San Francisco Marin Medicine, Vol. 95, No. 4, Oct/Nov/Dec

FEATURE ARTICLES

12 The Canary in the Coal Mine Scott Tcheng, MD 14 On the Front Lines: An Informal Survey Scott Campbell, MD 20 Give Health Care Workers the Mental Health Support They Deserve Corey Feist, Arianna Huffington, Deborah Marcus, Michelle A. Williams

22 As an ER Doctor, COVID Taught Me I Don't Matter. So I Quit. Molly Phelps, MD 36 How to Cure the Public Health Crisis of Burnout, an Occupational Disease Mihal Emberton, MD, MPH 38 As a Mom and an Abortion Provider, I Knew What Was at Stake on November 8th Maryl G. Sackheim, MD, MS 39 Ask Yourself Better Questions and Lessen Burnout Jessie Mahoney, MD 41 Beyond the Oxygen Mask Jessie Mahoney, MD

President's Message: Medical Abortion: Protecting Patients and Physicians Everywhere Michael Schrader, MD, PhD

Executive Memo: What Will 2023 Hold? Conrad Amenta

CMA House of Delegates Report Michael Schrader, MD, PhD

Kaiser News Maria Ansari, MD

Kaiser Permanente San Rafael Naveen Kumar, MD

October/November/December 2022 Volume 95, Number 4 Editorial and Advertising Offices: San Francisco Marin Medical Society 312 Sutter, Suite 608 SF, CA 94108 Phone: (415) 561-0850 Web: www.sfmms.org

2022 ELECTION RESULTS

2023 Officers (one-year term):

President-Elect: Dennis Song, MD, DDS

Secretary: Sarita Satpathy, MD

Treasurer: Jason Nau, MD

Editor: Gordon L. Fung, MD, PhD, FACC, FACP

2022 President-Elect, Heyman Oo, MD automatically succeeds to the office of President. 2022 President, Michael Schrader, MD, automatically succeeds to the office of Immediate Past President.

Board of Directors (three-year term 2023-2025):

Edward Alfrey, MD

Ayanna Bennett, MD

Clifford Chew, MD

Esme Cullen, MD

Cindy Greenberg, MD

Elizabeth Griffiths, MD Melanie Thompson, DO Kenneth Tai, MD Kristin Wong, MD Andrea Yeung, MD Helen Yu, MD

Nominations Committee (two-year term 2023-2024):

Robert Harvey, MD

Sam Kao, MD John Maa, MD

Delegation to the CMA House of Delegates (two-year term 2023-2025**):

*Determination of ‘Delegate’ and ‘Alternate’ status will be made in late 2022/early 2023, after final SFMMS membership count is confirmed by CMA.

**Delegates elected in the November 2022 election will serve terms running until the 2025 SFMMS election, at which time they will be eligible to run for re-election.

Edward Alfrey, MD Kavon Javaherian, MD

Peter Bretan, MD Jon Levin, MD

Daniel Flis, MD John Maa, MD

Gordon Fung, MD Heyman Oo, MD

Brian Grady, MD Sarita Satpathy, MD

Opal Gupta, MD Helen Yu, MD

SFMMS Young Physicians Section (YPS) Representative to the California Medical Association House of Delegates(Term: 2023-2024) Kavon Javaherian, MD (Representative Delegate)

Approval of Proposed Amendments to SFMMS Bylaws

A majority of eligible voters who cast a vote on the item related to proposed amendments to the SFMMS bylaws voted to approve the proposed amendments.

PRESIDENT’S MESSAGE

Michael Schrader, MD, PhD

MEDICAL ABORTION: PROTECTING PATIENTS AND PHYSICIANS EVERYWHERE

Beginning with the leaked Alito Dobbs opinion in May, the Supreme Court decision to overturn Roe v Wade has eliminated patient rights, eroded physician authority, and thrown medicine into a turmoil. This partisan, judicial activism overturned a 50 year precedent and has caused disruption to patient wellbeing and the practice of medicine. We are seeing narrow-viewed legislators attempting to control the practice of medicine in their own states and nationwide.

Medical and surgical abortion have become a standard of care over the past half century. The freedom of women patients to control their reproductive health is a cornerstone of economic, social, and political equality. In 2020, 240,000 abortions were performed in states that are now restricting or in the process of restricting abortion.

There are multiple repercussions of banning abortion. Many women denied legal abortion will seek out illegal procedures, putting themselves at great risk of harm and even death. Unwanted pregnancy has poorer health outcomes for both mother and child compared to intended pregnancy. OB/Gyn residents in many states will not meet national training standards. Decreased access to abortion will increase maternal and child poverty which strongly correlates to poorer health. Potential legal jeopardy has created an undue burden on physicians with yet unforeseen consequences for the practice of medicine.

Thirty years ago the San Francisco Medical Society made a bold move in support of medical abortion, which in France had already been called “The moral property of women.” The SFMS had policy supporting the medical abortion medication then known as RU-486, already in wide use in Europe, and had succeeded in getting that adopted by the CMA and AMA. The FDA had still declined to authorize RU-486 for use in the United States. Steve Heilig of the SFMS, who had already written about RU-486 for JAMA, UCSF, and other publications, and had published a survey of California OB/Gyn physicians showing they supported use of RU-486 here, was approached by a New York group called Abortion Rights Mobilization to recruit a pregnant woman seeking an abortion.

A number of SFMS OB/GYNs were selected to refer appropriate patients for screening, until one agreed to attempt a dramatic effort to publicize the need for this medication here. The woman flew to England, was handed RU-486 by a physician there, and then flew to JFK Airport. Customs officials and the media had been alerted that she would be smuggling this drug and it was seized at customs. Her case was on the front page of the New York Times and all television news networks. Federal seizure of the pills was immediately challenged. The Supreme Court had to rule quickly and denied her use of the illegal drug. The woman, whose anonymity was preserved as much as possible, subsequently underwent a legal surgical abortion.

This publicity effort eventually paved the way for legalization of medical abortion by the FDA. Presidential candidate Bill Clinton cited this event, pledging to bring the medication here. But even so, due to political factors it took eight more years for the FDA to approve it in 2000, and even then with undue restrictions not supported by evidence, some of which remain even today. Still, over half of all abortions done in the United States are now done via medication.

This year, the SFMMS Delegation to the CMA House of Delegates proposed policy to shield physicians who use telemedicine to prescribe medical abortion across state lines, supported by UCSF experts. This would be similar to recently passed legislation in Massachusetts to protect physicians and patients. While this was not initially successful, we have followed up with a resolution that has been submitted to the Year Round Resolution process. We have also urged FDA review of the possibility of making these medications Over-The-Counter to increase access. Medical abortion is a safe and effective treatment that should be available to all women.

Dr. Schrader practices internal medicine at Dignity Health, is President of the SFMMS, and co-chairs the SFMMS delegation to the CMA.

EXECUTIVE MEMO

Conrad Amenta, SFMMS Executive Director

WHAT WILL 2023 HOLD?

The physicians of San Francisco and Marin Counties faced myriad challenges in 2022, and their leadership proved indispensable to overcoming them.

Throughout the year, I heard from members that it sometimes felt like it had never been more difficult to be a physician. But our physicians came together to support their colleagues and friends and leaned into their values to advocate for policies that are rigorous, evidence-based, and compassionate.

At the local, state, and federal levels, SFMMS leaders were there —meeting with legislators, helping to author policies that responded to the moment, and picking one another up.

Among many other things, your physician leadership:

• Convened community stakeholders to meet with the Centers for Medicare & Medicaid Services (CMS) to advocate for continued funding to Laguna Honda Hospital. As a part of these efforts, UCSF residents raised their voices and published articles about the importance of long-term care in their communities. In October, CMS announced they’d agreed to a deal with San Francisco to extend federal funding to Laguna Honda for a year while the hospital pursues recertification, protecting some of our most vulnerable patients from ‘transfer trauma.’

• Stood shoulder-to-shoulder with Planned Parenthood and joined a coalition of pro bono lawyers from the San Francisco Bar Association to provide care and protection to patients traveling to California to seek abortions.

• Supported several local and state candidates for office who share our values, contributing to their campaigns via our SFMMS Political Action Committee and helping them to become our elected representatives. SFMMS’ Board of Directors endorsed then-candidates/now-Assemblymembers Matt Haney and Damon Connolly, longtime local policymakers who now represent us at the state level.

• Elected several physicians to key positions in organized medicine at the California Medical Association and American Medical Association, ensuring the voice and perspective of physicians in San Francisco and Marin is heard across the country.

• Brought together members via community and physician wellness initiatives and retreats to nourish and sustain their practice.

• Supported numerous community benefit organizations with grants disbursed via our Community Service Foundation.

You can read more about the accomplishments of our physician members in the SFMMS Annual Report, which you can find in this issue of our journal and on our website at www.sfmms. org/about.

In 2023, the SFMMS Board of Directors and Executive Committee will continue to identify opportunities to advance health equity, protect your patients, and support our physicians with the latest news, resources, community events, and leadership opportunities. Several policy opportunities are also on the horizon, including advocating for increased Medi-Cal payment to improve access to care, Medi-Cal program reform via the ‘CalAIM’ initiative, and working with our County Boards of Supervisors to articulate a strategy for long-term care and residential drug treatment capacity.

Thank you for your work in 2022, and all you do to inspire us. We’ve accomplished much together, and we’re just getting started.

CMA HOUSE OF DELEGATES 2022

Michael Schrader, MD, PhD

The 151st California Medical Association House of Delegates convened at LA Live on October 21, 2022 after a two year Covid hiatus. Our SFMMS District VIII Delegation was there to represent our members. As compared to the previous two years we were able to renew friendships and create new alliances. We had compelling Major Issues where we pushed for new policy and the election of Dr. Lawrence Cheung to Vice-Speaker of the HoD.

Prior to the convening of the HoD there were well-attended conferences on climate change and reproductive rights. There is a strong core of advocates in the CMA for climate change activism. They want the AMA to establish climate change as a public health crisis and have supported bills in the California State Legislature to address preparedness for catastrophic heat events and accurate collection of data about heat-related morbidity and mortality. SFMMS endorsed bill AB 2238 (L. Rivas) - “Statewide extreme heat ranking system” that was signed into law by Governor Newsom this year.

Reproductive rights and the repercussions of the Supreme Court Dobbs Decision were a major focus of the CMA HoD beginning with the pre-HoD briefing by Planned Parenthood and other experts. The issues are the right of patients to make reproductive choices and the role of the physician/patient relationship in forming individual decisions. The consequences of the Dobbs decision include catastrophic effects on the health of women with pregnancy complications, legal jeopardy for physicians and patients, and complications for residency programs that require abortion and pregnancy management training to maintain accreditation.

