2011AmericanMedicalAssociationAllrightsreservedAnnualWorkHoursAcrossPhysicianSpecialtiestuswasdefinedasanaffirmativeresponsetothediabetesvariableacodebetween250and25093diabetesmellitusinadiagnosticfi ID: 887817
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ARCHINTERNMED/VOL171(NO.13),JULY11,2011WWW.ARCHINTERNMED.COM ©2011AmericanMedicalAssociation.Allrightsreserved. AnnualWorkHoursAcrossPhysicianSpecialties tuswasdefinedasanaffirmativeresponsetothediabe-tesvariable,acodebetween250and250.93(diabetesmellitus)inadiagnosticfield,and/oranyof3NCHS-definedreasonforvisitvariablescodedas2205.0(dia-betesmellitus).AllstatisticalanalysestookintoaccounttheNHAMCSandNAMCSdesignsandsamplingplans,byretainingallrecordsandtheweighting,strata,andprimarysamplingunitdesignvariables,andusedSAS/STATversion9.2sur-veymodule(SASInstituteInc,Cary,NorthCarolina).Thesesurveyssamplingdesignspermitstatisticallyreliablees-timationwhentheestimateisbasedonatleast30recordsandtheassociatedrelativestandarderroris30%orlower.Thediabetesdatadonotmeetthesecriteria.VisitrateswerecalculatedusingUSCensusBureaudata.Between2003and2008therewere175rec- AnalyseswereconductedusingStataversion11(Stata-Corp,CollegeStation,Texas),accountingforthesurveydesign.Tworegressionanalysescomparedworkhoursamong41specialties,withandwithoutcontrolvariables,withfamilymedicineasreference.Twoadditionalregres-sionscomparedthe4broadcategories,withandwithoutcontrolvariables,withprimarycareasreference.Meanannualhoursworkedwas2524(median,2420;interquartilerange,1960-2940).Thesentsselectedresultsofalinearregressionofannualhoursonthe41specialtiesadjustedforcontrolvariables.Com-paredwithfamilypractice,the3highestspecialtieswerevascularsurgery,criticalcareinternalmedicine,andneo-natalandperinatalmedicine;the3lowestwerepediat-ricemergencymedicine,occupationalmedicine,andIntheregressionforthe4broad-specialtycategorieswithcontrolvariables,surgery(303hours;95%con-fidenceinterval[CI],219to387hours)andinternalmedi-cineandpediatricssubspecialties(208hours;95%CI,132to284hours)hadsignificantlyhigherhours,andothermedical(228hours;95%CI,295to161hours)hadsignificantlylowerhoursthanprimarycare.Con-trolvariablesdidnotmateriallyalteranyoftherank-ingsinanyregression.Excludingphysiciansclassifiedasworkingparttime(mean,32h/wk)didnotaffectrelativerankingsinanyregression.Wefoundthatspecialistscaringformoreacutelyillpatientsorthoserequiringintensivemonitor-ing(usuallyinhospitalsettings)worklongerhoursthanphysiciansfocusedonmorestable,chronicallyillpa-tients(mostlyinambulatorysettings).Theexceptionswerephysicianspracticingemergencymedicineorhos-pitalmedicine.Bothofthesespecialtiesarecharacter-izedbyfixed,hourlyshifts;althoughpatientacuitymaybehigh,thenumberofworkhoursperdayanddayspermontharelimited.Ourrankingsaresomewhatsimilartostudiesofan-nualincome,withproceduralspecialtiesbeingpaidmorethancognitivespecialties.Buttherearedifferences.Neu-rologicalsurgeryreceivesthehigheststatisticallysignifi-cantwage,yetisnotsignificantinthehoursrankings.Dermatologistshavesignificantlyhigherwagesandsig-nificantlylowerhours.Familypracticereceivesoneofthelowestwagesbutisnearthemiddleofthehoursrank-Finally,amongbroadcategories,primarycarere-ceivesthelowestwagebutisneitherthehighestnorlow-estforhours. Vascular surgery888 (446 to 1330) Critical care internal medicine 689 (350 to 1029) Neonatal and perinatal medicine 564 (307 to 820) Thoracic surgery488 (237 to 740) Other surgical subspecialties446 (144 to 748) Pulmonary diseases4
