26 minute read
BEHAVIORAL HEALTH
An Epidemic Within a Pandemic System-Level Changes for Physician Wellbeing
BY MICHELLE D. SHERMAN, PHD LP ABPP, ADAM SATTLER, PHD LP,
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BARBARA CARVER PSYD, LP, ROSEAN BISHOP, PHD LP, JENNIFER
NELSON ALBEE, MSW, LICSW
In recognition of research showing over 50% of United States physicians report significant symptoms of burnout, in 2017 the National Academy of Medicine created the Action Collaborative on Clinician Well-Being and Resilience. This program aimed to increase attention to the epidemic of clinician burnout and to advance researchbased solutions to provide support. Similarly, conceptual models have been offered (e.g., Shanafelt & Noseworthy, 2017; Shapiro et al., 2018) identifying key drivers of burnout, organizational strategies to mitigate burnout, and systems-level interventions. Efforts such as these are important and necessary, but broad application to everyday practice and measurable impacts have yet to be seen. Then, the COVID-19 pandemic suddenly and intensely hit our world in March 2020, therein exposing many societal issues (e.g., health/wealth inequities along racial lines) that adversely impact physician well-being and the patients they serve.
Medical school did not prepare anyone for the challenges 2020 would bring to the healthcare system and our patients.
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As psychologists/social workers embedded in family medicine residency programs at four large healthcare systems across Minnesota, we see and truly hurt for our physician colleagues serving on the front lines of the COVID pandemic. The levels of stress are palpable. Emerging research is documenting healthcare providers’ elevated rates of insomnia, anxiety, and depression (Pappa et al., 2020). Anecdotally, we hear some colleagues questioning if they want to continue their careers as physicians. Many have taken pay cuts over the past year due to financial challenges faced by healthcare. Witnessing such high rates of illness and death can be traumatic, and we worry about short-and long-term trauma-reactions including but not limited to PTSD, increased rates of self-harm and suicide, increased rates of substance use disorders and overdose, moral injury, and more. So, we see and honor physicians’ exhaustion, fear and anxiety, anger, sadness, sense of feeling overwhelmed and inability to do their jobs due to shortages of resources, and grief at lost colleagues, family, and friends. Of note, these struggles are not exclusively due to the pandemic, and they will not spontaneously remit once this virus is under better control. We thank physicians for their sacrifices, commitment, and courage during this incredibly stressful time.
Well-intended efforts
Across our healthcare systems, we have seen many well-intended efforts to support the healthcare workforce. EAP services, webinars, free pizza, resource toolkits teaching coping skills, emails offering appreciation….many of these individual efforts are important and definitely may be helpful to some people.
However, for many physicians, these efforts are not only falling flat but are actually offensive. For example, a wellness guide was emailed to physicians in one of our systems; residents found the suggestions of deep breathing and exercise to be really missing the mark in light of their current levels of stress and pain. Instead of experiencing the well-intended resource as helpful, it was a source of derision and mockery. Offering such resources without acknowledging the broader systemic issues affecting physician well-being has backfired; efforts such as this may be inflaming physicians’ longstanding and deeply held frustrations with the system. Further, many overwhelmed physicians experience resilience suggestions (e.g., exercise more, meditate more) as something else that they aren’t doing well – thereby worsening their well-being rather than improving it.
Steps for making change
We are committed to work alongside our physician colleagues in the journey ahead to build the healthcare system back to a place that is better than prepandemic time. This rebuilding may provide an opportunity to thoughtfully examine some long-standing systemic issues that impact well-being. The solution is NOT more resilience training focused at the individual level. Physicians are resilient people. Below are some specific systemic steps we urge healthcare leaders to consider to effectively support physicians.