This year there were three Major Issues presented to the HoD: Health Care Reform, Physician Workforce, and Mental Health. These were remarkably similar to the three Major Issues that were considered in 2017. The Mental Health Major Issue was educational only and therefore did not have policy recommendations attached. The Health Care Reform and Physician Workforce Major Issues offered some surprises.

The Health Care Reform Major Issue was directed primarily to Medi-Cal reform. Approximately one-third of Californians are

insured by Medi-Cal and approximately half of California children are covered by Medi-Cal. The low reimbursement rates for Medi-Cal have created a two-tier system of coverage with access problems for Medi-Cal patients. The thrust of the Recommendations for this Major Issue were to increase Medi-Cal funding to parity with comparable insurance plans. The key to raising Medi-Cal funding is to establish a secure source of funding that is not vulnerable to state budget revenue fluctuations.

Our SFMMS Delegation proposed an amendment to tax the sales of alcoholic beverages with revenue earmarked for Medi-Cal reimbursement to providers. This amendment was ruled out of order, but you have not heard the last of this.

The Physician Workforce Major Issue ended up primarily addressing reproductive rights. The Council of Delegate Chairs met in May shortly after the leak of the Justice Alito decision about the Dobbs decision. Our SFMMS Delegation initiated the proposal of reproductive rights for a Major Issue at the CDC. Ultimately reproductive rights were not selected as a Major Issue as Delegation Chairs chose the above issues. When the Major Issues were published reproductive rights were piggybacked on to Physician Workforce almost as an additional Major Issue. You may draw your own conclusions about the effect of SFMMS advocacy but we were the vanguard. We made two amendments by addition to the Recommendations, both about establishing telemedicine abortion shield laws: medical abortion using mifopristone/misoprostol prescribed across state lines via telemedicine. This was not adopted as CMA policy but our advocacy will continue. We have submitted a resolution to the Year Round Resolution process.

AMA President Dr. Jack Resneck of UCSF addressed the CMA HoD about issues including violence against physicians, physician burnout, pending Medicare payment cuts, administrative burden, racial justice and equity access to healthcare, and political intrusion into the physician/patient relationship. We invited Dr. Resneck to address our Delegation at our lunch meeting following the Saturday morning session. We discussed our SFMMS Delegation efforts to address violence toward physicians and healthcare workers.

SFMMS Past-Presidents Drs. Man-Kit Leung, Lawrence Cheung, Brian Grady, Shannon Udovic-Constant, George Fouras, and Kimberly Newell Green.

Governance reform was also addressed. We heard a presentation from Dr. Holly Yang at our Delegation meeting about the Governance Technical Advisory Committee (GTAC) and she later addressed the HoD. Our delegate, Dr. Roger Eng, is also on the GTAC. Our SFMMS Delegation has specific proposals for CMA governance reform with the primary aim of rebalancing the power of the CMA Board of Trustees with the County and Specialty Delegations.

The influence of our SFMMS Delegation on CMA leadership was reaffirmed by the honoring of Dr. Peter Bretan as twoterm President of the CMA, the announcement of BoT Chair, Dr. Shannon Udovic-Constant, to run for CMA President-elect next year, and the election of Dr. Lawrence Cheung to Vice-Speaker of the HoD. New CMA President Donald Hernandez, a hospitalist in Santa Cruz, was installed, and pediatrician Richard Pan was honored for his service as a state senator with strong leadership on multiple important health issues. And last but far from least, SFMMS past-president Dr. George Fouras was elected CALPAC secretary/treasurer, an important slot in CMA’s advocacy with our state’s legislators.

Our SFMMS District VIII Delegation has a strong voice at the CMA. We welcome the opportunity to represent our SFMMS members. We welcome your ideas and resolutions. We have opportunities for members who would like to become involved with our delegation.

SFMMS 2022 HOD ATTENDEES:

Ameena Ahmed, MD, Delegate, vice-Chair

Gordon Fung, MD, Delegate

John Maa, MD, Delegate

Jessica Duhe, MD, Delegate

Ian McLachlan, MD, Delegate

Michael Schrader, MD, Delegation Chair

Brian Grady, MD, Delegate

Roger Eng, MD, Delegate

George Fouras, MD, Delegate

Kim Newell Green, MD, Delegate Man-Kit Leung, MD, Delegate

Monique Schaulis, MD, Delegate

Dennis Song, MD, Delegate Haining (Helen) Yu, MD, Delegate

Cathlin Milligan, MD, Alternate Javaid Khan, MD, Alternate Charles Windon, MD, Alternate Larry Bedard, MD, Guest Mel Blaustein, MD, Alternate

Dr. Schrader chairs the SFMMS delegation (with Dr. Ameena Ahmed, newly-elected vice-chair) and is president-elect of the SFMMS.

Volume 95, Number 4

Editor Gordon L. Fung, MD, PhD, FACC, FACP

Managing Editor Steve Heilig, MPH Production Maureen Erwin

SFMMS OFFICERS

President Michael C. Schrader, MD, PhD, FACP

President-elect Heyman Oo, MD, MPH

Secretary Jason Nau, MD

Treasurer Dennis Song, MD

Immediate Past President Monique Schaulis, MD, MPH

SFMMS STAFF

Executive Director Conrad Amenta

Associate Executive Director, Public Health and Education Steve Heilig, MPH

Director of Operations and Governance Ian Knox

Director of Engagement Molly Baldridge, MPH

2022 SFMMS BOARD OF DIRECTORS

Edward Alfrey, MD Melinda Aquino, MD Ayanna Bennett, MD Julie Bokser, MD

Kristina Casadei, MD Anne Cummings, MD Manal Elkarra, MD Mihal Emberton, MD Beth Griffiths, MD Robert A. Harvey, MD Harrison Hines, MD Ian McLachlan, MD Jason R. Nau, MD Heyman Oo, MD Sarita Satpathy, MD Monique Schaulis, MD Michael C. Schrader, MD Yalda Shahram, MD Neeru Singh, MD Dennis Song, MD Kristen Swann, MD Kenneth Tai, MD Melanie Thompson, DO Matthew D. Willis, MD, MPH Joseph W. Woo, MD Andrea Yeung, MD

For questions regarding journal, including possible submissions, contact Steve Heilig: Heilig@sfmms.org

Cover Art: “Intensive Care” by Cynthia Fletcher, 20x16, oil on panel, 2021, from her Coronavirus series. http://www.cynthiafletcherart.com/

2022 Legislative Wrap-Up

By Janice Rocco, CMA Chief of Staff

In 2021, with emergency use authorization for COVID-19 vaccines, the hope was that the pandemic would end and life could go back to normal. Instead, it wasn’t until 2022 that the state legislature began moving back to something resembling business as usual.

The state declaration of the COVID-19 State of Emergency remains in effect. The State Capitol is again open to the public, but even that has changed in ways that provide less access to legislators and their staff than was the case prior to the pandemic. The Capitol building is undergoing construction and legislators have moved their offices outside the Capitol. Committee hearings are being conducted in person again, though often with a hybrid phone-in option. Separate from the legislature, public meetings held by state departments and commissions have begun shifting back to a hybrid approach, so that we can be back in person again. These changes mean that we have adjusted and found new ways that we, as advocates, communicate with legislators and their staff.

In California, we had five legislative seats become vacant during the year, which meant five special elections to fill them. By the time each of these races had concluded, a total of five new Democrats had been sworn into office. With these additions, Democrats continue to have a supermajority in both the Assembly and the Senate.

The closing of the 2021–2022 legislative session also brought with it the end of an era for a well-respected member of the legislature. Senator Richard Pan, M.D., spent 12 years serving California in the legislature by focusing on improving the state’s health care system, fighting for patients and the practice of medicine. Though Dr. Pan has many legislative accomplishments, we are particularly grateful for his leadership during the COVID-19 pandemic, where his expertise was critical to our state on a daily basis.

HEALTH CARE REFORM

As the legislative year began, AB 1400, the single payer health care coverage bill, was before the State Assembly for a vote. That bill died in the Assembly at the end of January, which then shifted the discussion to other health care reform measures. The Governor’s Office of Health Care Affordability proposal from 2021 was back for discussion and debate, with the California Medical Association (CMA) fighting to prevent this broad measure from becoming an administrative burden for physician practices.

Ultimately, we were successful in getting physician practices with fewer than 25 physicians exempted from both the data submission requirements and the cost targets that the state will develop. Similarly, we fought to prevent independent practice associations (IPAs) from being included as a way to impose cost targets and data submission requirements on smaller physician groups, ultimately seeing them removed from the bill. We were also able to get the Newsom Administration to commit to include $200 million in the state budget for grants to assist physician practices with implementation of some of the provisions in Office of Health Care Affordability legislation, such as a shift to alternative payment models.

STATE BUDGET

Another victory in the health care reform space was achieved via the 2022–23 state budget. Continuing California’s commitment to achieving universal health care access, the $308-billion budget includes a phasedin system to provide full scope Medi-Cal coverage to all income-eligible Californians regardless of age or documentation status by January 1, 2024. This makes California the first state in the nation to expand its Medicaid program to provide full benefits to all eligible individuals—a critical step in our shared goal of ensuring that every Californian has access to quality health care. Many other CMA priorities and supported issues were addressed in the 2022–23 budget, including: a permanent extension of key Medi-Cal telehealth flexibilities implemented during the pandemic; full funding for the Prop. 56 Medi-Cal supplemental payments and graduate medical education funding programs; major investments in health care workforce development; $1.3 billion for health care worker retention pay; $700 million in equity and practice transformation payments; and $200 million for reproductive health and reproductive justice issues. (For more details on the state budget, see cmadocs.org/ budget-22-23.)

MICRA

When the year began, the expectation was that CMA’s focus in 2022 would be working to defeat the socalled “Fairness for Injured Patients Act” (FIPA) ballot initiative that had qualified for the November 2022 ballot. The ballot initiative, if it had passed, would have eviscerated the protections of California’s Medical Injury Compensation Reform Act (MICRA). After Californians Allied for Patient Protection (CAPP), led by CMA CEO Dustin Corcoran, negotiated a legislative deal with FIPA proponents, Assemblymember Eloise Gómez Reyes put that legislative deal into AB 35, the MICRA Modernization Act. Just 16 days later, Governor Newsom signed the bill into law and FIPA proponents removed their initiative from the ballot. This historic agreement prevented a costly ballot fight and ushered in a new and sustained era of stability around malpractice liability.

MEDICAL BOARD

CMA aggressively fought AB 2060 (Quirk), which would have created a public member majority on the Medical Board of California. We were able to kill this bill in its first house.

At the same time, CMA sponsored legislation— AB 1636 by Assemblymember Akilah Weber, M.D. —to preserve the integrity of the medical profession by ensuring physicians convicted of sexual assault with a patient lose their license with no ability for it to be reinstated. This bill removes the medical board’s discretion to give or reinstate the license of a physician or surgeon who lost their license due to sexual misconduct with a patient. This bill would also deny a physician’s and surgeon’s license to an applicant who has been or is required to register as a sex offender.

