Speaker 1 0:00
They are doing all these things that are right for their patients, but it might be leading them to a work situation that is not tenable, and then they choose to leave clinical practice despite that excellent care delivery.

Austin Littrell 0:17
Welcome to Off the Chart, a business medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics senior editor Richard Payerton sat down with Dr. Lisa Rottenstein, a primary care physician at the University of California, San Francisco, and director of the Center for Physician Experience and Practice Excellence, Dr. Rottenstein is the corresponding author of a new study on physician attrition by gender, and its central finding is hard to ignore. Female physicians are leaving clinical practice at a median age of 49 compared with 64 for their male colleagues. That 15-year gap holds across specialties and in both rural and urban settings. Dr. Rottenstein digs into what's driving that earlier exit from persistent pay differences to the uncompensated asynchronous work that falls disproportionately on women physicians to the caregiving demands they still shoulder outside the clinic. She also turns to where the fixes might come from, including alternative payment models that reward time with patients, ambient documentation tools that she says are already bringing joy back to practice, and stronger physician control over the daily workflow. Dr. Lisa Rottenstein, thank you for joining us. And with that, let's get into the episode.

Richard Payerchin 1:32
I'm Richard Payerchin, reporting for Medical Economics. With me today is Dr. Lisa Rottenstein, a primary care physician and associate professor in residence for University of California, San Francisco. She's the corresponding author of a new study about physician attrition by sex, age, and specialty. Thank you for joining us today.

Speaker 1 1:54
Thank you for having me. The

Richard Payerchin 1:56
formal title of the study is "Sex Differences in Physician Attrition from clinical practice across specialties, a nationwide longitudinal longitudinal analysis. We're going to get into those details in a moment. Before we do, can you briefly introduce yourself and discuss your research? Of

Speaker 1 2:14
course. As you said, I'm Lisa Rottenstein. I direct the Center for Physician Experience and Practice excellence. We are funded by the Physicians Foundation, and very glad to be here to discuss this latest installment of our research regarding the physician workforce. The study was based on the fact that we know that there are higher rates of attrition among female physicians, and yet we know that female physicians also deliver better clinical care in some circumstances to their patients, and so we wanted to understand to what extent are those higher is that higher likelihood of attrition among female physicians present across different specialties, and when female physicians do decide to stop delivering clinical care, what is their age relative to that of male colleagues?

Richard Payerchin 2:58
I think it's a great introduction, and we're going to get to that age factor here in a moment. We'll dive into a numerical detail from the results. Your study found that female primary care physicians leave clinical practice at a hazard ratio of 1.55 compared to their male counterparts, and that was one of the higher differentials across specialties for a woman physician in primary care practice right now. What does that translate into? What does that actually mean for a career outlook?

Speaker 1 3:30
It means that female physicians are more likely to leave clinical practice, and so let me talk about what what we meant by leaving clinical practice. In this study, we looked at those physicians no longer billing for their patients' care, and specifically, we looked at Medicare patients because we know that the vast majority of physicians do accept Medicare payment. We asked that those physicians not have evidence of any billing for three consecutive years, and so that gave us, you know, it sort of eliminated those physicians who may have taken a break and come back, and it told us that these physicians were likely no longer seeing patients in the traditional ways. They may we don't know if they went to concierge practice, for example, and were no longer billing insurance. Those physicians could have gone on to industry to a teaching role only, but they were no longer delivering clinical care to patients, and that's really what we care about. We care about access for our patients, and it functionally means that we are training physicians. The training of physicians is long. We are training them, and then that means that our patients don't get access to their expertise. We also know that female physicians, as I mentioned, have better clinical outcomes in some circumstances, and they deliver care differently. We know my colleagues have shown that female physicians spend more time with their patients. They receive more messages from their patients. They write longer notes than male colleagues. They spend more time on the electronic health record, and so. You asked specifically about female primary care physicians. That means that they are doing all these things that are right for their patients, but it might be leading them to a work situation that is not tenable, and then they choose to leave clinical practice despite that excellent care delivery.