Ensure all healthcare providers have sufficient PPE, regular testing, and early access to the vaccine. Allocation of sufficient resources to help keep our frontline providers safe is essential. A recent article (Chin et
al., 2020) found that routine testing of asymptomatic providers substantially Foster an intentional culture of appreciation, connection, and focus reduces the risk of outbreaks. However, to the best of our knowledge, this is on meaning in work. Although leaders need to carefully consider and not routinely occurring in any of our healthcare systems. Professional sports respond to patient complaints and system breakdown, is equal (or more) teams, yes. Front line doctors, no. We are grateful that states are vaccinating attention paid to patient compliments, team successes, and bolstering team healthcare providers first so that they can stay well cohesiveness? Everyone in the clinic benefits when physically and care for their communities. team members at all levels make intentional efforts Make confidential, free mental health services to affirm, celebrate, and build relationships. easily available – on work time. Our physi- In addition, encouraging physicians to reflect cian colleagues have shared that this is the most Counseling must be made and draw upon the reason they chose the career of stressful time of their careers, and many desire accessible, and barriers medicine and the meaning they derive from work psychotherapy. However, carving out time during need to be eliminated. can be useful. How does each person’s contribution their already extremely busy schedules is hard, connect to the broader clinic’s values and mission? especially when balancing this with family needs. Although the drive home from work can be a Counseling must be made accessible, and barriers natural time to focus on the day’s challenges, can need to be eliminated. leaders encourage intentional reflection on one Reduce the frequency and burden of non-essential demands on phy- academic institutions, preceptors can specifically encourage trainees to reflect sicians’ time. After a busy clinic day or shift in the hospital, physicians on one thing they learned and one patient they positively impacted that day. often spend evening or weekend time attending to administrative tasks. Leaders can strive to minimize such burdens by limiting emails to those Eliminate state medical boards’ restrictions on licensure for physicians which are absolutely essential, combining and reducing required trainings, seeking therapy or experiencing mental illness. Asking for help for and releasing expectations for immediate responding when not on call. Sim- mental health concerns is hard, especially for physicians who dedicate their ilarly, increasing meeting efficiency and shortening required meetings can careers to helping others. We need to eliminate this substantial barrier of be very helpful; structuring meetings such that participants attend only the fear of negative licensure repercussions of seeking help. Clearly the medical parts that apply to their role is useful. positive interaction or progress on a project? In An Epidemic Within a Pandemic to page 264
3An Epidemic Within a Pandemic from page 25
boards have a societal duty to ensuring physicians are competent and able to provide care to patients, but the current stringent rules in many states deter physicians from seeking much-needed mental health care.
Dedicate funding to research and clinical initiatives to understand-
ing and appropriately addressing physician well-being. We applaud legislation such as the The Dr. Lorna Breen Health Care Provider Protection Act (S. 4349; HR 8094) which aims to “reduce and prevent suicide, burnout, and mental and behavioral health conditions among health care professionals” by grants, training, service provision, public health campaigns, and research. Funding to accomplish these goals is imperative. Prevention and early intervention approaches must be developed and evaluated.
Begin this mindset shift in early years of medical training. According to the Association of American Medical Colleges, the number of applicants to medical schools is up 18% in 2020 compared to 2019. Some have termed this the “Fauci effect,” as Dr Fauci’s leadership has inspired people to want to serve as physicians (Marcus, 2020). Given the anticipated shortage of physicians with large numbers retiring in the next decade, recruiting and training physicians is important. However, medical school and residency are known to be extremely stressful times with elevated rates of mental illness. Thus, systematic changes are necessary to recruit, retain, and graduate physicians who will choose to stay in this stressful career.
Many of these long-standing problems require system-level changes that take commitments of time, energy, and money. Our physician colleagues are exhausted and overwhelmed by caring for patients during this extremely difficult time. We need to broaden the locus of responsibility for physician well-being from an individualistic (physician, heal thyself) to a broader communitarian response. Just as a vaccine is offering hope for gaining some control over COVID, a substantive transformation of the healthcare system is necessary to sustain and offer hope for our greatest asset, our healthcare providers.
Michelle D. Sherman, PhD LP ABPP, North Memorial FMR Program, University of MN
Adam Sattler, PhD LP, North Memorial FMR Program, University of MN.