2 25 (263 to 587) Medical oncology340 (75
25 (263 to 587) Medical oncology340 (75 to 604) General surgery326 (174 to 478) Obstetrics and gynecology278 (132 to 423) Neurological surgery270 (418 to 958) Urology264 (78 to 449) Cardiovascular diseases234 (55 to 413) Orthopedic surgery215 (53 to 378) Pulmonary critical care medicine182 ( Gastroenterology166 (4 to 329) Nephrology164 ( Geriatric medicine 131 ( Other pediatric subspecialties117 ( Internal medicine109 (18 to 201) Internal medicine and pediatrics107 ( Rheumatology47 ( Infectious diseases41 ( Otolaryngology24 ( Hematology and oncology 4 ( Family practice0 Plastic surgery Radiation oncology Ophthalmology Neurology Hospitalists General practice Allergy and immunology Endocrinology Child and adolescent psychiatry Pediatrics Psychiatry Emergency medicine Physical medicine and rehabilitation Dermatology Occupational medicine Pediatric emergency medicine 1000 0 1000 500 500 1500Hours Hours above or belowFamily Practice and (95% CI) Adjustedmeandifferencesinannualworkhoursforphysicianspecialtiesvsfamilypracticeincommunitytrackingsurvey(n=6381).Note:Estimatesamultiplelinearregressionthatstatisticallyadjustedforphysician,practice,andmarketcharacteristics(seetextfordetails).Errorbarsrepresent95%confidence ARCHINTERNMED/VOL171(NO.13),JULY11,2011WWW.ARCHINTERNMED.COM ©2011AmericanMedicalAssociation.Allrightsreserved. Specialtieswithmore(less)workhourstendtohaverelativelylow(high)physicianjobsatisfactionratings.Forexample,pediatricians,dermatologists,andchildandadolescentpsychiatristsreportedrelativelylowhoursandhaverelativelyhighcareersatisfaction.Similarlyobste-tricianandgynecologistsreportedrelativelyhighhoursandhaverelativelylowcareersatisfaction.However,thisrelationshipdoesnotalwayshold;forexample,neona-tologistsandperinatologistsreportedhighaveragehoursyethavehighcareersatisfaction.Ourstudyhadlimitations.TheCTSexcludedradi-ologists,anesthesiologists,andpathologists.Self-reportedworkhoursdidnotcapturevariabilityacrossday,swing,ornightshiftsorforweekendsorweekdays,norwerehours-on-callincluded.Finally,theCTShavedatafrom2008,theonlywaveafter2004-2005.TheCTSadministrators,however,warnagainstcomparingthe2008datatostudiesusing2004-2005data.Weranked41specialtiesand4broadcategoriesbyannualworkhours.Webelievethisrankingwilllikelybeusefultomedicalstudents,residencydirectors,hos-pitaladministrators,physicianscontemplatingswitch-ingspecialties,andpolicymakers.AuthorAffiliations:CenterforHealthcarePolicyandRe-search,DepartmentsofPublicHealthSciences(DrLeigh),Pediatrics(DrTancredi),FamilyandCommunityMedi-cine(DrJerant),andInternalMedicine,DivisionofGen-eralMedicine(DrKravitz),UniversityofCaliforniaDavisSchoolofMedicine,Davis.DrLeigh,DepartmentofPublicHealthSciences,UCDavisMedicalSchool,1ShieldsAve,MS1C,Davis,CA95616-8638(pleigh@ucdavis.edu).AuthorContributions:DrLeighhadfullaccesstoallofthedatainthestudyandtakesresponsibilityforthein-tegrityofthedataandtheaccuracyofthedataanalysis.Studyconceptanddesign:Leigh,Tancredi,andKravitz.Acquisitionofdata:Leigh,Tancredi,andKravitz.sisandinterpretationofdata:Leigh,Tancredi,andJer-Draftingofthemanuscript:Criticalrevisionofthemanuscriptforimportantintellectualcontent:Leigh,Tan-credi,Jerant,andKravitz.Statistic
