Read the Top 10 HealthLeaders burnout and well-being stories since 2021.
Addressing healthcare worker burnout and well-being are key elements of improving healthcare andrising to the challenge of widespread workforce shortages at health systems, hospitals, and physician practices.
In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.
HealthLeaders has been following healthcare worker burnout and well-being developments for years. The 10 stories listed below have been popular with HealthLeaders readers.
Study Identifies Interventions Physicians and Nurses Want to Address Burnout: To address burnout, physicians and nurses prefer actions to boost nurse staffing, increase clinician control over workload, and improve work environments rather than wellness programs and resilience training, a research article found.
Battling Burnout: ANA Arms Nurses With an Effective Weapon: The program, developed by SE Healthcare, a healthcare data analytics provider, gives nurses on-demand access to more than 190 "bite-size" videos on real-world challenges faced by nurses, with topics such as Building a Better Day Off; Delegation—What a Revelation; Shared Governance; and Ethical Dilemmas.
Expert: Healthcare Worker Burnout Trending in Alarming Direction: Healthcare worker burnout has reached crisis proportions and urgent action is required to turn the tide, according to Bernadette Melnyk, PhD, RN, APRN-CNP. Melnyk is chief wellness officer of The Ohio State University and dean of the university's College of Nursing. She is a nationally recognized leader on healthcare worker burnout and well-being.
Nurses, Other Healthcare Workers Experience Reduced Stress and Burnout Through Mindfulness Program: An 8-week mindfulness program created by researchers at The Ohio State University Wexner Medical Center and The Ohio State University College of Medicine significantly reduced burnout and perceived stress for nurses and other healthcare staff, while increasing resilience and work engagement, a study found.
Researchers find that unfair treatment of parents and children in healthcare settings is linked to care disruptions such as delayed or foregone care.
Black parents are about twice as likely as parents who are White, Hispanic/Latinx, or of other races to experience unfair treatment in healthcare settings, according to a new study.
Earlier research has documented discrimination or unfair treatment based on race, ethnicity, and other personal characteristics. In healthcare settings, discrimination or unfair treatment has been linked to negative consequences for healthcare access, healthcare quality, trust in the healthcare system, and treatment adherence.
The new study, which was conducted by the Urban Institute, is based on data collected from parents with children under the age of 19. The data was drawn from the June 2022 Urban Institute Health Reform Monitoring Survey. That survey had a sample size of 9,494 adults.
The study features several key findings:
13% of parents said they were treated unfairly in healthcare settings based on race or ethnicity, language, health insurance type, weight, income, disability, or other characteristics
22% of Black parents said they were treated unfairly in healthcare settings, which was 10 percentage points higher than unfair treatment reported by parents who were White, Hispanic/Latinx, or additional races
3% of all parents said that their children were treated unfairly in healthcare settings because of the parent's or child's race, ethnicity, country of origin, or primary language
9% of Black parents said that their children were treated unfairly in healthcare settings because of the parent's or child's race, ethnicity, country of origin, or primary language
71% of parents who reported unfair treatment said they experienced disruptions in their healthcare
40% of Black parents and 30% of Hispanic/Latinx parents said they were concerned that they or a family member would be treated unfairly in healthcare settings in the future because of race, ethnicity, or primary language
Black parents were more likely than White parents to be treated unfairly based on health insurance type (9% versus 4%); weight (8% versus 5%); gender, gender identity, or sexual orientation (9% versus 4%); income level (6% versus 3%); or disability or health condition (5% versus 3%)
Interpreting the data
Healthcare organizations should find the research alarming, Dulce Gonzalez, a research associate at the Urban Institute's Health Policy Center and co-author of the study, told HealthLeaders. "It is a concern because all people regardless of their background and regardless of their personal characteristics deserve access to respectful and high-quality care. It is concerning to us that not everybody—particularly people of color—is getting that kind of treatment in healthcare. It points to systemic issues in the healthcare system, including both implicit and explicit systemic biases as well as policies that are systemic to the healthcare system that allow for racism, classism, and ablism."
The findings are "striking," she said. "People of color and especially Black parents reported feeling treated unfairly at much higher rates than White parents. Among Black patients, the rates of unfair treatment among children specifically are much higher than those of other races and ethnicities. Notably, rates of unfair treatment for parents with the youngest children are just as high as parents with older children. That is significant because young children are going through an intense period of development, and exposure to negative experiences in healthcare early on in life is particularly concerning."
Unfair treatment has negative consequences for patients, Gonzalez said. "It is concerning that these experiences of unfair treatment have the potential to affect healthcare access generally. When people told us that they experienced unfair treatment, many people reported they also experienced disruptions to care such as delayed or foregone needed care, switching providers, and not following providers' recommendations, which speaks to the breakage of trust between patient and provider. Based on prior research, we know that unfair treatment can be associated with higher levels of stress and adverse mental health outcomes."