HEALTH IT

CMA had three significant victories addressing health information technology issues. The passage of AB 852 (Wood) eliminates administrative burdens associated with complying with California’s electronic prescribing mandate. AB 32 (Aguiar-Curry) permanently ensures parity in reimbursement for telehealth services provided through Medi-Cal managed care plans, so that this reimbursement reform lasts beyond the public health emergency. Finally, SB 1419 (Becker) helps physicians comply with the new federal information blocking rule and protects patients’ sensitive medical information.

REPRODUCTIVE RIGHTS

In June, the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health caused shockwaves on a national scale, as access to reproductive health care services was stripped away from millions of Americans overnight.

CMA and other organizations had begun planning for this reality in late 2021 by forming the Future of Abortion Council to develop legislative and budget proposals to ensure that access to abortion care would not be denied in California once the court overturned Roe v. Wade. This year, 15 reproductive health care bills were signed into law by Governor Newsom, including bills meant to strengthen protections for physicians and other health care providers from civil or criminal actions that could arise in other states if providers treat patients from outside California. Additionally, $200 million was included in the 2022–23 state budget to expand access to reproductive health care, including abortion.

ADMINISTRATIVE BURDENS

CMA sponsored SB 250 (Pan) to reduce administrative burdens from health plans’ prior authorization requirements and ensure that patients get the care they need, when they need it. This bill was strongly opposed by the health plans and although it passed the Senate, it fell short in the Assembly Appropriations Committee.

SCOPE OF PRACTICE

Another big fight this year was CMA’s work with the California Academy of Eye Physicians and Surgeons to oppose AB 2236 (Low), which would have allowed optometrists to perform certain surgical procedures without the same training as ophthalmologists. This bill was hard-fought in the legislature and was the last bill to pass the Assembly before midnight on the final night of the legislation session, when it eventually received the 41st vote it needed for passage. Even though this bill narrowly made it out of the legislature, Governor Newsom heard from hundreds of physicians and vetoed it to protect patients, issuing a strong statement about the inadequacy of its training requirements.

LOOKING BACK AT A BUSY SESSION

By the time the Governor’s bill final signing period for the 2021–22 legislative session ended, Governor Newsom had signed 997 bills into law and vetoed 169 bills.

The California Medical Association (CMA), working to empower physicians to lead and transform the health care system, recently welcomed Stuart Thompson, J.D., as its new Senior Vice President. In that role, he will lead the association’s government relations and political operations efforts.

“Stuart’s impressive record of success inside the halls of government and across California’s political landscape will be a great asset as we navigate rapid changes in our health care delivery system and look for opportunities to improve the health of all Californians by helping people get timely, high-quality care,” said CMA CEO Dustin Corcoran. “We have a big year ahead of us and Stuart’s deep understanding of health care policy, and the legislative and regulatory agencies in California, will position CMA as an even greater force in the health care advocacy space.”

Thompson has over 15 years of legislative, government and legal experience in California, most recently serving as the Chief Deputy Legislative Secretary in Governor Gavin Newsom’s administration. Having already served as Associate Director of Government Relations at CMA for five years prior to joining the Newsom administration, Thompson’s wealth of experience advocating on behalf of physicians and the patients they serve makes him uniquely suited for the role.

For more details on the major bills that CMA was involved with in 2022, visit cmadocs.org/legwrap2022 Subscribe to CMA’s free biweekly Newswire and stay informed on CMA’s legislative efforts and other issues critical to the practice of medicine at cmadocs.org/ subscribe.

“This is a pivotal time for health care in our state and I am thrilled to join CMA’s lobbying team to advance meaningful, measurable improvements in California’s health care delivery system,” said Thompson. “By bridging the gap between policymakers and medical professionals, we can achieve a health care system that delivers for all Californians.”

THE CANARY IN THE COAL MINE

Scott Tcheng, MD

The emergency department (ED) has been called many things by many people: “The front door to the hospital.” “Society’s safety net.” “The canary in the coal mine.” We are, in fact, all these things, but the troubling part of the last metaphor is the unspoken implication. Historically, canaries were carried deep into coal mines where their small size and high metabolism made them especially susceptible to carbon monoxide and other toxic gases, providing the miners an early warning and hopefully enough time to escape. In other words, the canary is meant to be sacrificed, and its loss is considered acceptable as part of the cost of doing business.

“Word cloud” from physician survey question re "What are the potential contributors to patient violence?"

friends or family. However, almost 30% of assaults resulted in no response by the hospital or hospital security, and in only 2% of cases were charges pressed by hospital security. Several respondents indicated that they were encouraged NOT to press charges out of fear that it would reflect negatively on the hospital.

The last several years of the COVID-19 pandemic have accelerated growing burnout among healthcare workers, including emergency physicians (EPs), who ranked highest in burnout on a recent Medscape survey. As more attention is paid to wellness and burnout, we are finding that a substantial proportion of nurses and physicians are considering leaving the professions entirely, which will only worsen existing staffing shortages and create a positive feedback loop of resignations. The roots of burnout in healthcare run deep, with violence and workplace safety being just one of them. To be sure, they are not the top driver of burnout in medicine, but they are a symptom of a larger disease and still warrant attention.

Recent high-profile incidents involving hospital shootings continue to make the news, but there are data going back decades indicating that a large majority of nurses feel unsafe in their workplaces due to workplace violence. Moreover, despite California passing a law requiring hospital safety standards after a nurse was attacked and killed, a 2020 survey showed that in the three years since going into effect, California healthcare facilities reported nearly 23,000 assaults, while 77% of hospitals made no safety improvements following an assault.

A more recent survey in August of this year by the American College of Emergency Physicians (ACEP) revealed that nearly nine out of ten EPs agree that violence in the ED has increased in the last five years, and almost eight out of ten have either witnessed an assault or been assaulted themselves. Similar percentages feel that this has negatively affected patient care (89%), increased wait times (85%) and adversely affected physician and staff productivity (87%). Most assaults were by patients or by patients’

So how did we get here, to a point where the system prioritizes protecting the abusers over the abused? There is a term known as the “normalization of deviance.” It has been used when examining the root causes of large-scale disasters, such as the ill-fated Challenger space shuttle launch and Chernobyl power plant meltdown, as well as to the healthcare system. It holds that people within an organization become so accustomed to a deviance from standard or proper behavior that they no longer consider it abnormal.

We would never (or at least should never) tolerate daily verbal and physical attacks in any other workplace, and yet they have come to be viewed as “just part of the job” for us. I would argue that the simmering possibility that a patient might erupt and lash out has been normalized in healthcare, to our detriment. Chronic exposure to such toxic behavior has a pernicious effect on the healthcare workforce through a gnawing, indolent decay in morale, and it is time for change.

As a first step forward in ensuring the safety of our healthcare workforce, I would propose several ideas:

(1): Establish and enforce a definitive code of conduct for hospital patients with zero tolerance for abusive or assaultive behavior. Voluntary violations of this code of conduct, that is, not as the result of mental illness or medical delirium, should have tangible consequences. Mass General Brigham, which includes two of the most prestigious teaching hospitals in the country, recently implemented such a system, and “violations of this Code may lead to patients being asked to make other plans for their care and future non-emergency care at Mass General Brigham may require review.”

(2): Establish legal protections for healthcare workers, akin to those afforded to crew members on airplanes. The FAA has responded to an alarming rise in aggressive and violent behavior on flights by adopting a zero-tolerance policy with legal enforcement and consequences. It is a violation of federal law to interfere with, intimidate, or assault the flight crew on an airplane, and such actions are punishable through fines and jail time. They have even released public service announcements with the tagline “You Don’t Want Your Pilot Distracted: Unruly Behavior Doesn’t Fly.” I would argue that an unruly patient can be just as distracting to the smooth functioning of a hospital as an unruly passenger is to a flight.

Healthcare adopted measures like safety checklists from the airline industry, and we would benefit from adopting this as well. The bipartisan “Safety from Violence for Healthcare Employees (SAVE) Act” has been proposed, and it has the backing of the American Hospital Association and ACEP. A separate bill, the “Workplace Violence Prevention for Health Care and Social Service Workers Act,” has been passed in the House but is still awaiting passage in the Senate.

(3): Commit to adequate staffing and security. A large driver of patient anger and frustration can be boiled down to long wait times and ED boarding. The pandemic has exacerbated ED boarding times and left without being seen (LWBS) rates, bringing EDs across the country to their breaking points.

These have been historically viewed as problems of ED “flow,” rather than larger hospital or systems-level dysfunction, but the entire pipeline, from patient arrival to hospital discharge, needs to be re-examined, including the effect of “lean” nurse and ancillary support staffing.

It is also not enough just to have a security presence in hospitals; security staff need to be trained and empowered to respond to incidents in an effective manner, whether that be through verbal de-escalation, or physical intervention if that fails. Often, they are not allowed to physically touch patients, even ones who have become dangerously violent and disruptive. Such policies signal to the rest of the staff that their lives are not worth protecting and are acceptable collateral damage.

In the end, platitudes about practicing mindfulness and using meditation apps are insulting at best, and ineffectual at worst, gaslighting us into believing that the problem is just a matter of being more resilient, and not that the current system has grown increasingly untenable. After we all spent the greater part of a decade (or more) in training to get where we are today, our fortitude should not, and cannot, be questioned. We all strapped in and helped pull society back from the brink of the worst pandemic in a century. We will continue to do so, with the love and empathy that we have always strived to show. All we ask is that that same care and compassion be extended back to us. Otherwise, there might come a day when we look up and realize there are no more canaries left.

Scott Tcheng, MD is an emergency physician at multiple San Francisco hospitals and co-chair of the San Francisco Emergency Physicians Association. The views expressed here are his own.

ON THE FRONT LINES: AN INFORMAL SURVEY

Scott Campbell, MD

How do emergency physicians and other frontline clinicians feel about their work these days? The leaders of the San Francisco Emergency Physicians Association (SFEPA), a 30+-year old group dedicated to improving emergency medical services, conducted a quick online survey of members and others, eliciting about 90 responses, 80% of them emergency physicians. This nonscientific survey was intended to get a glimpse of impressions and opinions of those working in various emergency settings, and some select results follow. –Editors

Mental health—no surprise was big here as were wait times, nursing staffing and legal repercussions.

It was surprising how high the estimates were for "What percent of docs do you think are leaving medicine?" (majority thought 35 to 45%!)

"What are the potential contributors to patient violence?"

Solutions: The top thing respondents wanted was less annoying tasks, particularly administrative:

How satisfied are you with your career in medicine? (by specialty and sex). It’s concerning regarding female vs male and career satisfaction disparities, especially in emergency medicine.

A National Hospital Based Physician Burnout Survey

San Francisco Emergency Physicians Association

Hello and thanks for responding last month.