3 alanalysis:LeighandObtainedfunding:Admin
alanalysis:LeighandObtainedfunding:Administrative,tech-nical,andmaterialsupport:Leigh,Jerant,andKravitz.FinancialDisclosure:Nonereported.ThisstudywasfundedinpartbygrantstoDrLeighfromtheNationalInstituteforOccupa-tionalSafetyandHealth(grant1R01H008248-01)andDrsTancrediandKravitzfromtheUCDavisOfficeoftheViceChancellorforResearch.RoleoftheSponsors:Thefundingsourceshadnoinvolvementinthedesignandconductofthestudy;collection,management,analysis,andinterpretationofthedata;orpreparation,review,orapprovalofthe1.LeighJP,TancrediD,JerantA,KravitzRL.Physicianwagesacrossspecial-ties:informingthephysicianreimbursementdebate.ArchInternMed.2010;2.DorseyER,JarjouraD,RuteckiGW.Influenceofcontrollablelifestyleonre-centtrendsinspecialtychoicebyUSmedicalstudents..2003;290(9):3.RosenthalMP,DiamondJJ,RabinowitzHK,etal.Influenceofincome,hoursworked,andloanrepaymentonmedicalstudentsdecisiontopursueapri-marycarecareer..1994;271(12):914-917.4.FletcherKE,DavisSQ,UnderwoodW,MangrulkarRS,McMahonLFJr,SaintS.Systematicreview:effectsofresidentworkhoursonpatientsafety.AnnIn-ternMed.2004;141(11):851-857.5.LeighJP,TancrediDJ,KravitzRL.Physiciancareersatisfactionwithinspecialties.BMCHealthServRes.2009;9:166. COMMENTSANDOPINIONS Outcome-BlindedPeerReviewhestudyconductedbyEmersonetalstrongevidenceofpositiveoutcomebias,yetdoesnotfullyaddresshowtoapproachtheproblem.Makingreviewersandauthorsmoreawareoftheprob-lemofpositiveoutcomebias,asEmersonetalcouldincreasethenumberofarticlespublishedwithnullfindings.Butaddingacounteractingbiastothealreadypresentpositiveoutcomebiasmightleadtoover-orun-dercompensation.Theoretically,onecouldonlyre-move(asopposedtocounteract)positiveoutcomebiasbyblindingreviewerstotheoutcomesofstudies.Aprac-ticalversionofthiswouldbetosemiblind.Reviewersevaluatingamanuscriptunderasemi-blindapproachwouldassessitinsteps.Reviewerswouldfirstbeprovidedwithamanuscriptshellthatwouldin-cludethemanuscriptbackgroundanddetailedmethodssection.Thelatterwouldcontainenoughdetailtode-terminethepowerandpotentialgeneralizabilityofthestudy.Reviewerswouldalsoreceiveallofthedatatablesandfigures,withbreakdownsofavailablesamplesizesandrelevantfollow-uptimesforsubgroups.Butthesetablesandfigureswouldbestrippedofactualresults.Onthebasisofthisinformation,reviewerscouldrenderapreliminarydecisionregardingtheimportanceofthemanuscript.Oncethereviewershadenteredtheirevalu-ation,theresultsanddiscussionsectionofthemanu-scriptcouldthenbereleasedtoandevaluatedbythesamereviewersandtheirfinalinputwouldbesought.Hope-fully,thereviewersinitialcommitmenttoassessingthequalityandimportanceofthestudywouldminimizetheimpactofanybiasintroducedwhenthereviewersfi-nallyseethestudysresults.AuthorAffiliations:HealthOutcomesResearchGroup,DepartmentofEpidemiologyandBiostatistics,Memo-rialSloan-KetteringCancerCenter,NewYork,NewYork.DrBach,HealthOutcomesResearchGroup,DepartmentofEpidemiologyandBiostatistics,Me-morialSloan-KetteringCancerCenter,307E63rdSt,Sec-ondFloor,NewYork,NY10065(bachp@mskcc.org).FinancialDisclosure:Nonereported.J.PaulLeigh,PhDDanielTancredi,PhDAnthonyJerant,MDRichardL.Kravitz,MD,MSPHJoshuaN.Mirkin,ABPeterB.Bach,MD,MAPP ARCHINTERNMED/VOL171(NO.13),JULY11,2011WWW.ARCHINTERNMED.COM ©2011AmericanMedicalAssociation.Allrightsreserved