Barbara Carver PsyD, LP, St Cloud FMR Program, CentraCare, University of MN.
Rosean Bishop, PhD LP, Mayo Clinic/University of MN FMR Program.
Jennifer Nelson Albee, MSW, LICSW, Duluth FMR Program, Essentia Health.
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3Turning the Table from page 19
In the past, one of the only options for nerve repair was to harvest a nerve from another site on the patient’s body—typically the leg in order to repair the injury. This procedure caused a patient to have two surgical sites in addition to often permanent and bothersome numbness at the harvest site.
Today there is another option. Axogen, a pioneer in peripheral nerve repair, has developed the Avance® Nerve Graft which offers clearly documented improvements in the way nerves are repaired and eliminates the potential comorbidities associated with a second surgical site.
Avance Nerve Graft has since been widely used to help surgeons successfully repair damaged and injured peripheral nerves across the body. There are over 100 published clinical papers describing the use of Avance® Nerve Graft for the repair of sensory and motor nerves in the hands, arms, face, torso and lower extremities.
Moving Forward
While I was aware of these medical advances prior to my injury, I have become more of an advocate for the technology ever since, using it frequently when working with patients suffering from nerve damage. I recommend the same procedure I had done and the same technology that helps me do my job to patients with similar or even much more severe injuries than myself. My goal is to help patients return to normal life as soon as possible.
I find this particularly valuable when it comes to my patients who are suffering from pain. While I was able to connect my nerve pain to my traumatic injury relatively easily, many chronic pain patients may not realize a neuroma is causing the issue and that it’s something that can be surgically repaired. It’s important to know that if a patient’s pain is still present three months after a traumatic injury or a surgery, there is a good chance a nerve injury may be to blame and they should be evaluated by a nerve specialist like myself. If a neuroma is the cause of the pain, through surgical nerve repair, patients have an opportunity to live pain free and resume a more normal life, and we should do everything our power to give that to them.
Nerve damage, however small the originating injury, can cause excruciating pain, put lives on hold and jobs at risk when not addressed properly in a timely manner. I stress the importance of nerve repair procedures to my patients daily.
My job is dependent on the proper function of my hands. You don’t truly realize the importance of the ability to use your hands until you lose it. Had I not recognized the cause of the pain and numbness as a nerve injury and sought care in a timely manner, my situation could have become more permanent.
Fortunately, nerve repair technologies are widely studied, and we now have groundbreaking options to help ensure these injuries are temporary. My experience on the operating table heightened my passion for my career choice and supplemented my goal to provide my patients the best options for their recovery.
Patrick H. Smock, MD, is an orthopedic surgeon specializing in hand, wrist and elbow injuries at Allina Health Orthopedics in St. Paul, MN.
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3The Age Friendly Network from page 17
safe, affordable places to live, a community commitment to health and wellness and opportunities to stay engaged and productive.
Whether at the state or local level, supporting Age-Friendly States and Communities ensures that we are moving in tandem with leading thinkers on the social determinants of health by creating what has served as a potent guiding framework to effect local change — in health, well-being, and engagement — all through changes to the built environment as well as social supports. We’ve long known about the long-term health and income disparities that can be traced to where you were born; but a recent AARP study demonstrates that where you live can even more dramatically impact people in middle age. The report, How Growing Geographic and Racial Disparities Inhibit the Ability to Live Longer and Healthier Lives, notes that people living in healthier communities in middle age “are benefitting from increasing longevity, while the residents of the worst-performing counties are not given the same opportunity”. Addressing the health, economic and social disparities that have persisted in our state for too long must be a priority for any age-friendly initiative.
Fortunately for all of us, some of the most effective age-friendly community initiatives are those that spring forth from the ground up. While some age-friendly initiatives begin with mayors and city councils, just as many if not more are pushed by engaged citizens and grassroots organizations. Research into the champions and leaders of age-friendly community work shows that there is a role for everybody.
Getting Involved
As physicians and health care professionals you can play a vital role in creating community-level change by engaging in the communities where you live. Stay informed, spread the word, get involved and push for change.