These care disruptions have short-term and long-term effects on patients, she said. "It is possible that if people are not getting needed healthcare that they are also not able to get preventive care, routine care, or primary condition management care in the short-term. It is also possible that not getting these kinds of care could have a negative effect on health in the long-term."
Addressing unfair treatment of patients
Several steps can be taken to reduce the unfair treatment of patients based on personal characteristics, Gonzalez said. "You can uncover and address the implicit and explicit bias that exists among providers and their front-office staff. You can also make broader changes to the healthcare system to improve the experiences of people of color such as diversifying the healthcare workforce along race, ethnicity, and other dimensions to help build trust between providers and their patients. Another avenue is expanding on community programs, which can leverage community expertise to help bridge communication and trust gaps for people of color."
A pair of government programs should be focal points in efforts to address unfair treatment of parents and their children based on personal characteristics, she said. "You could leverage Medicaid and the Children's Health Insurance Program, with the acknowledgement that these programs serve a large number of children. Being able to leverage those programs to reward providers who are excelling at providing high-quality and respectful care could be a powerful incentive to promote better treatment of patients."
In value-based care, it is helpful to have clinician compensation tied to quality measures and outcomes.
To succeed in value-based care payment arrangements, healthcare organizations and their payer partners must have a clear understanding of what they are trying to achieve, the chief medical officer (CMO) of Yuma Regional Medical Center says.
Bharat Magu, MD, MHA, has been CMO of Yuma Regional Medical Center since September 2015. He was recently named as the medical center's senior vice president of medical affairs.
HealthLeaders recently talked with Magu about a range of topics, including his challenges as CMO, the key to success in service line development, and value-based care payment arrangements. The following transcript of that conversation has been lightly edited for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as CMO of Yuma Regional Medical Center?
Bharat Magu: The No. 1 challenge coming out of the pandemic is to maintain access of services for the local community. Yuma and the surrounding communities are an underserved healthcare area that has seen attrition of providers during the pandemic. One of my challenges is to recruit and retain providers to maintain access to primary care and specialty services.
My second challenge is to minimize transfers of patients out of our primary service area. We transfer about 15% of our patients to Phoenix, Tucson, and other areas for specialty needs. We are trying to limit our transfers, particularly for pediatric subspecialties.
The third challenge is minimizing subsidy to the medical group and maintaining market-level productivity to match our providers' compensation.
HL: How are you rising to these challenges?
Magu: I created a team for provider support and recruitment. Since 2016, we have added 16 services and 150 additional providers. We offer a competitive compensation package. We have a culture where providers feel valued—they have leadership roles. We have a medical leadership structure under executive medical directors in three divisions—surgery, medical specialty, and primary care. Those three executive medical directors report to me. This structure has not only helped recruit candidates but also keep providers here. We have physician-led projects, which is also helpful in recruitment and retention.
To reduce patient transfers, we added services. We have partnered with a tele-stroke program. We have also established a children's rehab services program, with specialty providers from Phoenix and Tucson—they come once a month to provide services in our community. We don't do transplants. We don't have extracorporeal membrane oxygenation. We don't have neurosurgery. So, we do have transfers that we cannot avoid.
Aligning provider productivity and compensation is challenging because fair-market benchmarks are dependent on the Medicare fee schedule. We want to make sure that our providers have incentives to come and work in a rural area like Yuma versus Phoenix, San Diego, and other markets. But at the same time, we have to align compensation with fair-market benchmarks.
In addition, we are trying to give our providers operational support to minimize their bottlenecks in the clinics. We have hired additional medical assistants if they need them. We have centralized the scheduling of patients to optimize all of the empty slots in providers' schedules. Finally, we have a program with five physicians who are certified as champions for our electronic medical record. They help providers in the clinics to be more efficient and spend less time in the EMR, which improves their throughput.
Bharat Magu, MD, MHA, is chief medical officer and senior vice president of medical affairs of Yuma Regional Medical Center. Photo courtesy of Yuma Regional Medical Center.
HL: What is the key to success in service line development?
Magu: The No. 1 key in service line development is alignment of goals between providers, operations, and the administration. It goes beyond sharing the financial benefits of an optimized service line. The service line medical director and operations director should be in a dyad partnership to meet the needs of the community and the patients. If the clinical leader and the operational leader are not aligned, a service line will fail.
HL: What is the key to success in quality improvement initiatives?
Magu: You need to have providers involved. You will not get the desired outcomes, or an initiative will fail if you do not have the providers fully engaged. Quality improvement initiatives should be led at least in part by a provider. We have shifted our focus significantly from nursing-led initiatives and operational-led initiatives to having dyad-led initiatives, which can include our executive medical directors.
HL: What are the keys to success in value-based care payment arrangements?
Magu: The payment arrangement is what matters the most. You must be very clear with your payer partner about how you define the incentives for quality activities as well as shared savings. Initially, we did a lot of work on value-based care and improved quality, but we did not generate shared savings because the cost of care was not significantly lower. So, having a clear understanding of what you are trying to achieve with the payer is No. 1.
