1st, 2020. Data focused on 30 informational categories, derived from published methodology, along with three additional categories concerning diversity, based on suggestions for inclusive graduate medical education recruitment strategies, were compared using two-tailed t tests. We defined websites with 70% or more of the 30 informational categories as “comprehensive websites.” Affiliation with a National Cancer Institute (NCI) Designated Cancer Center, NCI Designated Cancer Center + National Cancer Center Network (NCCN) member institution, and a top 50 ranked cancer hospital by U.S. News was also considered in the analysis. Results: A total of 156 program websites were analyzed: 37.2% NCI; 19.9% NCCN; 29.5% U.S. News ranked. Only 31 (19.9%) were “comprehensive websites,” and 34 (21.8%) had information pertaining to at least one of the diversity categories. There was a significant association between inclusion of diversity content and being a “comprehensive website” (p = 0.001). Compared to those that were neither designated nor ranked, programs designated by NCI, NCCN, or ranked by U.S. News were more likely to have more complete information available (p &lt; 0.001, = 0.008, and &lt; 0.001, respectively). However, only programs ranked by U.S. News were more likely to include information about diversity on their websites (p = 0.006). Conclusions: The vast majority of HO fellowship program websites were not comprehensive, including a lack of diversity and inclusivity content. NCI designation, NCCN participation, and US News ranking were significantly associated with more complete fellowship websites. Given the context of the COVID-19 pandemic in which institution visitation is restricted, program websites may have elevated importance in recruitment. HO programs should direct resources to offering more complete and inclusive websites to better inform applicants, including URM residents.

Trends in US Internal Medicine Residency and Fellowship Applications During the COVID-19 Pandemic vs Previous Years

This cross-sectional study evaluates the number of applicants and number of applications submitted per applicant to internal medicine residency and subspecialty fellowships for 2021 compared with 5 prior application cycles.

ICRE Abstracts: Quality Improvement

ICRE Abstracts: Quality Improvement

Evaluation of the Effects of the COVID-19 Pandemic on Electronic Consultation Use in Primary Care.

Background: Little is known about electronic consultation (e-consult) utilization during the COVID-19 pandemic when health systems rapidly implemented and scaled telehealth alternatives to in-person care. It is also unknown if e-consult utilization during the pandemic replaced or merely deferred the need for a specialty appointment. We evaluated if primary care providers' (PCPs) e-consult utilization and specialists' recommendations for specialty appointments changed after the transition to telemedicine during the COVID-19 pandemic. Methods: This cohort study used an interrupted time series analysis of e-consult utilization in a large, urban academic health care system between December 1, 2019, and June 27, 2020; the post-telemedicine time period began March 15, 2020. The primary outcome measure was the odds of an e-consult ordered during a PCP appointment; the secondary outcome measure was the odds of a specialist recommending a specialty appointment in an e-consult. Results: During 193,263 PCP appointments, 1,318 e-consults were placed to internal medicine subspecialties. Compared to the pre-telemedicine time period, the odds of a PCP ordering an e-consult increased (OR 1.04, 95% CI [1.02-1.07]) and the odds of specialists recommending specialty appointments increased (OR 1.11, 95% CI [1.06-1.15]). Conclusions: E-consult use increased following the transition to telemedicine in the context of the COVID-19 pandemic, suggesting that PCPs consider the e-consult a valuable tool for patient care when there is limited availability of specialty appointments. However, recommendations for specialty appointments following an e-consult also increased, suggesting that the e-consult may not replace the need for a specialty appointment.

Internal medicine residents' and program directors' perception of virtual interviews during COVID-19: a national survey.

This survey study aims to understand the perceptions and experiences of internal medicine residents and subspecialty programs directors during virtual CaRMS interviews in the evolving COVID-19 pandemic. In the likely event that medicine subspecialty interviews occur virtually again next year, findings from this survey can help inform and improve the experience for residents, program directors, and faculty.

Gastroenterology Fellowship Applicants’ Perspectives on GI Program Preferences

Gastroenterology fellowship continues to be highly competitive among internal medicine subspecialties. Recruiting excellent applicants is also important for GI fellowship program directors. We aim to examine factors that influence GI fellowship applicants' perspectives about a fellowship program. The authors conducted an anonymous online survey of applicants focusing on program characteristics including location, faculty, research/clinical opportunities, website, and interview day experience. Anonymous survey responses were recorded regarding program characteristics, and subsequent candidate preferences were evaluated for factors influencing their decision. Candidates were also asked to evaluate their interview experience and share other comments about the program. Though GI fellowship applicants have varying preferences regarding the ideal training program, some opinions converged. The study of these trends can inform program directors regarding areas for improvement that in turn can help attract the best applicants.