Richard Payerchin 5:17
Again, a great setup for so many issues we can talk about here, and I want to get to the the the those some of those implications here in just a moment. And before we do, though, I want to go back to another practical result that was in the study because the study found the results showed that the median age at attrition for female physicians who left practice was 49 compared to 64 for male physicians, and that's a 15 year gap for for both ages that may be considered a little bit perhaps later in life and hopefully fairly well established in the career of a physician. But because it is a 15 year gap, what's happening in the careers of women physicians in their 40s that makes it a critical decade to their careers, and then maybe influences their decision to leave the workforce.

Speaker 1 6:13
So you are exactly right. We are seeing this earlier peak of attrition in the 40s for female physicians, and if you look at the graphs in the paper, they're actually pretty striking in that the male physicians sort of have this peak around the time of retirement, right before retirement. Maybe they're retiring a few years early, but the female physicians almost have a bimodal distribution in that when they're leaving, some of them are leaving around a regular retirement age, and some of them are leaving earlier. And so it does make that first decade and a half of practice really, really critical. We can't know exactly what is happening in every specialty, but we do know that female physicians experience a different workplace than their male male counterparts. Their patients may expect different things of them. Their colleagues may expect different things of them. They may not have in as much support as their male colleagues, for example, in terms of concrete resources, the number of staff that they work with, the the amount of administrative support, there continue to be compensation differences for female versus male physicians, and so there are multiple factors in the workplace that are driving these choices. And the reality is that we know that female physicians continue to experience disproportionate caregiving demands, both related to younger and older generations. And while certainly that can be present for male physicians, the unfortunate reality is that female physicians continue to experience those to a greater extent, and so there are both workplace and societal pressures that are making clinical practice no longer tenable for a portion of our workforce, with real implications for our patients.

Richard Payerchin 7:53
If I may, I'm going to switch gears ever so slightly because one of the issues that has come up a lot in our coverage deals with, frankly, rural healthcare and the difficulties that patients may face if they don't live in a big city. In the study, the data showed that the sex-based attrition gap held fast in both rural and urban settings. What does that finding tell you?

Speaker 1 8:19
It tells us that this is an issue again across the workforce, and if we want to retain, so it's important to retain female physicians across the workforce. But particularly if we are trying to address issues of access to care in rural areas, we have to think long and hard about what would make that kind of job sustainable to all members of the workforce, and and the specifics will vary based on the specialty, the type of institution. But to your point, that is an an area where we really need to retain our workforce, and so we should be paying particular attention into how to sustain the workforce so it's not leaving early.

Richard Payerchin 9:02
You know what? And a great segue into other issues that I wanted to talk about dealing with the the workforce and some workforce retention. And you've already touched on some of these in the study. You also suggest that alternative payment models, such as time-based billing and value-based payment, could help retain female physicians by better rewarding their care. Can you talk a little bit more about that? What does that mean in primary care? What would you like to see happen?

Speaker 1 9:30
There are studies again that show that female physicians practice differently, and likely it's good for our patients. They spend time with both more time with both male and female patients in a fee-for-service system. Functionally, what that means is that they see fewer patients, and then that means less revenue, and then they're compensated less. And so, one of my colleagues did a study showing that female physicians are generating 80 cents of revenue for every dollar of male PCPs, even when they are spending more time with their patients. And so, ideally. Time-based billing would help compensate female physicians for the time that they are spending in the visit, but also we know that they bear a disproportionate burden of asynchronous work of messages, of paperwork, of calls. Some of that has already been put into place, for example, with the E and M coding changes. Now, value-based care is is a is a different but related topic in that ideally we should be paid for the cadre of patients that we care for, whether we're seeing them in front of us synchronously or we are caring for them in asynchronous ways. My my team has shown, for example, that the more time one spends on the electronic health record, including on in-basket messages, that's associated with better panel-level quality outcomes, like better disease control for diabetes, more appropriate magmography, and so that care that happens outside the visit is valuable care. It's just not routinely compensated, and so in a value-based payment system where you are being compensated for the the panel of patients you care for, and ideally even being incentivized for quality outcomes, it would reward that type of appropriate care delivery that meets the patient wherever they are and where is most convenient for them.

Keith A. Reynolds 11:22
Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch, but the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to be true. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide, let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute.