• Take some time to browse the robust set of resources at aarp.org/ livable for everything from the basics of the Network to DIY guides around how to assess the walkability of your neighborhood streets, to examples of how communities are addressing everything from housing to public spaces.
• Sign up for our Minnesota-specific AARP Livable Communities newsletter by emailing a request to jhaapala@aarp.org.
• Assess your community’s livability features and explore where there may be gaps and opportunities for improvement by exploring the
AARP Livability Index at livabilityindex.aarp.org.
• Push for change at the local and state level by informing community leaders of the benefits of more livable, age-friendly communities and ask them what they are doing to address aging – including enrolling in the Network.
• Connect with state legislators to make them champions for healthy aging.
Will Phillips, is the state director for AARP Minnesota, a non-partisan, nonprofit social impact organization with a membership of more than 650,000 Minnesotans over the age of 50. Will can be reached at wphillips@aarp.org.
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Physician/employer direct contracting
Exploring new potential
BY MICK HANNAFIN
With the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.
Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk,
Physician/employer direct contracting to page 124 CAR T-cell therapy Modifying cells to fight cancer
BY VERONIKA BACHANOVA, MD, PHD
University of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.
CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia.
CAR T-cell therapy to page 144
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3Digital Therapeutics from page 15
Big Health’s Sleepio showed that sustained sleep health can be achieved in 76% of users with sleep problems.
A randomized controlled trial with Vorvida demonstrated significant improvements in patients with alcohol use disorder, increasing those with “low risk drinking patterns” from 7.5% at inception to 38.9% by the six- month mark.
ReSET, a DTx product for substance use disorder, is able to double abstinence rates among individuals with opioid and other substance use disorders.
Freespira demonstrated that approximately 88% of patients with Post Traumatic Stress Disorder (PTSD) experienced an alleviation of symptoms. Additionally, PTSD patients had a statistically significant reduction in CAPS-5 (Clinician-Administered PTSD Scale for DSM-5) at two months post-treatment, with 50% in remission at six months.
What’s next?
As with any new category of medicine, the rewards and risks must be intensely studied to appropriately guide patients, clinicians, and health systems through the development and adoption phases to ensure quality outcomes. Stakeholders across the digital therapeutics spectrum have made significant steps in terms of product design, evaluation, and meaningfulness in the context of patient care. There is still much to be done across the broader health care industry to ensure that these products are appropriately represented in clinical guidelines, covered alongside other medical treatments, and delivered at scale to patients across the world.
Advances made within other sectors of the digital health technology landscape, such as telehealth, need to be expanded to include DTx products. Interoperable platforms must be further developed to enable greater fluidity between monitoring, diagnostic, and therapeutic tools, while providing an increased ability to reach target populations.
Digital therapeutics can produce significant personal and public health benefits. Product quality, efficacy, usability, and appropriateness are of paramount importance. The Digital Therapeutics Alliance (DTA) is committed to advancing these principles and working with health care decision-makers to ensure that industry education and convening efforts directly support patients, caregivers, and clinicians as they face critical changes in how health care is delivered during and beyond this pandemic era.
Megan Coder, PharmD, MBA, is executive director of the Digital Therapeutics Alliance (DTA). Dr. Coder graduated from the University of Wisconsin—Madison School of Pharmacy and completed an Executive Residency in Association Management & Leadership with the American Pharmacists Association.
Christina Nyquist, is chief strategy officer at the Digital Therapeutics Alliance. Previously, she spent eight years as vice president, regulatory affairs with Aetna and 18 years with the Blue Cross Blue Shield Association.
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3Administrative Overload from page 13
as the department of health, fire marshal, and city officials. Systems that are larger and with multiple locations require complex training programs led by a safety officer and often a team focused on compliance and performance improvement. interoperability between the systems as the auditing checklists differ greatly.