Can You Hear Me Now? Helping Faculty Improve Feedback Exchange for Internal Medicine Subspecialty Fellows.

IntroductionFeedback is an important tool that describes an individual's performance in a specific activity. Trainees at all levels grow from feedback exchanges to develop knowledge, skills, and attitudes in their specialty. However, there is a dearth of faculty development on providing advanced trainees feedback effectively.MethodsWe designed and delivered internal medicine subspecialty-focused 60- or 90-minute interactive workshop to train faculty to improve feedback exchange with fellows. The workshop included addressing barriers to feedback specific to fellowship, tool and skills for feedback exchange, and case-based skills practice specific to scenarios seen in each subspecialty fellowship program. We utilized surveys of faculty assessing comfort with feedback exchange with fellows before and after the workshop.ResultsWe delivered the workshop to two separate specialty sections, gastroenterology and endocrine. Overall, faculty (N = 14) self-reported comfort improved significantly from pretest to posttest (p < .01). Ten participants’ comfort ratings increased, while four remained the same at posttest. The evaluation identified several common themes as important learning points including labeling feedback, setting expectations around feedback exchange, and identifying elements of high-quality feedback exchange.DiscussionThis workshop for faculty was designed to improve the skills, knowledge, and attitudes related to feedback exchange specifically within an internal medicine subspecialty fellowship training program. Analysis of pre- and postsurvey data demonstrated increased faculty comfort providing fellows-in-training with feedback.

Effects of removing a fee-for-service incentive on specialist chronic disease services: a time-series analysis.

Physician payment models are known to affect the nature and volume of services provided. Our objective was to study the effects of removing a financial incentive, the fee-for-service premium, on the provision of chronic disease follow-up services by internal medicine, cardiology, nephrology and gastroenterology specialists. We collected linked administrative health care data for the period 1 April 2013 to 31 March 2017 from databases held at the Institute for Clinical Evaluative Sciences (ICES) in Ontario, Canada. We conducted a time-series analysis before and after the removal of the fee-for-service premium on 1 April 2015. The primary outcome was total monthly visits for chronic disease follow-up services. Secondary outcomes were monthly visits for total follow-up services and new patient consultations. We compared internal medicine, cardiology, nephrology and gastroenterology specialists practising during the study timeframe with respirology, hematology, endocrinology, rheumatology and infectious diseases specialists who remained eligible to claim the premium. We chose this comparison group as these are all subspecialties of internal medicine, providing similar services. The number of chronic disease follow-up visits decreased significantly after removal of the premium, but there was no decrease in total follow-up visits. There was also a significant downward trend in new patient consultations. No changes were observed in the comparison group. The decrease in volume of chronic disease follow-up visits can be explained by diagnostic criteria being met less often, rather than an actual reduction in services provided. Potential effects on patient outcomes require further exploration.

A single center evaluation of applicant experiences in virtual interviews across eight internal medicine subspecialty fellowship programs

ABSTRACT Due to the COVID-19 pandemic, most graduate medical education (GME) training programs conducted virtual interviews for prospective trainees during the 2020–2021 application cycle. Many internal medicine (IM) subspecialty fellowship programs hosted virtual interviews for the first time with little published data to guide best practices. To evaluate how IM subspecialty fellowship applicants perceived the virtual interview day experience. We designed a 38-item questionnaire that was sent via email to applicants in eight IM subspecialty programs at a single tertiary academic medical center (University of California, San Francisco) from September–November, 2020. Seventy-five applicants completed the survey (75/244, 30.7%), including applicants from all eight fellowship programs. Most survey respondents agreed that the length of the virtual interview day (mean = 6.4 hours) was long enough to gather the information they needed (n = 65, 86.7%) and short enough to prevent fatigue (n = 55, 73.3%). Almost all survey respondents agreed that they could adequately assess the clinical experience (n = 71, 97.3%), research opportunities (n = 72, 98.6%), and program culture (n = 68, 93.2%). Of the respondents who attended a virtual educational conference, most agreed it helped to provide a sense of the program’s educational culture (n = 20, 66.7%). Areas for improvement were identified, with some survey respondents reporting that the virtual interview day was too long (n = 11) or that they would have preferred to meet more fellows (n = 10). Survey respondents indicated that the virtual interview was an adequate format to learn about fellowship programs. These findings can inform future virtual interviews for GME training programs.