Richard Payerchin 12:13
You know, doctor, one of the things that I find interesting here, and and it you know the notion of finding this right balance between number one, obviously, patient outcomes. More time with patients means better. I shouldn't generalize here, but you know, more time with patients may mean better outcomes for those patients, but fewer patients, perhaps less revenue. Where I'm going with this is though, is that if a doctor leaves the workforce, the clinical workforce, for whatever reason. Like you said, they may retire, go into an academic or an industry post. When that doctor leaves, they see no patients.

Speaker 1 12:51
That's right.

Richard Payerchin 12:52
So, I guess what I'm trying to to to get to here is that, especially when patients of female physicians tend to have better outcomes and receive that higher quality care. How does that translate in practical terms for a retention plan, so to speak, for those female physicians, based on again good patient outcomes and the notion that treating some patients is better than treating no patients?

Speaker 1 13:22
Well, I think it's an excellent point, and I'm not sure that the standard health system is is thinking that way. But I think it comes down to this fact that if we acknowledge these differential practice patterns and that our patients value those practice patterns, then we should be having realistic conversations about what would make this job sustainable for you? What supports can we provide that would make this job doable? Because you don't want to be in a situation exactly as you said, where somebody is providing excellent care for a while and then they can't anymore, and then they don't care take care of patients. And so, it really we know that there are substantial costs to physician turnover: 500,000 to a million dollars per physician, depending on the specialty, and so while there may be benefits in the short term to having people, physicians see more patients, we really it behooves us to think of the medium and long term costs for health systems, and then for for society as a whole. But those can be complicated conversations because again, the costs of turnover may be a few years out, whereas the cost of what would really make a difference for a particular physician would be in the near term. But we have to catch up with that; otherwise, we will not have access for our patients.

Richard Payerchin 14:35
Another great segue, because I think I'm trying to look to both the present, sort of that that retention factor, but then also the future, because in the paper acknowledges there's a projected physician shortage, and I, I'm to the point where I don't. It's there. We're not in a projected. There's not a projected shortage. We're in a physician shortage. Just put it that way. We're in a physician shortage, and if physicians are leaving the workforce. Now looking ahead, I guess there's going to be medical students who look at some of the data, some of these studies, and perhaps have some ideas or thoughts about how that might affect their own careers. What would you say to them?

Speaker 1 15:13
Well, I think it's such an important point that you bring up because all of us go through medical school and we look at our role models. And so, if you are looking at a role model, and you're saying, "Wow, that person's doing an excellent job, but their life does not seem sustainable. And then they leave the workforce. That gives that sends you a signal. And so there's a signal here about individual specialties. You look to who is practicing in a particular specialty. Could I see myself being that person? And then there's you know, and so I talk about the comparative time of departure from different specialties, the different hazards of departure from different specialties. But to your point, there's a there's there's a broader issue here of female physicians are leaving the workforce earlier overall, and so we need to think about the implications for our medical school classes, where we know that over 50% of matriculating medical students are female at this point, and that is wonderful. And so we should be creating an example that suggests to them that clinical medicine, which is what they went into medical school aiming to do, is a sustainable career path.

Richard Payerchin 16:17
You know what? One of the things that we do like to focus on too is to provide provide maybe some ideas on solutions, and as I understand it, I believe that some of your research may entail examining on how artificial intelligence programs may affect some physicians, and especially with EHR and records management. Can you talk a little bit about your maybe some initial thoughts or findings on that? Is that going to be the solution that can help keep women physicians in the workforce?

Speaker 1 16:47
I think it's a really promising solution. I don't. I think there will not be one single solution that keeps women physicians in the workforce, but I do think it's a solution that can help bring joy back into practice. So we published a study founded or funded by the Physicians Foundation this past fall, and it showed reductions in burnout across two health systems associated with use of AI scribes. And the qualitative comments were really revealing. Folks were saying, "I can pay attention to my patients again. I can look them in the eye. I can call my patients back before seven or 8p.m. There's probably a question there of, "Is that sustainable? Is that you know is that is that timing sustainable? But let's start with improvements, and so that is great that people are feeling better about their work. We also have some data suggesting that the the clinicians who have a relatively greater burden of documentation at baseline benefit proportionally more from ambient documentation technology, and so that does include female clinicians. It also includes primary care clinicians, advanced practice providers, and so certain groups that are spending more time at baseline on documentation are likely to benefit more. I do think beyond. So this is a great, great start. I do think we have to move beyond just documentation into the rest of the work of medicine that doesn't feel like the work of medicine. And so, for example, AI drafted inbox responses haven't been quite as as successful. But we know, as we were talking about, that that asynchronous work is a major driver of burden. Prior authorizations, I think, are a next frontier that I really do hope that AI can help us with general paperwork. I hope we will be able to tackle with AI, and so I hope that ambient documentation is just the beginning.

