Gender Differences in Electronic Medical Record Usage Between Plastic Surgeons at a Single Institution

Abstract

Background:

The electronic medical record (EMR) has many benefits but has been shown to be a source of burnout for physicians. Data suggest that female physicians in ambulatory medicine spend more time using the EMR than male physicians, though this has yet to be studied in the surgical setting. This study aimed to analyze EMR usage patterns between male and female plastic surgeons at a single institution.

Methods:

Thirteen attending plastic surgeons at a single institution were included in this study. EMR usage data were extracted from Epic from December 2021 to December 2022. Extracted variables included time spent on messages, precharting, notes, orders, the in-basket feature, and total usage during and outside the workday. Demographic analysis was performed, and a univariate regression model was used to compare variables between groups.

Results:

Three surgeons were women, and 10 were men. Female plastic surgeons spent 18.9 seconds longer on each message in the EMR (P < 0.05) and 5.52 minutes longer using the in-basket feature compared with male surgeons (P < 0.05). Additionally, female surgeons spent 15.3 more minutes on notes (P < 0.05).

Conclusions:

Female plastic surgeons spend significantly more time on messages with patients and staff and spend more time in notes than their male counterparts. In our study, these differences reflected nearly 2 additional hours/wk spent on EMR usage. Because workload related to the EMR may contribute to burnout, institutions can work with physicians to recognize time spent on required documentation and identify ways to improve efficiency.

Takeaways

Question: Are there differences in electronic medical record (EMR) usage between male and female plastic surgeons, and what implications does this have on communication, efficiency, and burnout?

Findings: Female plastic surgeons spent more time on messages, the in-basket feature, and notes within the EMR than male plastic surgeons. This was a single-institution study, and data were extracted from Epic spanning the course of 1 year.

Meaning: Female plastic surgeons spend more time using communication tools within the EMR, which may contribute to burnout and lost time for academic and personal pursuits.

INTRODUCTION

Burnout is the triad of emotional exhaustion, depersonalization or cynicism, and feelings of diminished personal efficacy or accomplishment in the work environment.¹ Unfortunately, within the medical field, burnout affects most practicing doctors and disproportionally impacts female physicians. The literature has demonstrated up to 60% higher burnout rates in female physicians compared with their male counterparts.^2,3 Although the cause of burnout is multifactorial, a few factors have been definitively linked to this higher prevalence in female physicians, including differences in communication style impacting patient expectations, patient satisfaction, and gender bias in interprofessional relationships.^4–6 We hypothesized that the communication burden is exacerbated with the rise of the electronic medical record (EMR).

With the implementation of the EMR, work outside of in-person hours has become increasingly common for physicians and again impacts female physicians to a greater degree, compounding the factors of burnout already discussed.⁷ A study of 125 internists in an ambulatory environment (76 women and 49 men) showed that women spend more time on in-basket features and notes than their male counterparts.⁸ An additional cross-sectional study of 318 physicians demonstrated that female physicians spend more time on the EMR and notes and care for significantly fewer patients each hour and each month.⁹ To our knowledge, this has not yet been studied in plastic surgery. The aim of this study was to analyze differences in EMR usage between plastic surgery faculty at a single institution to determine if there is a difference in EMR usage between male and female plastic surgery faculty.

METHODS

Thirteen plastic surgeons at a single institution were included in this study. EMR usage data between December 26, 2021, and December 31, 2022 were extracted from Epic (Epic System, Verona, WI). Demographic information was collected for each of the surgeons, including sex, career stage, and subspecialty within plastic surgery. Career stage was further defined as early stage of career (<5 y), middle stage of career (5–15 y), and late stage of career (>15 y). Subspecialties included aesthetics, craniofacial, gender, hand, microsurgery, and general plastic surgery.

Regarding EMR variables, extracted data included time spent on messages, precharting, notes, orders, the in-basket feature, and the EMR both during and outside the workday. Additionally, the average number of appointments per clinic day, the average number of patient and staff messages, and patient advice requests per surgeon were collected. The surgeons were stratified into subgroups based on sex, career stage, and subspecialty. An analysis of demographic data was performed, and a univariate regression model was used to compare variables between groups.

RESULTS

Of the surgeons included, 3 were identified as women and 10 as men. Of these, 2 surgeons were in the early stage of their career (years 1–5), 7 in the middle stage (years 5–15), and 4 in the late stage (>15 y). One female surgeon was in the early career stage and 2 were in the middle stage. One surgeon was included in the aesthetics subspecialty, 3 in craniofacial, 1 in gender, 3 in hand, 3 in microsurgery, and 2 in general plastic surgery (Table 1). The female surgeons represented craniofacial, gender, and hand subspecialties.

Table 1.

Surgeon Demographic Information

Surgeon	Sex	Career Stage
1	Male	Middle
2	Male	Late
3	Male	Early
4	Male	Middle
5	Female	Middle
6	Female	Middle
7	Female	Early
8	Male	Middle
9	Male	Middle
10	Male	Middle
11	Male	Late
12	Male	Late
13	Male	Late

Demographic information including identified sex and stage of career are included for the 13 surgeons.