Leveraging Interdisciplinary Teams for Pre-Visit Planning to Improve Pneumococcal Immunization Rates Among Internal Medicine Subspecialty Practices.

Background:Despite the ready availability of pneumococcal vaccines and recommendation of vaccination by Center for Disease Control and Prevention (CDC), the immunization rates among adults less than 65 years of age with chronic and immunocompromised conditions remain low.Methods:This interventional (cohort) study aimed to improve the pneumococcal vaccination rate for patients with an increased risk of pneumococcal disease by utilizing a three-pronged approach. This included: (1) clinician education webinar, (2) pre-visit counseling performed by registered nurses, targeted toward patients with upcoming appointments, to address vaccination status, and (3) modified pre-visit interdisciplinary team huddle with clinicians and registered nurses to review which patients are amenable to vaccination at the time of visit and those who may benefit from re-engagement and further motivational interviewing. After the completion of the 10-week intervention, study organizers reviewed the percent of patients with completed pneumococcal vaccinations.Results:In this 10-week rapid cycle initiative, a total of 482 patients were eligible for vaccination. During the intervention phase, 370 patients were contacted and of these 38% of patients were amenable to receiving a vaccine during the pre-visit counseling, 5% were previously vaccinated, 18% were not amenable, and 38% were unreachable prior to visit. This initiative resulted in a 43% increase in the vaccination rate in this cohort.Conclusions:The significant increase in vaccination rate supports the utilization of a framework in the multidisciplinary approach to pre-visit planning in non-primary care specialties and other vaccination efforts, especially emerging diseases such as COVID-19. Future directions of study include the efficacy of telemedicine counseling with a same-day appointment for vaccination, co-location of registered nurses within the practice sites, as well as the use of other ancillary staff (such as medical office assistants) to engage patients in pre-visit planning.

1123. Improving Quality Improvement: Increasing QI Competency in Internal Medicine Subspecialty Fellows

BackgroundMedical errors contribute to 44,000 – 98,000 deaths annually, which can result in total national costs upwards of 17-29 billion dollars. The Institute of Medicine suggests the application of QI as on of its five core competencies for all health care providers. ACGME has recognized the importance of QI curriculum in the training of both residents and fellows. To date, most QI curriculums focus on participation rather than application proficiency. A review performed by ACGME found that participants appeared to have a limited understanding of QI even after partaking in QI curricula. An activity that emphasizes practical application and meets the time constraints of residents and fellows would prove more beneficial than standard approaches.MethodsThis study included 13 ID, Allergy and Immunology, and Endocrine fellows from the University of Kansas Medical Center. Utilizing a QIKAT-R assessment tool, fellows were given 3 cases for which they had to develop a QI project. The assessment was made based on the ability to make an aim, find a measurable outcome or process that could easily be tabulated, and propose a change that could be tested. Following this, a 1-hour power point presentation which included active learning prompts in developing a QI project was given to the fellows. At the conclusion of the presentation, 3 additional cases were given to the fellows. Their ability to develop a QI project was again evaluated using the QIKAT-R assessment tool. At the end of the session a 5-question satisfaction survey was completed. As a group mean, scores prior to the 1-hour presentation were compared to those afterwards. A paired, single-tail, t-test was utilized to obtain a p-value in order to determine significance of change.ResultsIn total, there was a 42.2% (p=0.00001) increase in total QIKAT-R score after “QI Power Hour.” 92.3% of participants had a positive perception (Agree/Strongly Agree) of the 1-hour session.ConclusionThe findings suggest that fellows are able to show a higher proficiency in QI understanding as well as development of future QI projects. Fellows satisfaction of “QI Power Hour” was overall favorable. This study shows that it is possible to easily integrate QI understanding for practical application into the time constraints of a fellowship or residency curriculum.Disclosures All Authors: No reported disclosures

Making the case for an obstetric medicine subspecialty in South Africa

Obstetric medicine is a subspecialty of internal medicine that involves the management of medical conditions that may affect the course of pregnancy. It is an established subspecialty in many parts of the world, with recognised training programmes and an active international society; however, no formal training programme has been developed in South Africa (SA) as yet. Medical problems are responsible for the majority (60%) of maternal deaths in SA and women of childbearing potential are disproportionately affected by medical conditions such as HIV and obesity. Obstetric physicians would play a complementary role in the care of pregnant patients and could contribute to improving maternal health and lowering the maternal mortality rate in SA.