We sent the survey to approximately 500 physicians and got about 100 responses. (Primarily EM physicians). It’s not incredibly scientific of course but does offer some insight; happy to answer any burning questions.

Thanks, again Scott

Scott J. Campbell MD, MPH

San Francisco Emergency Physicians Association Scampbell@zhourmed.com

Media are (likely) significantly underestimating the % of physicians looking to leave medicine (“20%”). Unfortunately, looks to be closer to 35 to 40%

Top 5 reasons physicians would leave?

1. Support for less annoying, non-clinical tasks

2. Less admin burden

3. Safer working environment

4. Higher compensation

5. More time off

On a scale of 1-5, how safe from violence at work do you feel? (never =1 to always 5) (by specialty and sex). Women in emergency medicine do not feel at all safe at work vs men.

ON THE FRONT LINES: AN INFORMAL SURVEY

continued from page 15

What are the top 5 drivers of possible increased patient violence in the hospital?

1. Decrease mental health service availability combined with increased mental, behavioral, and substance abuse issues in patients

2. Lack of legal repercussions when HCW assaulted

3. Patient frustration with wait times

4. Inadequate nurse and other staff levels

5. Lack of ownership by hospital leadership of truly owning HCW safety

What things interest you outside of your current clinical medicine? Lots of interest in more teaching, lecturing (50%); International health; Lifestyle medicine; Volunteerism, and medical device

How long do you plan to practice medicine? (by sex and specialty). Many EM physicians want out now or in the next five years, particularly women.

Finally, what concerns you most about the current state of hospital-based medicine?

Scott Campbell MD, is a retired San Francisco emergency physician and former president of the San Francisco Emergency Physicians Association.

UNEDITED ANSWERS TO OPEN

MIC PRIOR QUESTION:

• Poor access to outpatient clinics and mental health has caused explosion of patients coming to ED, as well as increased annoyance and frustration by patients and staff, and resulting decrease quality interactions, decreased quality of care, decreased empathy, increased burnout. Boarders (including pts waiting for psych, SNF placements, memory care etc) has led to overflow and hallway medicine (which is also linked to worse outcomes, worse satisfaction, inhumane care, staff moral injury).

• Decreasing compensation while hospital administrator comp skyrockets.

• Boarders, boarders, boarders! This leads to obstipation and downstream queues. Also poor outpatient access, leading to more nonemergent visits.

• Like a primary care axis, emergency departments not used for actual emergency medicine, homeless/social issues, difficult that everything gets dumped on the ED in the end, limited flexibility for office/outpatient specialties, 40-hour workweek expectation for full-time at KP.

• Everyone else quitting and those of us left having to work more.

• I worry that emergency medicine takes on too much work that others fail to do.

• Inability to say 'no' in the ER.

• The corporatization of medical care, VC backed medical groups.

• It is run by folks with MBA, who have never practiced clinically. There is no parallel in any other professional. Academic hospitals are in double jeopardy, as physicians have to deal with hospital and university administrators, each vying to be more incompetent, obnoxious and destructive.

• Lack of capacity throughout our system (from unsafe conditions in the ED waiting room, to no capacity in MRI, inpatient and outpatient settings at our center).

• I said most of it above. But staffing is a huge problem. It feels like nurses are leaving in droves. From the outpatient side (I do outpt pulmonary too) there needs to be more time with patients in the outpatient world (especially for primary care- if they can do a better job with their patients less will end up in the hospital!)

• The health care, mental health care, substance abuse care, homeless resource and elder care systems are completely broken and the Emergency Dept has become the "catch-all" for all. Our hallways are full of homeless people that want a place to sleep, elderly people that are not sick but can't care for themselves.

• Because of EMTALA, a physician is required to see everyone that shows up at an Emergency Department.

• Cms metrics that don't meaningfully affect patient outcome but affect physician practice by means of reimbursement/penalty and hospital accreditation.

• General population lacks respect for healthcare workers. Patients are sources of financial gain. Healthcare is a business. The business is to make money. People, in general, are not very bright. Average intelligence and below average frequent the ED. Intelligent patients want to tell you how to practice. So many efforts are being made to control physician practice. Contract management companies are largely about billing for services rendered.

• Our patient population is getting less healthy which means they use the system more. There's not enough access to primary care appointments which leads to more people coming to the ER instead, this causes long ER wait times. The majority of the hospitals in the bay area are overcrowded and at capacity so it makes it difficult and frustrating to get specialist care for the patients that really need it and you can't transfer patients so they just sit in the ER and don't get care. The state of mental health care is sad and frustrating and feels like a revolving door for most of our chronically mentally ill.

• Uncompensated work (overtime after shifts, patient calls/emails, charting, lectures).

• The emergency department is already the safety net for the entire system and we are cracking under the weight of the pressure. What happens if this breaks too? Already patients aren’t getting the follow up and care they need, so they came back more sick and require even more recourses.

• Ever increasing reliance on emergency departments to solve all the ever increasing failures in public health, primary care, and social issues. No recognition or support from hospital leaders when hospital is full yet ED must keep its doors open. Experienced nurses and doctors leaving practice. Nurses with minimal bedside experience.

• Not centralized. Small ICUs and moderatesizedhospitalsaretoomanyinJapan.

• Staff ratios are already pushing remaining staff to overwork, and will only worsen as more leave the field / new hires come into a worsening field. There needs to be a significant increase in ED staffing and compensation before the whole system collapses. Or at the very least, there needs to be a push for some of the “overcrowding” to be shared with inpatient units, as the number of boarders becomes increasingly unsafe.

• Lack of nurse staffing, and inadequate FTE when "fully staffed", lack of urgency by hospital systems about critical overcapacity issues/boarding, behavioral health delays and capacity issues ,terrible transport delays, constant executive leadership turnover, lack of vision in leadership, not listening to front line clinicians but highly compensated consultants instead.

• Every shift is miserable and I have to code patients in triage because the ED runs at 50% capacity because there are no nurses to staff beds.

• Increasing patient visits, boarders, violence and acuity. Increasing tribalism and physicians taking their stress out on each other (usually the ED). No more compensation nor adjustments in work environment or hospital throughput.

• Lack of outpatient resources and the resulting need for the ED to be the safety net for all services. Lack of understanding that nursing needs/deserves better compensation. Too much admin. We don’t need MDs not seeing patients Too much influence of insurance and for profit groups on billing and how it negatively effects care.

• Way too much money given to admin and health insurers, not enough basic care provided to patients who need it.

• US medicine is all about money. Every issue. I practiced half my career overseas and half here. If you leave the system and see how it is elsewhere, the quest for the almighty dollar in everything we do here becomes even more obvious.

UNEDITED ANSWERS TO OPEN MIC PRIOR QUESTION:

continued from page 17

• Emergency medicine is no more emergency medicine or may be never been emergency medicine in the UK. We call extended triage as emergency medicine. In majority of NHS hospitals EM physicians don't or unable to do any Airway procedures or look after critically unwell patients independently and rely completely on Anesthesia and critical care colleagues. Arrive and call anesthetist - BreatheCall Critical care - Drama - Exist (Unfortunately this has become the ABCDE of EM in many places).

• Powerlessness.

• The overwhelming environment of profit over patients… THIS is the source of today’s moral injury.

• Non-profits hoarding cash for endless turbulent times and not investing direct care.

• The nurses, who have a different agenda, run the emergency department. The administration continues to have a market driven philosophy vs patient care oriented. Not having enough input into my work environment- I never thought I would be told what to do and how to practice medicine.

• Patient entitlement, lack of continuity of providers.

• Crowding and lack of staff. There is nowhere to put patients and not enough people to take care of them. The powers that be want to cut corners and make us do more with less, while they earn their millions and cut our salaries.

• We feel comfortable pitting ourselves against each other and other medical specialties/professions and are hesitant to address the bigger, truer drivers and profiteers of strained medicine such as pharmacy, insurance, and administration. I believe that fighting for limited resources (such as time, funding) could be improved by dealing with the factors that create the limits in the first place. It also doesn't help that many in our profession feel more comfortable ignoring these issues and that many outside of our profession are not willing to believe a privileged group like ours can suffer. We need a megaphone for these issues, and these problems have to be on the lips of all doctors in hospital medicine, and these issues have to be brought up to lawmakers.

• All about patient volume and not quality. Patients have innumerable medical and social needs. They can’t get into see other physicians due to insurance or transport constraints or there just not being any available. They are kicking people out of the inpatient side as fast as they can but inpatient is now the ONLY place where actual tests and care and consultation can be done. You are forced to play chicken with other specialists and providers: everyone says this isn’t their problem to help the patient with and pass the buck and the patient gets left stuck unless someone blinks and goes out of their way to help. And that group is the first to burn out. Also I am ID. And while a lot of lip service is given to the value and knowledge of ID docs, when we are actually called to consult people seem to believe they are calling us to do something beneath them or act like ‘what should I use to treat this and how long’ is an easy curbside question and not literally our whole job and what we trained an extra 2 years to answer. Finally, ID docs make less than even PCPs and actually act as many patients PCPs but they are overlooked in all the talks about resources and the like.

• More experienced physicians driven out by overwhelming practice burdens, leaving younger physicians to miss out on benefits of learning from them.

• Unhealthy skepticism, anti-vax movement, EMRs, bloated hospital admin, constant fear of litigation, regulatory agencies, stagnant wages in the setting of inflation and overhead costs, sunk cost fallacy, inertia, professional handcuffs, community obligation without a route to escape, etc.

• Massive increases in volume, with unrealistic turnaround time expectations. Hopefully not leading to increasing errors.

• Shit rolls downhill. Every case that a specialty doesn't think is a quick fix goes to the hospitalist service. These patients have nowhere to go. Nurses have caps but physicians don't so we just have to suck it up. We haven't gotten a raise, cost-of-living or otherwise for 5 years despite handling the pandemic while the administrators got 7 figure bonuses. We're told there's not room in the budget for us to get a raise, so we can’t recruit, so we have less doctors to handle more patients, so patients get less time/care, so they stay longer in the hospital, rinse and repeat.

• Too much admin. Too much "productivity" emphasis.

• See above re: lack of patient responsibility for their behavior; lack of collegiality in many interactions with consultants/other services; the external threats to our medical system by new fangled techbased systems such as Amazon, etc, that may provide an excuse for our leadership to try to squeeze yet more out of us for less, under the pretense of saving the organization. Outpatient providers are leaving, and this places additional stress on clinics, with the overflow of patients invariably ending up in ED. Outpatient providers favoring telehealth for all encounters, where patients prefer to be seen in person and again, end up in ED. Lack of forethought and meaningful planning from leadership to appropriately staff the department, in the face of ever-increasing patient volumes. Lack of real and meaningful acknowledgment of the fact that our schedules, and the lack of any circadian planning, is crippling our health (particularly an issue in ED environment where there’s no pattern or rhyme to our schedules whatsoever).