Richard Payerchin 18:35
You know what, Doctor? One of the items that we've really focused on in the last year or so, particularly this last six months, has been to kind of keep an eye on independent practice, and I know there have been there's been different research and different measurements about burnout levels with and and work environment in large kind of healthcare systems versus independent practice. Can you talk a little bit about the findings in relation to independent practice, and is there a chance that that is the stresses of independent practice may be forcing some women physicians to reconsider their careers and leave early, or is that in fact invigorating and exciting when the chance the doctor has a chance to be the boss, so to speak?

Speaker 1 19:19
Yeah, we we know that fewer physicians are working for themselves, and I actually think that that is a driver of attrition across the workforce, and and certainly it might be a greater driver of attrition among female physicians. I'm not sure that I've seen the the research to demonstrate that, but what we do know is that physicians who feel less control over their work environment are more likely to say they want to cut back on clinical care or they want to leave. So that has been demonstrated, and there's other ways in which that plays out. We did a study some years ago showing that physicians who worked for themselves were more likely to be happier with their EHR, regardless of which EHR they used. And so what it tells us is that it's not actually about the EHR; it's about their. Choices in their clinical practice. We have done research showing that in clinician-owned practices, their clinician-owned practices have lower burnout rates overall, and they're more likely to be able to improve quality of care without increasing burnout. So to make changes in practice without increasing burnout, and we think again that that is because physicians or clinicians are in charge of how care is delivered, and they feel agency. And so, I think that is a real opportunity for improvement. It is less likely that you know physicians are working for themselves less and less, and so then the opportunity is to find out how we can empower physicians, even within the large systems in which they work, to control key aspects of their life. Maybe it's their schedule. Maybe it's who's on their clinical team. Maybe it's one aspect of their practice that really matters to them-the technology that that they're using every day. But we have to figure out how to give physicians back control, even when the trends are moving against that.

Richard Payerchin 21:03
You know, doctor, I was going to say it's we've covered a lot of ground in a short amount of time, and it's been a great conversation. To go back to the study, what was a finding or a result that maybe I didn't ask about that you would like our audience to know?

Speaker 1 21:16
I think you covered really the main points, which are that across specialties, higher hazards of physicians or women physicians leaving clinical practice, and that that double peak of women physicians leaving practice, suggesting an earlier exit from practice, is really critical. And I'll underscore that we are losing decades of potential expertise from a really highly trained workforce, and it behooves us as a society, for our own health, for your my health, for my health, to keep these women physicians in practice and to figure out how to make the work sustainable for them day to day.

Richard Payerchin 21:55
I'm Richard Payerchin, reporting for Medical Economics. My guest today has been Dr. Lisa Brottenstein, a primary care physician and a researcher, who's becoming a well-known expert on physician workplace conditions. Doctor, it's been a great conversation. I hope we get a chance to talk again sometime.

Speaker 1 22:12
Thank you so much.

Austin Littrell 22:22
Once again, that was a conversation between Medical Economics senior editor Richard Payerton and Dr. Lisa Roddenstein, a primary care physician at the University of California, San Francisco, and director of the Center for Physician Experience and Practice Excellence. My name is Austin Latrell, and on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories, and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts. And if you'd like the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and PhysiciansPractice.com. Off the chart, a business of medicine podcast is executive produced by Chris Mazlini and Keith Reynolds, and produced by Austin Latrell. Medical Economics and Physicians Practice are both members of the MJH Life Sciences family. Thank

Unknown Speaker 23:14
you.

Transcribed by https://otter.ai