Working Papers

Nonprofit teaching hospitals contribute almost half of Health Care and Social Assistance GDP and educate more than 90% of all future physicians. Despite the importance of teaching, both policy discourse aimed at improving healthcare efficiency and existing models of nonprofit hospitals do not account for it, thereby missing an important trade-off between the short-term delivery of health services and the long-term benefits of physician training. I leverage unusually detailed electronic health record and audit log data from the emergency department of a large, urban teaching hospital to characterize the static costs of training across a range of granular patient outcomes and process measures. Using panel variation in patient assignment to residents, I find that hospitals must extend length of stay for complex patients by 1% to make a resident 0.047% faster in the future. Over the four-year program, this accrues to a reduction of about 9.4% and implies faster patient throughput. Then, to understand how the hospital trades off throughput costs today with future benefits of more intense physician training, I develop and estimate a dynamic model of training and care quality. Commonly-discussed payment reforms for insurers to reduce costs may increase the shadow cost of training. This could have negative effects on the career outcomes of graduating physicians 17 times larger than the savings for the teaching hospital, but feasible remedies such as increasing the staffing of attending physicians by 5% lessens the penalty by 81%.


Work in Progress

The use of Electronic Health Records has rapidly proliferated throughout the healthcare industry. In just a few short years, the nature of work has shifted dramatically for physicians in that documentation now makes up a large portion of physicians’ day. Using unusually detailed data from a large urban teaching hospital comprising a comprehensive panel of granular actions by physicians across multiple specialties, we first document that women spend 10% more time writing clinical notes than their male counterparts and write longer notes. We show that these note-taking differences lead to more efficient care for patients admitted to the hospital via the emergency department: there are no differences in patient outcomes but final treatment decisions are reached faster and fewer costly procedures and medications are ordered. Despite these positive outcomes, women physicians are not rewarded for their actions: there are no differences in salary, grants, or publications.

We leverage novel audit log data from the UCSF Emergency Department to study the role of provider fatigue and cognitive load on both provider treatment decisions and patient outcomes. The data have granular physician-patient level data on myriad micro-interactions, such as physician note writing, note reading, order requests and completions, patient test results. We use these data together with the stochastic arrival of patients to the ED to estimate how physician’s workplace burden, in terms of the number of patients they treat and patient complexity, impacts subsequent care for patients that they see. We study physician heterogeneity in the impact of cognitive load and fatigue.