• ER can’t go on zoom, we need buildings space supplies and staff and even though we support the whole medical center they abuse us, steal our nurses and send us patients while they zoom as if we had infinite places to put them. We don’t, they are in our waiting rooms bathroom hallway parking lot and they are angry and uncomfortable and they leave and or bad things happen, people fall, bleed, vomit, the other end, sugar crashes, Blood pressure soars, fib races, Covid spreads etc..: we aren’t urgent care infusion center transfusion center pre op pre admit your extra procedure lab a psych ward or a nursing home except we are right now and we can’t even practice our specialty any more, we have something called a front system I call a system failure, corporate people are making decisions clinicians should, priorities are all wrong, our boss is quitting, our nurses striking, my colleagues futility pinging away our labor dreams on social media when they should actually be marching loudly in the streets and I’ll probably get dinged for not attending enough required wellness because I’ve been too busy with required performance improvement as if admin actually had any commitment to real collaboration and changing anything when the docs are apparently all requesting modules on saving time and dealing with patient complaints – sigh—can’t make this up.

• The fact that everything falls back to the physician when we truly have very little say or power over anything.

• So many issues. Low pay, poorly staffed, increasing responsibilities of the ED physician where not enough PCP availability drives patients to ED, expected working hours greater than national ED average. Poor patient care because wait times are so long. Few resources. High burnout. Poor recognition of how hard the ED has worked during the pandemic, where we got pulled into doing ICU, IR, hospitalist work.

• Increasing amount of work for inflation depreciated pay, worsening staff safety, lack of recognition and support by other physicians / hospital admin / patients for EM being truly frontline in an increasingly difficult practice environment, a system that is causing worsening patient care.

• Decreased availability to primary care leads significant increases in ER visits. We are not protected with patient caps and the fact that we are carrying 15 patients at a time without a full staff or an ER big enough to attend to these patients, does not matter to the patients, the health system, etc. We are still expected to perform at the same level and deliver the same care despite this overwhelming reality. Not to mention each shift is so challenging that it is hard to recover between them. The toll on our well-bring and negative impact on our families and patients is too much to bear.

• Capitalist for profit system of US health care not conducive to federal mandate for ER to care for all comers in a decent humanitarian way. We who choose to work in ED become witness to huge amounts of real time chronic suffering (drugs, homeless, mental, uninsured) yet can’t do anything meaningful to help. And it hurts and burns us out, especially with suffering plus after covid because we are part of this broken fucked up system. And the high paid surgeons, specialists, and concierge med folks give zero shits about our 24/7 work, our burnout, our patients.

• Everyone is part-time or not interested in partnership- creates less investment in sites and EM in general. Decreasing doc compensation in the face of increasing wages to other positions- makes going to medical school seem like a bad financial decision.

• Lack of accountability of violent and aggressive behavior towards our colleagues in the local legal system.

• EM-boarding and lack of ability to receive reimbursement for quality care.

• Low pay, high volume, bad consultants.

• The ER has become the dumping ground for all patients who cannot access their physicians or even care to establish a primary care doctor, regardless of how acute their complaints are. Then, patients' expectations in promptness of care and giving out exact diagnoses are distorted to what the emergency departments was designed to do and what they can handle. We are not the urgent care, amazon.com, or McDonald’s. The push to quickly see and dispo patients when there's high volume become dangerous to patient safety and to the mental health of the staff caring for these patients.

• For-profit groups, too many residents, decreasing insurance pay -> to decrease pay.

• Lack of admin/hospital executive commitment to people/staff over profit, admin's continued effort to do more with less, and the continued talk about likely to recommend/patient satisfaction scores with no desire to spend money to improve staffing and hospital capacity to decrease wait times/improve flow at every level of care.

• Money reigns over everything. Out of touch decisionmakers.

• Contract metrics from for-profit hospital corporations and CEOs and C-suite executives with no clinical experience.

• Lack of adequate administration causing loss in nursing, staffing, loss of trust, poor financial decisions leading to inadequate patient care. Inability to transfer patients for higher level of care due to inadequate staffing nationally. Overuse of ED for nonemergent cases. Overcrowding of entire hospital systems. I fear the US healthcare system is moving towards total collapse.

• Emergency medicine had become the primary source of Healthcare for everyone. It's not intended for that and not staffed for that.

• Administrative burdens and dangerous mid levels.

• We need significant reforms. I work in EM, and we have become the dumping ground for all of medicine. Can't get that non-emergent test on a Thursday? Send them to the ER. Chronic issue that's suddenly slightly worse? Send them to the ER. Meanwhile there is increased government oversight hindering my ability to practice while increasing my liability. We have been asked to do more with less for many years, and it's getting worse. It is driving people out of medicine.

• Corporate business and insurance business taking over medical practice at all levels.

• EM is the safety net of health care and it is breaking. Our system is so dysfunctional and it all rolls down to us. We're expected to do more and more with less and less (staff, rooms, time, etc.) and when the physicians quit in frustration we'll be replaced by PAs and NPs.

• ED staffing is terrible, private equity in EM.

• CMGs reducing staffing levels for both doctors and nurses to bare minimums, but then increasingly higher rates of malpractice suits, often for system problems out of your control. Being responsible for midlevel mistakes when you don’t even see the patient. system where you’re presumed guilty of malpractice until you prove your innocence.

• The for profit system of medicine has failed. The only people who benefit are top hospital admins, insurance companies and pharma. The profit is at the expense of patient care. The inequities are increasing. What used to be possible in the outpatient follow up world no longer is, while what used to be an “acceptable” admission no longer is either. It is now also effecting those with private insurance. Working with inadequate resources puts us in a position where we are part of providing inadequate care and a terrible patient experience. We are bogged down with meaningless clicks in the name of increasing revenue and pressured to take it upon ourselves to correct the metric of the month or improve the patient experience without being given any means to do so. It is demoralizing to be practicing medicine in the current healthcare system yet the needs of the people are many and increasing.

• Hospital leadership completely sold out to price centric medicine but call it value driven patient centric.

A recent survey found that 80% of physicians feel there is stigma around doctors seeking mental health care.

Advocating for health care workers has become an essential part of our day-to-day. In March, we were proud to see the Dr. Lorna Breen Health Care Provider Protection Act enacted to provide $135 million for programs aimed at supporting the mental health and well-being of health workers. However, while this was a welcome first step, it’s only the beginning of the work needed to protect our clinicians.

The next crucial step falls to the states: They must remove language in their licensing and credentialing processes that stigmatizes health care professionals who have sought treatment for mental health concerns.

Our research has identified 31 states, plus the District of Columbia, that may still use invasive or stigmatizing language requiring applicants to disclose any history of mental health concerns or to explain why they have taken breaks from work. Some require applicants to disclose any past psychiatric impairment, potentially going back decades, even to adolescence. These questions might violate the Americans with Disabilities Act. They certainly violate applicants’ privacy. And there is significant evidence that they deter clinicians from seeking the care they need – at tremendous risk to their well-being and their lives.

Indeed, a survey of more than 1,500 physicians conducted this year found that 80% agree there is stigma around doctors seeking mental health care. Nearly 40% reported that either they personally or a colleague they know has been scared to seek mental health care because that treatment would need to be disclosed on their licensure, credentialing or insurance applications.

This is unacceptable.

Like everybody, health workers deserve the right to pursue the care they need whenever they need it, without fear of losing their license or job. This is especially important now, as health

WORKERS

care workers have reported sharp increases in emotional exhaustion due in large part to the extraordinary strain of caring for patients, while also enduring a surge of intimidation, threats and physical violence during the COVID-19 pandemic.

On the contrary, the public interest is harmed by these questions, since we know that when doctors, nurses and other clinicians are afraid to seek the care they need, they may find themselves unable to work due to depression or burnout. Some may turn to drugs or alcohol. And tragically, some will turn to suicide. In fact, stigma associated with seeking – or even discussing – behavioral health care is a primary driver of suicide among the health care workforce.

The Dr. Lorna Breen Act is named after the sister-in-law of Corey Feist, a co-author of this piece. An emergency room physician, Lorna died by suicide in April 2020, after weeks of incredibly intense work caring for patients in the first wave of COVID-19. At one point during that surge, Lorna called her sister to confide that she was overwhelmed with exhaustion and grief – but she was fearful that she would lose her medical license or be ostracized at work if she acknowledged that she needed help.

In the years since Lorna’s death, we have heard from many families who have lost physician loved ones to suicide. We recently connected with an emergency medicine doctor in Florida who reported that four of her physician colleagues died by suicide this summer. In too many of these cases, the clinicians have acknowledged to friends or family that they are reluctant to get treatment because of the stigma around mental health issues.

One such tragedy involves Dr. Matthew Gall, a devoted oncologist who practiced medicine for 16 years in Minnesota, one of the states that until recently used invasive questions on licensing applications. In 2019, Matthew moved to North Carolina with

GIVE HEALTH CARE

THE MENTAL HEALTH SUPPORT THEY DESERVE

Corey Feist, Arianna Huffington, Deborah Marcus, and Michelle A. Williams

States must do more to help clinicians access mental health care. Their lives depend on it.

his wife and their three children. The move to a new practice was difficult, and Matthew struggled with depression, yet he declined to seek help. His wife, Betsy, told an interviewer that her husband felt “ashamed and embarrassed” about his depression, and feared he would lose his medical license and his livelihood if he sought treatment. “He honestly thought that he’d no longer be able to be a practicing oncologist,” Betsy said. “The fear was real, and being a doctor meant everything to him.” Matthew died by suicide on Thanksgiving Day 2019.

A terrible irony in this tragedy is the fact that North Carolina does not actually ask intrusive questions about mental health treatments in its licensure process. But having just moved to the state, Matthew was not aware of that fact. Lorna, too, was unaware that New York does not use invasive questions.

These stories are painful. They are powerful reminders that we must work toward universal reform of licensure applications, as our team did in Minnesota, which updated its questions to be less stigmatizing after testimony from Lorna’s sister and brother-in-law. It’s also clear that simply changing the language on applications is not enough. We must also get the word out widely, so no clinicians ever fear they will lose their job if they seek the help they need. In addition, we must continue to change the culture inside health care systems so that physicians, nurses, pharmacists and other health care workers feel comfortable being open about their mental health concerns and their need for support.

We are fighting for those reforms through our campaign ALL IN: WellBeing First for Healthcare, which brings together more than a dozen organizations including the American Medical Association, the American Hospital Association, the American Nurses Foundation and the Physicians Foundation. Thousands of individuals have joined us in contacting state medical boards to demand change.

We are also working to address clinician burnout through common-sense reforms that we expect will eliminate some of the bureaucracy that can consume so much of a clinician’s time and remove the joy from patient care.

Ensuring that health care workers can access necessary mental health care is critical for their well-being and for the health of our entire country. Let’s do our part to support them. Together, we can show our vital health care workforce that they aren’t alone in this fight for their lives.