Use of Telehealth During the COVID-19 Pandemic: Scoping Review.

BackgroundWith over 37.8 million cases and over 1 million deaths worldwide, the COVID-19 pandemic has created a societal and economic upheaval of unparalleled magnitude. A positive transformation has been brought about by innovative solutions in the health care sector that aim to mitigate the impact of COVID-19 on human health. For instance, the use of telehealth has been on the rise amidst this public health emergency.ObjectiveGiven the unprecedented scale of the pandemic with no definitive endpoint, we aimed to scope the existing telehealth-related literature during a defined period of the ongoing pandemic (ie, January to June 2020).MethodsOur scoping review was guided by the Joanna Briggs Institute Reviewer Manual. We systematically searched PubMed and Embase databases with specific eligibility criteria. Data extracted from the shortlisted articles included first author and affiliation, journal title, publication type, terminologies used to describe telehealth and their accompanying definitions, health discipline or medical specialties and subspecialties wherein telehealth had been applied, the purpose of telehealth use, and the authors’ overall sentiment on telehealth use. We collated the available information and used descriptive statistics to analyze the synthesized data.ResultsIn all, 543 articles published across 331 different journals were included in this scoping review. The Journal of Medical Internet Research and its sister journals featured the highest number of articles (25/543, 4.6%). Nearly all (533/543, 98.2%) articles were in English. The majority of the articles were opinions, commentaries, and perspectives (333/543, 61.3%). Most authors of the articles reviewed were from high-income countries (470/543, 86.6%), especially from the United States of America (237/543, 43.6%). In all, 39 different definitions were used to describe terms equivalent to telehealth. A small percentage (42/543, 7.7%) of the articles focused on the provision of COVID-19–related care. Moreover, 49.7% (270/543) of the articles primarily focused on the provision of multiple components of clinical care, and 23% (125/543) of the articles focused on various specialties and subspecialties of internal medicine. For a vast majority (461/543, 84.9%) of the articles, the authors expressed a celebratory sentiment about the use of telehealth.ConclusionsThis review identified considerable emerging literature on telehealth during the first six months of the COVID-19 pandemic, albeit mostly from high-income countries. There is compelling evidence to suggest that telehealth may have a significant effect on advancing health care in the future. However, the feasibility and application of telehealth in resource-limited settings and low- and middle-income countries must be established to avail its potential and transform health care for the world’s population. Given the rapidity with which telehealth is advancing, a global consensus on definitions, boundaries, protocols, monitoring, evaluation, and data privacy is urgently needed.

Cardio-Renal-Metabolic Care Models

Cardio-Renal-Metabolic Care Models

Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey

Cognitive task load can affect providers' ability to perform their job well and may contribute to burnout. The researchers evaluated whether task load, measured by the National Aeronautics and Space Administration (NASA) Task Load Index (TLX), correlated with burnout scores in a large national study of US physicians between October 2017 and March 2018 with a 17.1% response rate. Burnout was measured using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, and a high score on either score was considered a manifestation of professional burnout. The NASA-TLX was chosen to evaluate physician task load (PTL) due to its robust validation and use across many industries, including health care, over the past 30 years. The domains included in the PTL were mental, physical, and temporal demands, and perception of effort. Mean score in task load dimension varied by specialty. In aggregate, high emotional exhaustion, depersonalization, and one symptom of burnout was seen in 38.8%, 27.4%, and 44.0% of participants, respectively. The mean PTL score was 260.9/400 (standard deviation = 71.4). The specialties with the highest PTL score were emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties. A dose response relationship between PTL and burnout was observed. For every 40-point (10%) decrease in PTL there was 33% lower odds of experiencing burnout (odds ratio = 0.67, 95% confidence interval = 0.65-0.70, p < 0.0001). The relationship between PTL and burnout may suggest areas of particular focus to improve the practice environment and reduce physician burnout.