Moving Forward
The U.S. health care system continues to evolve and is a world leader in many areas – but the increasingly disproportionate amount of effort spent on administrative tasks that don’t correspond to an increase in quality or outcomes needs to change. Administrative overload is one of the expensive aspects of our health care system, with no noticeable gain or benefit. The results are more expensive care, increased provider burnout and in some cases a worse patient experience. In the most damaging cases, the layers of administrative requirements create increased
An example of administrative overload in We need to determine the right balance of this area is the expensive burden of the various administrative services that support the triple and often overlapping audits that are required. Audits are usually associated with accounting and even medical records, however, there is often an even greater administrative overload in regulatory The U.S. could reduce administrative spending by 30 percent. aim, without creating redundancy, frustration, and unwieldy costs. There needs to be the same level for accountability and focus on quality in administrative processes as there is for patient requirements in auditing other functions such as care. Health care workers, whether administrative billing and coding, pharmacy and medication or direct care providers, are motivated to heal logs, medical equipment, server security and and help others. The shift of the regulatory focus networking permission and more. Each of these to processes and paperwork within healthcare is are critical functions and deserve astute attention, but often auditing detracting from quality care initiatives. Until we can get administration requirements are redundant, or in some cases irrelevant to a particular functions under better control and concentrate more on what really setting, yet still mandatory. Hospitals dedicate entire departments and matters in health care, costs will continue to increase as we compromise software applications to maintaining compliance in these areas, with little on actual quality.
potential for adverse patient events.
Todd Archbold, LSW, MBA, is a licensed social worker and the Chief Executive Officer at PrairieCare.
Dr. Leah Schammel, Carris Health Physician
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3Corporate Culture in Health Care from page 11 the job of senior leadership; as important as quality, operations and responsibility or accountability for the culture of the organization and its • Ongoing oversight: Governance holds the responsibility and component parts, including the physician services organization. Governing accountability for ensuring that ongoing evaluation and boards of healthcare organizations “own” the culture of the organizations development of organizational culture becomes an essential they lead. The physicians will look to the board as component of leadership, management and the designated body that holds the responsibility performance evaluation of the senior to ensure a stable, productive and mission-driven leadership team. culture on behalf of all in the organization.
With this in mind, what is the role of the health The culture of the organization cannot be expected to understand all there is to the system board as it relates to the culture of the physician is affected and reflected leadership, operations and management of community organization? Boards should think of their role as the by physicians employed health systems. They can be expected to fully engage “ keepers of culture” within in a framework of: by the health system. with, and understand the cultures of the organizations • Acceptance: Governance holds the they lead, including the cultural complexities of the responsibility and accountable for the culture embedded physician services organizations. The of the organization, including the physician mantle of governance requires it. services organization.
• Understanding: Governance holds the responsibility and accountability to connect with the people of the organization to understand the state and status of the culture they lead, including direct engagement with employed physicians as participants in the process.
• Engagement and action: Governance holds the responsibility and accountability to engage with senior leadership and plan action required to ensure that culture development becomes integral to financial management. In conclusion, members of governing boards
Daniel K. Zismer, Ph.D. is Co-Chair and CEO of Associated Eye Care Partners Stillwater, Minnesota. He is also Co-founder of Castling Partners and a Professor Emeritus, Endowed Scholar and Chair School of Public Health, University of Minnesota.
Some of this article derives from administrations of the “CulturePulse” a proprietary organizational culture evaluation tool developed by D.K Zismer and B.J. Utecht.
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URGENT RESOURCES FOR URGENT TIMES.
In a pandemic, speed and access to information and resources are vital. Knowledge saves time, and you need all the time you can get to save lives. Introducing the COVID-19 Resource Center. Right here, right now, for you. On our website, you’ll find the latest information and resources for important topics like: • Telemedicine: including best practices and plain language consent forms • Links to infectious disease prevention guidance • Education and resources for healthcare providers on the front lines You can access Coverys’ industry-leading Risk Management & Patient Safety services, videos, and staff training at coverys.com. All in one place, for our policyholders as well as for all healthcare providers. Thank you. For all that you are doing. You are our heroes, and we are here if you need us.
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