Corey Feist is co-founder of the Dr. Lorna Breen Heroes’ Foundation, which seeks to reduce burnout of health care professionals and safeguard their well-being and job satisfaction, including through the ALL IN: WellBeing First for Healthcare campaign with #FirstRespondersFirst. Michelle A. Williams is the dean of faculty at the Harvard T.H. Chan School of Public Health and a co-founder of #FirstRepondersFirst. Arianna Huffington is the founder and CEO of Thrive Global, the founder of The Huffington Post and the author of 15 books. Deborah Marcus is an executive in the CAA Foundation, the philanthropic arm of leading entertainment and sports agency Creative Artists Agency. A previous version of this piece appeared in US News and World Report.

AS AN ER DOCTOR, COVID TAUGHT ME I DON’T MATTER.

SO I QUIT.

After nearly 20 years as an ER doctor, I walked away from the profession I once loved and I’m not alone.

According to a new report, 117,000 physicians left medicine in 2021. Each departure cost the healthcare system an estimated half million dollars— $58 billion last year alone—and the ripple effect has already led to worse medical care for all of us.

This mass exodus of dedicated professionals is the canary in the coal mine for a growing healthcare crisis and the solution is not more resiliency training for the remaining canaries.

It’s time to fix the mine.

As physicians, our indoctrination begins in medical school with an unspoken rule: the only way to be a truly good doctor is to put our patients’ needs above our own at any cost. For example, early in my career when I was eight months pregnant, I contracted H1N1 at the hospital where I was working and despite a 102F fever, never called in sick. Years later, when my mammogram looked suspicious for breast cancer, I created a schedule allowing me to work shifts in the ER after every radiation treatment. Luckily, the biopsy was benign.

Every physician has similar stories — from pushing their IV pole into patient rooms while fighting a gastrointestinal bug to admitting oneself to the hospital at the end of a shift after working with appendicitis. We keep going because what we do matters.

But increasingly, many of us are asking, do we matter? The pandemic and its ongoing aftermath have hastened a growing sense of disillusionment that the answer is actually no— at least not to our healthcare leadership.

There is little doubt that our medical system’s unwavering focus on profitability puts reimbursement and patient throughput above the well-being of its workforce. Before Covid, there was a delicate detente as doctors are notoriously bad at asking for help anyway. But now, as we frantically wave our white flags, we are summarily dismissed.

In the early days of the pandemic, administrators minimized our physical safety. As medical workers succumbed to the virus in both China and Italy, I was admonished for wearing an N95 mask and was told, “you’re going to scare the patients and the nurses will want to wear them, too.” Others received similar

Molly Phelps, MD

messaging and several professional societies were compelled to release statements in support of adequate PPE.

As the pandemic continued, our emotional health was disregarded. A recent study found that nearly 70% of physicians report symptoms of depression and one in eight acknowledge suicidal thoughts. I lost all interest in food and eventually dropped to my junior high weight. Of course I went into therapy and got help for my symptoms, but the work—and the dismissiveness—kept coming. The antidote that we needed had to come from our healthcare leaders.

It never did. In fact, it got worse.

There was never any meaningful recognition of the relentless trauma we’d endured, and the disconnect between the support we needed and our leadership’s efforts to help us was striking. Hospital administrators ordered pizzas, encouraged yoga, and told us to keep gratitude journals on our bedside tables. While well-intended, these efforts felt tone-deaf in the aftermath of surge after surge of a deadly pandemic.

Doctors shouldn’t be told how to be well by a committee of managers far removed from patient care. Instead, we should be asked — asked what support we need to stay healthy and what can be changed to help us to do our best possible work.

What would our healthcare system need to do to get us to stay? Probably less than you might think. We need to be seen and trusted.

See that we put our lives on the line and risked the health of our families every single workday before vaccines became widely available. See the moral injury we absorb shift after shift when, despite doing the very best we can, perpetual short-staffing and overcrowding keep us from giving the quality of care we’d want for our loved ones. See that if we’re asking for help, we have tried absolutely everything in our power to fix the situation ourselves and our goal is to do right by our patients.

In July of 2021 after nearly 18 months on the front line, I asked my hospital leaders for an unpaid leave of absence to regain my humanity and was told, “then everyone else would want one too,” as my request was flatly denied.

At that moment, I knew I was done.

I’d always planned to remain in the ER for the next 13 years until I retired and instead, I submitted my resignation. For decades, medicine had been my everything and I finally understood that it never loved me back.

There are over 100,000 doctors like me and many of us would have stayed — even under our currently abysmal working conditions — if only we’d been treated as respected partners instead of a depersonalized commodity.

There is clearly no easy fix, but we can start improving the well-being of our battered workforce by taking small, attainable steps like encouraging respite and making the effort to show up.

First, establish a sabbatical program immediately. Plugand-play models already exist, so there is no need to reinvent the proverbial wheel. Pilots have mandatory rest periods and soldiers come home between tours of duty, yet we somehow expect our doctors to keep giving their very best care after three brutal years on the frontline. Pragmatically, it’s far less expensive to support short breaks to recharge than it is to train our replacements.

Also, don’t underestimate the power of showing up. In the pandemic’s first year, I saw the head of our hospital in the ER

exactly one time for less than five minutes. Physicians would feel far more seen and supported if our leaders made a point to walk in our Danskos, regularly joining us in the trenches to bear witness to our reality and share in our burden.

Keeping our best physicians in the game is clearly in everyone’s best interest. The tipping point is here and we must immediately and radically alter our hospital culture before all of the canaries fly away.

Dr. Molly Phelps is a board-certified emergency physician who is completing a memoir about her time on the pandemic’s front line.

An earlier version of this piece appeared in the San Francisco Chronicle on November 19, 2022.

HOW TO CURE THE PUBLIC HEALTH CRISIS OF BURNOUT, AN OCCUPATIONAL DISEASE

Mihal Emberton, MD, MPH, MS

Background

To prevent the unhealthy and often toxic workplace conditions that lead to demoralization and burnout, organizations must recognize and remove unconscious bias from their leaders, their policies, and their processes. By operationalizing the autocratic-democratic belief-behavior systems© framework, leaders can now understand where unconscious bias occurs in our thinking, why it is so difficult for us to recognize, and how we can learn to overcome it. Additionally, this framework describes the science of social justice and democracy, why humanity often struggles to achieve social justice and democracy, and how we can create true democracy and social justice within our social systems. And finally, this framework describes the human thinking and human behaviors that result in diversity, equity, and inclusion, social values being sought in nearly all sectors of society. This organizational investment in democratizing our leaders, policies, and processes is essential to create engaging, protect and serve cultures that not only prevent burnout but that also exceptionalize the health and wellbeing of frontline workers which subsequently drives organizational success and sustainability.

Defining Burnout

Nearly one third of US adults suffer from symptoms of depression (National Institute of Mental Health, 2020) or anxiety (National Institute of Mental Health, 2007) each year. This widespread mental and public health crisis commonly recognized as “burnout” (World Health Organization, 2019) and “adverse childhood experiences (ACEs),” (Walsh et al, 2019) does not stem from pervasive brain dysfunction, but rather is the result of systemic organizational dysfunction.

Many businesses and organizations today share the laudable goal of creating workplace cultures where frontline workers are not only intrinsically valued, but one where frontline worker knowledge, insights, and experiences are sought out and effectively used to solve organizational problems. Unfortunately, many organizations are far from this utopia because hierarchies generally insulate rather than eradicate the unconscious biases within their policies, their processes, and their leadership. The persistence of these unconscious biases goes on to create and support cultures of coercion, suppression, and status quo, cultures of burnout. (Emberton, 2020, 2021)

The United Nations’ International Covenant on Economic, Social, and Cultural Rights emphasizes

“

The right of everyone to the enjoyment of just and favourable conditions of work, which ensure, in particular safe and healthy working conditions, [especially] the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, and the prevention, treatment, and control of occupational diseases.”

Additionally, the World Health Organization emphasizes that burnout is an occupational disease resulting from chronic workplace stress that has neither been successfully addressed nor prevented by the workplace. (World Health Organization, 2019)

To prevent the unhealthy and often toxic workplace conditions that lead to demoralization and burnout, organizations must recognize and remove unconscious bias from their leaders, their policies, and their processes.

Leaders’ Unconscious Beliefs define Workplace Culture

In order to address the unconscious bias of leaders, organizations must train each leader to recognize when they have unconsciously toggled into their autocratic belief-behavior system ©. Because there is a pattern to human behavior, human behavior is not only fascinatingly predictable, but it is thankfully changeable. Once a leader recognizes the signs and symptoms and patterns of their own autocratic thinking and autocratic behaviors, they can then learn to toggle into their democratic beliefbehavior system © more often, ideally always.

It is no secret to frontline workers as to which mindset their leader has toggled into because feelings and thoughts are clues and behaviors are evidence of their leader’s unconscious beliefs.

Leaders’ Behaviors sustain Workplace Culture

The mindset of the leader not only determines the workplace culture, but it also determines how that leader views and utilizes organizational resources. When leaders are in their autocratic belief-behavior system©, they stockpile the resources for learning (time and money) away from the people doing work, even though the people doing the work fund that organizational time and money. In a democratic culture, the people doing the work can and do have a fundamental role in correctly allocating organizational time and money to solve organizational problems.

Additionally, the mindset of the leader also determines whether that leader will be able to effectively solve organizational problems. When leaders are in their autocratic beliefbehavior system©, they do not recognize the knowledge, insights, and experiences of frontline workers as a resource for learning and thus they behave like judges who listen to only one side of a case before issuing a ruling, making uninformed, unjust, and generally wrong decisions. Whereas leaders in their democratic belief-behavior system © rightly use the intellectual currency of frontline workers to comprehensively understand problems and collaboratively generate solutions, producing informed, just, and generally effective organizational outcomes.

Democratic Policies help Leaders maintain Democratic Belief-Behavior Systems

Organizations often try to overcome the unconscious bias of their leaders by encouraging frontline workers to “speak up” and “share their knowledge, insights, and experiences” about how to improve the organization. When frontline workers are invited and allowed to collaborate and share their knowledge, insights, and experiences to solve organizational problems, true innovation and growth can occur, a truth also asserted by Albert Einstein in 1954:

“By academic freedom I understand the right to search for truth and to publish and teach what one holds to be true. This right also implies a duty: one must not conceal any part of what one has recognized to be true. It is evident that any restriction of academic freedom acts in such a way as to hamper the dissemination of knowledge among the people and thereby impedes rational judgment and action.”

This strategy appears to be a reasonable one on the surface because the frontline workers do own the intellectual currency that is necessary for solving organizational problems justly and effectively. However, the fundamental flaw with this strategy is that when leaders are in their autocratic belief-behavior system©, the knowledge, insights, and experience of frontline workers creates discomfort in the autocratic leader, who subsequently punishes and/or censors frontline workers to prevent further discomfort. Einstein described this dysfunctional pattern of autocracy poignantly when he wrote, “A dictatorship means muzzles all round, and consequently stultification. Science can flourish only in an atmosphere of free speech.”