Male and female surgeon EMR usage patterns were compared in multiple categories. On average, female surgeons spent 18.9 seconds longer on each message in the EMR than their male counterparts (95% confidence interval [CI] 2.33–35.4, P < 0.05) (Fig. 1). Female surgeons also spent an average of 5.52 minutes longer per day using the in-basket feature compared with male surgeons (95% CI 0.046–11.0, P < 0.05) (Fig. 2). Additionally, female surgeons spent 15.3 more minutes on notes daily (95% CI 1.14–29.5, P < 0.05) (Fig. 3). Additional variables including time spent on precharting, time spent on orders, number of appointments, number of patient messages, number of patient advice requests, number of staff messages, time spent on the EMR outside of office hours, and total time spent on the EMR each day did not significantly differ between male and female surgeons.

Fig. 1.

Time spent on each message by sex. Female plastic surgeons spent significantly more time on each message received in the EMR. The average increased time was 18.9 seconds per message.

Fig. 2.

Time spent on the in-basket feature by sex. Female plastic surgeons spent an extra 5.52 minutes per day using the in-basket feature in the EMR when compared with male surgeons.

Fig. 3.

Time spent on notes by sex. Female plastic surgeons averaged 15.3 additional minutes on notes each day, which was significant when compared with male plastic surgeons.

In addition to sex, time spent interacting with the EMR was stratified and compared based on career stage. Surgeons in the middle and late stages of their career spent 25.1 (95% CI −6.82 to −43.4, P < 0.05) and 28.6 (−8.83 to −48.3, P < 0.05) fewer seconds on each message, respectively, when compared with surgeons in the early stage of their career (Fig. 4). In the late stage of their career, surgeons spent 2.20 fewer seconds precharting on each patient than early career surgeons (95% CI −4.36 to −0.031, P < 0.05) (Fig. 5). Time spent on notes per day and time spent on the EMR outside patient hours also significantly varied with the career stage. Compared with surgeons in the early stage of their career, surgeons in the middle stage of their career spent 19.3 fewer minutes per day on notes (95% CI −35.7 to −2.85, P < 0.05) and spent 32.2 fewer minutes per day on the EMR outside of work hours (95% CI −52.1 to −12.4, P < 0.05) (Figs. 6, 7). Surgeons in the late stage of their career spent 23.0 fewer minutes per day on notes (95% CI −40.7 to −5.27, P < 0.05) and 28.8 fewer minutes per day in the EMR outside of work hours (95% CI −50.3 to −7.28, P < 0.05) (Figs. 6, 7). Time spent on orders, number of appointments, number of patient messages, number of patient advice requests, number of staff messages, total in-basket time, and total time spent on the EMR each day did not significantly differ by the stage of career.

Fig. 4.

Time spent on each message by career stage. Surgeons in the middle and late stages of their career spent 25.1 and 28.6 fewer seconds on each message, respectively, compared with those in the early stage.

Fig. 5.

Time spent on precharting by career stage. Late-stage surgeons spent 2.20 fewer seconds precharting on each patient compared with early career surgeons.

Fig. 6.

Time spent on notes by career stage. Surgeons in the middle stage of their career spent 19.3 fewer minutes per day on notes than early stage surgeons. Late-stage surgeons spent 23.0 fewer minutes per day on notes.

Fig. 7.

Time spent on EMR outside of work by career stage. Compared with early career stage surgeons, middle-stage surgeons spent 32.2 fewer minutes per day on the EMR outside of work hours and late-stage surgeons spent 28.8 fewer minutes per day on the EMR outside of work hours.

EMR usage patterns of the subspecialties revealed that hand surgeons received significantly more patient messages than their counterparts in other specialties. Gender surgeons received the fewest number of patient messages, averaging 2.91 messages fewer than hand surgeons (95% CI −5.13 to −0.690, P < 0.05). On average, aesthetic surgeons received 2.59 fewer patient messages than hand surgeons (95% CI −4.81 to −0.374, P < 0.05). Of the remaining subspecialties, when compared with hand surgeons, craniofacial surgeons received 1.92 fewer patient messages (95% CI −3.49 to −0.346, P < 0.05), general plastic surgeons received 2.56 fewer patient messages (95% CI −4.31 to −0.804, P < 0.05), and microsurgeons received 2.06 fewer patient messages (95% CI −3.63 to −0.488, P < 0.05).