Recognizing the unfortunate truth that leaders often continue to unconsciously toggle into autocracy, organizations committed to social justice, success, and sustainability will create

organizational policies to help them overcome this encumbered reality. Such an organizational policy, for example, to protect frontline workers from censorship and retaliation for their freedom of speech looks like:

“The organization agrees that academic freedom, the right and responsibility to study, investigate, present, interpret, and discuss all the relevant facts and ideas in the field of a frontline worker’s professional competence, is essential to the fulfillment of the purposes of the organization; and the organization acknowledges that fundamental need to protect frontline workers from censorship or restraint which interferes with a frontline worker’s obligation to pursue truth in the performance of their jobs within the organization.”

Additionally, organizations committed to creating and maintaining a protect and serve democratic culture, in alignment with United Nations and World Health Organization values, will develop policies, for example, that correct discrepancies between shareholder rights and employee rights: “Protecting the civil and human rights of all employees and shareholders is fundamental to the purposes of our organization; and our organization holds itself accountable and responsible to adhere to state and federal labor, civil, and human rights laws for both employees and shareholders alike.”

When organizational policies and processes are used to guide and assist leaders in maintaining a democratic mindset, rather than to regulate and oppress frontline workers, they begin to justly sustain organizational cultures of innovation and growth. Further examples of such policies are 1) those that shift the accountability of leaders from the top of the organization back down to the frontline workers via elections rather than promotions, 2) those that promote democratic use of feedback mechanisms to help leaders find and overcome their unconscious bias, and 3) those that incentivize and appropriately equip frontline workers to perform their jobs effectively and comfortably.

Democratic Belief-Behavior systems, preserved by Democratic Policy, cure Burnout

Because unconscious bias is a human condition and we can all unconsciously toggle into autocracy, organizations must not only train their leaders how to toggle into their democratic belief-behavior system©, but they must also create and maintain democratic policies and processes to continuously guide, direct, and even forbid their leaders from unconsciously toggling back into their autocratic belief-behavior system©; these are the organizational investments that are necessary for creating democratic, protect and serve cultures that not only prevent burnout but that also exceptionalize the health and wellbeing of frontline workers which subsequently drives organizational success and sustainability.

Mihal Emberton, MD, MPH, MS practices at Kaiser San Francisco and is Clerkship Site Director, UCSF Department of Family & Community Medicine and Associate Clinical Professor, UCSF Department of Family & Community Medicine.

References available on request

AS A MOM AND AN ABORTION PROVIDER, I KNEW WHAT WAS AT STAKE ON NOVEMBER 8TH

Maryl G. Sackeim, MD, MS

“Mommy, when are they cutting out your baby-grower?” my 6-year-old son asked me one morning after climbing into my bed, groggy and rubbing his eyes.

It had been exactly three months since Roe Vs. Wade was overturned and my son was referring to the hysterectomy and bilateral salpingo-oopherectomy I was planning to undergo a few months later. He was simply looking forward to Mommy being on sick leave and therefore available some days to pick him up from school.

My son knew that my “baby-grower” was something that my colleagues had cut open twice to deliver him and his little brother by c-section. And although he is too young to understand what the BRCA1 mutation is or that my having it gives me a significantly elevated lifetime risk of breast and ovarian cancers and a slightly increased risk of a rare type of uterine cancer, he also seemed to intuit that for some reason that organ could hurt me.

With his comment, I felt pride that he knew about reproductive organs, the existence of which have shaped so much of both my personal and professional identities. As both a doctor who delivers babies and a doctor who provides abortions, I have seen the uterus and ovaries create what is wanted and unwanted, what is healthy and what is sick, what may be hoped for or dreaded. As a parent who is also a patient, I have also felt the uterus and ovaries in their bipolar existence live within me.

I have already had a bilateral mastectomy to prevent breast cancer, and I am planning this next surgery in-order to pre-

vent ovarian and uterine cancers. I used in vitro fertilization technology (IVF) to genetically test the embryos that would later become my children to make sure that they would not also carry the BRCA1 mutation. These decisions have been difficult and painful, and they have been deeply personal; not all patients with this mutation would make the same choices. With my breasts, I lost the ability to ever try to breastfeed; when I lose my uterus and ovaries, I will go through menopause in my 30’s. Even though I have felt sad to give up pieces of me, I feel empowered by having the knowledge and resources to be able to make medical choices based on my own values.

When Roe vs. Wade got overturned in June, it put all reproductive decision-making on the line. In a day, patients found themselves in dire binds, sometimes pregnant but without the ability to make empowered choices. They had a baby-grower, with the potential for good and for bad, but unlike me, they didn’t get to decide what to do with it.

The threat to reproductive rights goes beyond abortion. Overturning Roe also put assisted reproductive technologies, like IVF, at risk and threatens the ability of women to use contraception to prevent pregnancy. It still seems far-fetched and frightening but the reality is clear: Individuals no longer have the constitutional right to privacy regarding reproductive autonomy; reproductive rights are dependent upon the state in which an individual lives.

On November 8th, Californians decided to enshrine our state’s existing abortion rights into the state Constitution. As an OB/GYN doctor and patient with OB/GYN needs, nothing felt more important on that ballot. I have made choices about BRCA1 and my reproductive organs for myself and my children. By voting to pass Prop 1, we have ensured that the next generation, including my children, will have the same reproductive rights as we do.

An earlier version of this essay was published in the San Francisco Chronicle on 10/27/22.

ASK YOURSELF BETTER QUESTIONS AND LESSEN BURNOUT

Jessie Mahoney, MD

The way you ask questions and the questions you ask significantly impacts whether you feel content or happy with your job, your patients, and your family life.

The questions I am referring to are not the questions you ask others–they are the questions you ask yourself.

We spend a lot of time and pay careful attention to how we ask questions of others.

We ask patients, children, partners, parents, colleagues, and bosses strategic questions.

We do not give the same attention to the quality of questions we ask ourselves. Yet they are the most important. The questions we are constantly asking ourselves in the background determine the quality of our lives.

We occasionally pause to ask ourselves big questions. We carefully consider who to marry, whether to have a child, or whether to quit a job. In fact, we often ruminate about these.

What we don’t pay attention to are the questions our brains ask in the background.

The questions that happen constantly on autopilot. These questions get us into a lot of trouble.

These question lead us to feel pessimistic, hopeless, helpless, and stuck.

They cause us anxiety, stress, frustration, resentment, and disappointment.

Why can’t I figure this out?

Why does my husband not care about me?

Am I a good mother?

Why are things so hard?

What if I make a mistake?

Why is everything on my shoulders?

Simply pausing to notice the questions we ask ourselves in the background is a magic tool to lessen stress, overwhelm and burnout. Noticing these questions can create huge shifts in our level of contentment and happiness.

What are the questions you ask yourself most often?

Are they:

What do I have to do today? Why are things so hard? Why isn’t anyone helping me? Why don’t they care? Why don’t they understand? Why do my patients/colleagues/nurses always/never do….?

Or are they:

What did I do well today? How did I make an impact? How can I make the greatest impact? How do I want to show up today? How did I learn and grow?

How can I get more help?

What would an amazing mom, doctor or spouse do?

How did I get helpful help today?

In my experience they are more likely the former. Most humans ask themselves significantly more disempowered questions than empowered ones.

Why?

In medical training, we were taught to ask other people questions. We were taught that if we asked our patients the right question, with the right energy, we would get the response we needed to solve the problem.

In medical training we were not taught to practice asking ourselves good questions.

In fact, we were taught to ask ourselves questions from scarcity, inadequacy and a fear of disappointing others.

What might I not know that could cause harm?

What might I not be considering that could go wrong?

What bad thing could happen?

What am I not prepared for?

What could I do better?

What would make the system better?

These types of questions work well in the medical setting but not in the rest of our day to day lives. These questions are not an effective strategy for finding happiness or contentment. These questions lead us to burnout and lives of unhappiness and discontent.

Because we are so well trained, we apply these same types of questions —about what’s wrong, missing, and could go wrong— to our parenting, our marriages, our travel decisions, and to our whole lives. These questions are a key contributor to chronic discontent and exhaustion.

Our education and training explain both the questions we ask and the questions we don’t ask.

We rarely ask questions that lead us to feel content, happy and proud because we are taught in higher education and professional school that focusing on what feels good and how we are doing a good job might be complacent, potentially lazy, and arrogant and lead us to “fall behind.”

If we asked what would feel good, it would be selfish. If we asked what we did well, we wouldn’t learn from what we didn’t.

If we ask what’s going well, we might miss what’s not.

The good news is that noticing our patterns and our questions is where our power lies. When we see them, we can choose to change them.

What questions do you ask routinely in your day? What energy do you ask these questions with?

Do they give you the feelings and life experience you are wishing for? Are your questions mindful, empowered, directed, strategic, intentional, or helpful? With this knowledge, you can choose to change.

You can decide to no longer ask yourself disempowering negative questions. You can decide to ask more neutral questions and you can even decide to ask empowering, hopeful, loving and strategic questions.

Asking better questions can create ease in your life. It helps you be happier, more calm, content, and even get unstuck.

What would peace do?

What would ease do?

What if it were simple?

What would your future self wish you had done?

Good questions can change the trajectory of your marriage, parenting, and career. They can change your health. They are key to finding contentment and happiness.

Questions are a way of directing your attention. Good questions are a form of GPS. Good questions help you end up where you want to be.

What makes a good question? One that helps you generate a feeling you want in your life.

Empowering questions helped me be brave enough to change my career at age 50. Loving questions helped me save my neurodiverse marriage and raise healthier, happier and more responsible young adult children. Strategic and intentional questions helped me figure out how to finally feel more content, calm, and happy with my life.

When I untrained myself from asking myself questions from a place of scarcity, imposter syndrome, fear, inadequacy, and catastrophizing, my world changed. I used to ask questions like:

Why can’t I figure it out?

Why am I not happy?

Why am I so burnt out?

Why does my life feel so hard?

Why is work so hard?

Why am I not getting the help I need?

Why am I so busy?

What if I make a mistake?

These types of questions kept me stuck, feeling discontent and fearful. I did less, risked less, hid my shine, and stayed stuck. Shame, blame, guilt and anxiety were abundantly present (as they are for most physicians I work with as a coach.)

Learning to ask mindful and intentional questions is an art and a skill. One absolutely worth learning. It’s not hard. But it takes self compassion, a commitment to kindness, mindfulness, and intention.

Good questions feel better. How am I not stuck? What went well today? How can I make today fun? What would feel good today?

Good questions lead to feelings of hope, abundance, self compassion and more fun. Good questions empower you to take action and start being in control of your life experience.

How do I want to show up?

What would courage do? What would hope do?

What would smart do? What would strategic do?

Mindful question-asking is life-changing. Intentional questions can change your self concept, lessen burnout, resentment, bitterness, victimhood, fatigue and so much more. Intentional questions can create excitement, inspiration, courage, and amazing impact.

What am I proud of? What did I do well today? What am I an expert at? What do I love?

These questions help you see possibilities and make change and big dreams possible.

What will the world miss out on if I don’t follow my dream? What if it’s possible for me too?

The more you ask better questions, the better answers you get. It creates a positive feedback loop. Powerful questions give you powerful answers. Strategic questions give you strategic answers.

Loving questions give you loving answers. This works both at home and work. It lessens burnout and allows room for living.

If you want to create a life roomy enough to live in, ask roomier questions:

What would spacious do? What would patience do?

What if it were simple?

What if I have everything I need?

How am I resourced?

What if I have what I always wanted?

These questions come from a place of abundance and acceptance. They provide relief and they lead to expansive answers.

Yoga teacher training taught me something else about asking good questions. The energy that you embody when you ask a question also adds to the value of the answer. The physiologic

state you are in when you ask a question does too. The feelings you embody when you ask yourself a question have a real effect on the answer.

Feelings and emotions impact your physiology. When you feel ashamed when asking a question—what did I do wrong? Shame, stress and cortisol rule the day. When you feel fear you tend to ask questions such as “What if something terrible happens?”

Anxiety, blame, stress and guilt are created.

Taking a moment to pause, breathe and notice your physiologic and emotional state before you ask yourself a question is key. Deep breaths, hand to heart, yoga, and nature all offer opportunities to cultivate calm, change your nervous system physiology, and optimize your question asking.

Questions asked from calm and grounded energy, yield wise, calm, centered answers. Questions asked when you feel relaxed and safe rather than overwhelmed or threatened, yield possibilities and creative solutions. Mindfulness encourages curiosity, non judgement, compassion, patience, gratitude. In addition to calm, these are worth intentionally channeling when you ask yourself a question.

Love is also.

Love is one of the most energizing, activated, hopeful, optimistic and expansive emotions.

Love is powerful when it comes to asking questions.

If you take only one thing from this article—borrow my favorite most empowered question “What would love do?”

This question is versatile and universally helpful. It helps in moments of stress and decision making of all kinds. It helps provide clarity and a path forward in marriage conflict, parenting

struggles, career transitions, and conflict with colleagues. It even helps with patients.

Love makes decisions that are good for you. Good for your patients and good for your team. Love makes decisions that are good for your children, your partners, your families, and the world. Love doesn’t feel resentful or bitter. Love takes good care of yourself and others. Love exercises and eats healthy most of the time. Love doesn’t stay in toxic relationships, departments, or jobs.

Love can even help you ask yourself better questions-loving questions.

What questions would LOVE ask from now?

Likely ones that will make you calmer, happier, and more connected with those you love.

If you want to learn more about how to ask yourself empowering helpful loving strategic and smart questions- ones that lessen burnout and help you feel more satisfied with your life, take a listen to this recorded session on the topic by visiting https://youtu.be/8Yk5OC6HT4I or scanning this QR code with your smartphone.

BEYOND THE OXYGEN MASK

I used to share the idea of putting on your own oxygen mask first as a physician wellness concept. No longer.

Oxygen masks are needed in depressurized planes in the midst of a crisis. That is not wellness. It’s crisis management. Medical culture says it's ok to care for yourself in a crisis. It's a worthwhile endeavor to keep yourself from passing out.

Putting on your oxygen mask can be a first step.

But there is much more to wellness, health, and contentment than this.

What's needed for longevity as a healer is full body, mind, and spiritual nourishment. When we are replete as physicians, parents and humans, we are able bring our best to the world and others. This shouldn't be the exception. It should be the norm.

What would it look like to take care of yourself beyond an oxygen mask? If no one were judging, and it didn't take a crisis to simply pause and breathe, what would you do to care for yourself well? What do you need to be healthy and feel alive?

What do you want for your life?

What feels good? If you are this capable when you are depleted, exhausted, burnt out, stretched, and irritable, imagine

Jessie Mahoney, MD

what might happen if you were replete? A loving nudge to let go of the oxygen mask analogy and instead commit to and invest in true wellness for yourself.

Every human deserves to be well. Even you.

Jessie Mahoney is a Pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced Pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching. She specializes in helping ease career transitions and burnout, parenting struggles, and relationship challenges. She is a leader of the Mindful Healthcare Collective and is co-host of the Mindful Healers Podcast. She teaches virtual weekly yoga to physicians and other healthcare providers and leads yoga, coaching, and wellness retreats in spectacular natural locations. You can read her blog at www.jessiemahoneymd.com. You can connect with her at jessie@jessiemahoneymd.com.

SFMMS WELLNESS EVENT HIGHLIGHTS

Wellness Retreats Continue to Make A Difference for SFMMS “Connecting with an amazing group of fellow physicians, learning skills, laughing, and restoring. Thank you for this amazing healing and restorative experience!!”

– SFMMS Member, TPMG Physician, and Retreat Attendee

Using physician wellness funding from CMA and Sutter Health, SFMMS sponsored members to attend the Honoring Diastole Wellness Retreat at Pie Ranch in September. SFMMS Wellness plans on continuing these sponsorships in 2023.

Honoring Diastole at Pie Ranch is a day-long retreat that includes yoga, meditation, reflective writing, coaching, a tour of the sustainable farm. The highlight of the day is a farm-to-table lunch prepared by the staff at Pie Ranch, and a coaching session to optimize your wellness.

Why should you attend?

“Gail and Jessie – a heartfelt thank you to you both.

I attended my 1st retreat with you at Pie Ranch on March 26.

I attended that retreat because I “won” a raffle sponsored by the SFMMS (SF Marin Medical Society). Little did I realize what I had truly won!

That retreat happened at just the right time for me. As the Buddha said, “when the student is ready, the teacher will appear”.

Thank you for being my teachers and guides on this beautiful journey of self-discovery and growth.

Going back this past Saturday was wonderful and made even more meaningful because I was able to share the experience with my friend and mentor, Laura.

You both have a gift and I am so grateful you choose to share this with people like myself.”

– SFMMS Member & TPMG Physician

Upcoming LOCAL Physician Wellness CME Retreat Opportunities: 2023 Dates

Connect in Nature Mindful Healers Retreat: July 14-16th, 2023

Honoring Diastole Retreat: February, March, September 2023

Nourish & Transform: A 4-5 night all-inclusive intimate physician wellness retreat opportunity for women physicians in Santa Margarita CA.

Find out more and sign up here: https://www.jessiemahoneymd.com/retreats.

Stay tuned for more SFMMS Membership retreat sponsorships in early 2023.

OTHER UPCOMING WELLNESS OPPORTUNITIES

Mindful Yoga for Healers

A quarterly weekend offering of free Mindful Yoga for Healers. This is specifically for SFMMS members to join their colleagues in order to heal, replenish, restore, and connect!

Sign up at https://mindfulyoga.jessiemahoneymd.com/ to be notified of class dates and times.

Stay tuned for our 2023 outdoor in-person yoga option. Date TBD.

Have you missed a recent Wellness Event?

You can learn more about upcoming wellness events or view recordings of past events on the SFMMS Wellness Page at www.sfmms.org/get-help/physician-wellness

COMMUNITY MEDICAL NEWS

Kaiser Permanente Maria Ansari, MD

Kaiser Permanente San Rafael Naveen Kumar, MD

When monkeypox (MPX) first appeared in news headlines, we did not know if the disease would establish itself in the U.S. and what efforts would be required to combat it. But at Kaiser Permanente San Francisco, concerned infectious disease experts started to mobilize as soon as the global alarm was sounded. This proved prescient when San Francisco became a hotspot for the disease, with the first cases diagnosed in June 2022.

A multi-disciplinary work group was formed with involvement from adult medicine, infectious disease, emergency department, nursing administration, laboratory, pharmacy, and other departments to develop critical workflows for testing, infection control, and clinical management. As cases began to trend rapidly upward in late June, swabbing kits went out to the Emergency Department and others likely to see symptomatic patients and a dedicated testing site was established. Given the disproportionate burden of infections among our gay, bisexual, and transgender patients, KPSF also launched an education and awareness campaign for our patients at increased risk for infection.

With attention turning to vaccination, we worked with the San Francisco Department of Public Health (SFDPH) to procure vaccines. The first vaccine dose was administered in late June, with more than 11,000 doses administered since. Despite the early constrained vaccine supply, we maximized the doses we had to vaccinate both members and nonmembers, collaborating with our public health department and community organizations, including the SF AIDS Foundation and Strut, their health center located in the heart of the Castro, to provide community vaccination clinics that have vaccinated thousands of patients. By late September, cases had plummeted, and San Francisco was heralded as a national model for MPX vaccination, diagnosis, and treatment.

By building upon our learnings during the COVID-19 pandemic, our multidisciplinary team was prepared to respond to this outbreak rapidly and effectively. We are extremely proud of our medical communities’ collaborative team effort and of how much we were able to accomplish in MPX prevention and treatment in a very short time.

For more than 60 years, Kaiser Permanente San Rafael has been a part of Marin County, caring for our patients and promoting the health and well-being of our community. The new offices were designed with the community in mind, guided by our commitment to high-quality care, high levels of customer service, and convenience. San Rafael Park Medical Offices offer comprehensive primary care and onsite access to pharmacy, lab, rehabilitation therapies, imaging, endocrinology, and eye services—all under one roof.

The departments and services available at San Rafael Park Medical Offices: Adult and Family Medicine; Endocrinology; Health Education; Imaging; Lab; Ob-gyn; Ophthalmology; Optometry; Outpatient Eye Surgery Suite; Pediatrics; Pharmacy; Physical/Occupational Therapy; and Vision Essentials (includes Optical Sales).

“At this new technologically advanced building, our members can expect to receive the same high-quality, integrated, and industry-leading care they’ve come to depend on,” says Naveen Kumar, MD, Physician in Chief, San Rafael Medical Center. “I have tremendous gratitude for our care teams, whose clinical excellence is reflected in this beautiful new space.”

The project represents years of hard work and thoughtful collaboration with environmental stewardship top of mind. One example was the decision to repurpose an existing building instead of constructing one from the ground up. The three-story, 145,000 square-foot building has features like all LED lighting, electric vehicle charging stations, reclaimed water in the plumbing fixtures, and solar panels, which provide 100 percent of the building’s electrical needs. There are also bike racks and commuter showers to make it easy to leave the car at home.

The San Rafael Park Medical Offices was years in the making and is a testament to the San Rafael leadership team’s long and deep commitment to our community. We welcome the opportunity to serve the broader Marin County and surrounding communities in our spacious new building.!

With so many Marin County residents entrusting Kaiser Permanente with their care, we were pleased to open the new San Rafael Park Medical Offices in July.

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