DISCUSSION

Previous studies, primarily in the ambulatory care space, have examined communication styles as they relate to physician gender.¹⁰ Roter et al¹¹ performed a meta-analysis demonstrating that female primary care physicians conducted longer office visits than male providers and spent significantly more time engaging in patient-centric conversation. Similarly, previous literature has shown that, compared with male colleagues, female physicians engage in more psychosocial counseling, question asking, positive talk, and empathetic communication.¹² Female physicians are more likely to be seen as attentive by patients, and this can lead to patients discussing relational aspects of health and building trust.¹² Although this can lend to strengthen the patient–physician relationship, it can also lead to lengthy visits.¹² As a result, female physicians in ambulatory settings spend approximately 2 minutes longer on each clinic visit and see 160 fewer consultations per year than their male colleagues.^11,13

Although the communication styles used by female physicians would seem to be beneficial, female physicians do not receive higher satisfaction scores.¹⁴ In fact, there does not seem to be a detrimental impact on satisfaction for male physicians who do not use a caring communication style.¹⁵ To further iterate this point, a 2019 study sought to characterize patient perceptions of male and female surgeons’ warmth and competence. The authors found that female surgeons received significantly higher warmth scores than male counterparts while receiving significantly lower competence scores.¹⁶ We predict that gender stereotypes play into these scores, as they contradict the results of a recent retrospective cohort study published in Journal of the American Medical Association demonstrating that patients of female surgeons have lower adverse postoperative events at 90-day and 1-year intervals after surgery.¹⁷

With knowledge of these differences in communication styles, we then aimed to evaluate the patterns of usage of the EMR of plastic surgeons of various sexes and career stages at our institution. This revealed interesting trends in time spent using different features of the EMR, particularly related to communication-based tools. Based on the data collected, female plastic surgeons at our institution spent significantly more time on each message in the EMR, more time using the in-basket feature, and more time on notes than their male colleagues. These increases in EMR usage resulted in an additional 20.8 minutes spent on documentation and in-basket communication per day, equating to roughly 104 extra minutes per week and 90 extra hours per year. This significant time burden can impact availability for direct patient care responsibilities, research, teaching, leadership opportunities, and personal time. We did note some variation in time spent on the EMR across subspecialties, with hand surgeons receiving significantly more patient messages than other subspecialties. There was 1 female hand surgeon in this group and 2 male hand surgeons, making the specialty relatively comparable to the other groups in terms of the male-to-female ratio of providers.

These findings are of importance because the implicit and explicit bias, as well as increased communication burden placed on female surgeons, may provide an explanation for higher burnout rates among female physicians compared with male physicians. Dyrbye et al¹⁸ surveyed all members of the American College of Surgeons and found that female surgeons had significantly higher rates of burnout (43.3% versus 39% in men). Specific to plastic surgery, the 2023 Medscape Plastic Surgeon Lifestyle, Happiness, and Burnout Report demonstrated that 50% of female plastic surgeons reported feeling burned out or depressed, whereas only 37% of male plastic surgeons reported this.^19,20 With female plastic surgeons spending 90 additional hours per year on computerized documentation and communication, as seen in our study, it is probable that this has contributed to the rise of burnout in this population.

Based on the literature and our results, we believe the additional time spent on the EMR seen by female plastic surgeons may reflect the expectations of other providers and patients. We do believe that there are actionable ways to combat these disparities. A study out of Ohio State University aimed to provide a framework for improving physician efficiency with the EMR, given the documentation burden it often imposes.²¹ “Efficiency workshops” were held between health professionals and IT professionals, focusing on ways to more effectively use the EMR.²¹ Specific topics included finding information quickly in the EMR, efficient documentation within specialties, and use of communication features.²¹ The results were overwhelmingly positive, with physicians reporting acquisition of new skills and strategies to use the EMR and improvement in patient care.²¹ Based on our data, we feel that a similar program between physicians and IT professionals would be beneficial at our institution to help personalize the EMR further to meet the communication and documentation burden felt by different plastic surgeons.

We recognize that this study has limitations. It is a single-institution study that collected data during a 1-year period. Only 13 plastic surgeons were included in the initial data collection. Our sample size is small, resulting in an increased risk of type II error, and although this is an interesting study, a continuation of the study with expansion to additional surgical subspecialties at our institution would provide more meaningful results. Differences in documentation style, practice composition, subspecialty, and/or individual workflow and efficiency impact these data. Additionally, there are user variations within the EMR that this study was not able to fully capture, such as the use of scribes or resident assistance with notes. This may influence the data as it relates to time spent on notes, but the majority of variables were independent of this. Differences in EMR demands between subspecialties within plastic surgery may also exist, specifically in instances when patients may require inpatient hospitalization, extensive collaboration with other medical specialties, or long-term follow-up for more complex problems. Although female surgeons were not limited to a single subspecialty, this can act as a confounder. Additionally, although all attending surgeons have had the same EMR training, the stage of career could confound results, as surgeons later in their career may not be as savvy with the EMR and using it efficiently.

CONCLUSIONS

Physician burnout is not new, but attempting to understand its causes and mitigate risk factors is becoming increasingly important. As the communication burden has risen and access to work outside the workplace has become commonplace with the advent of the EMR, we must seek to understand those who are most vulnerable to burnout and attrition. This study represented an initial step in understanding variations in EMR usage between female and male plastic surgeons and how communication style and expectations may vary between the 2 groups. We found that female plastic surgeons spend significantly more time communicating with patients and other providers through the EMR in the form of messages, in-basket use, and time spent on notes. This is time lost that could otherwise be used on other clinical, academic, and personal pursuits. Better understanding of these trends in female plastic surgeons’ communication, perceptions, and expectations, in turn, might allow us to alleviate the burnout that female surgeons feel disproportionately and therefore minimize the academic, economic, and emotional repercussions that result.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.