No. 2 is designing a good compensation plan for providers. Often, a productivity-based model is not compatible with a value-based care arrangement. So, we have some physicians who are providing value-based care and their compensation is not tightly tied to productivity—their compensation is tied to quality and outcomes.
HL: How are physicians involved in administrative leadership at your medical center?
Magu: Physicians are heavily involved in administrative roles. We have the executive medical directors overseeing surgery, medical specialty, and primary care. Under them, there are medical directors in areas such as trauma, stroke, and intensive care. We send our medical directors through a leadership development program, with roughly six leadership sessions per year. Our chief medical information officer is also a physician. Our physicians present their initiatives periodically to the governing board.
HL: You have a clinical background in internal medicine. How has this clinical background helped prepare you to serve in leadership positions such as CMO?
Magu: I see patients once a week—I have my own panel of patients. I hear directly from patients. I am the only active clinician in the senior executive team. I was a hospitalist before I became the CMO. So, having these patient insights has greatly facilitated my journey in the CMO role.
The new proposed federal rule from the Biden administration builds on the Mental Health Parity and Addiction Equity Act.
A new proposal from the Biden administration to strengthen parity for behavioral health services with physical health services is a step in the right direction, according to Carl Marci, MD, a psychiatrist at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School.
Research indicates that access to mental health services is more difficult to obtain than access to physical health services. For example, one study found that Americans with commercial insurance are more than twice as likely to have to go out of network to get mental health services than to get physical health services.
Since 2008, the federal Mental Health Parity and Addiction Equity Act (MHPAEA) has sought to make it easier for people to obtain treatment for mental health and substance use disorders by requiring health plans that cover these conditions to do so on par with other health needs.
The Biden administration proposal includes three elements to build on the requirements of MHPAEA:
Health plans should make changes when they are providing inadequate access to mental health services. Health plans should evaluate the outcomes of their coverage rules to ensure that people have equal access to mental health services and physical health services.
"The proposed rule will provide specific examples that make clear that health plans cannot use more restrictive prior authorization, other medical management techniques, or narrower networks that make it harder for people to access mental health and substance use disorder benefits than their medical benefits," a statement from the White House says.
The proposed rule would close a loophole in MHPAEA that does not require non-federal government health plans such as those offered to state employees to comply with the law.
"President Biden's proposed rule is critically important. A lot of people are suffering—only half of adults with mental health issues get access to care, and it is worse for children and people with substance abuse issues," Marci told HealthLeaders.
The proposed federal rule will likely shine light on how many people seek behavioral health services out of network, he says. "It is a great idea to have more transparency and accountability for insurance companies. Making regulators aware of the percentage of patients who are using out-of-network providers for mental health services versus physical health services is an important indicator."
Tackling onerous prior authorization for behavioral health services is essential, Marci says. "Another good element of the proposed rule is to minimize prior authorization, which requires clinicians to justify providing mental health services to insurance companies. An example that I use is if you have a large cut on your arm and you go into an emergency room, the physician does not stop half-way through the visit and call the insurance company to see whether care can be provided. In mental health, we routinely have to justify care part way through treatment. Reducing that kind of friction in providing care is important."
There are three reasons why there should be behavioral health parity with physical health coverage, he says.
"No. 1, in the medical field, we are morally and ethically obligated to treat people who are suffering. No. 2, it is a false distinction between physical health and mental health. They are two sides of the same coin. There are plenty of examples such as people who have chronic pain and depression, and when their chronic pain is addressed, their depression improves. The reverse of that happens frequently—if you have patients who are chronically depressed and have diabetes or high cholesterol, it is hard to get those people to exercise or eat well, which makes their physical health worse. Third is the economic issue. We know that any physical illness when combined with depression is harder to treat and will cost more to treat."
More needs to be done to establish coverage parity between behavioral health services and physical health services. Marci says.
"The status of behavioral health parity is poor, which is why the Biden administration is taking action and directing several agencies in the federal government to try to enforce rules and laws that have been on the books for years. We have a situation where there are not enough providers—psychiatrists, nurse practitioners, physician assistants, social workers, and therapists—to satisfy the need for care. The reimbursement rates for treatment are not high enough to incentivize mental health providers to go in-network and take patients. We need to do a better job at attracting more professionals to the field of behavioral health."
WellSpan Health has established an extensive tiered huddle system, revamped patient safety reporting system, and culture of safety.
WellSpan Health has made significant gains in patient safety over the past three years.
Patient safety includes medical errors that impact patients and "near misses" that could have reached patients. Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System.
York, Pennsylvania-based WellSpan Health reassessed the health system's approach to patient safety in 2020, says Michael Seim, MD, senior vice president and chief quality officer.
"We looked at our long-term goal to focus on zero harm to patients and zero harm to team members. As part of our annual plan, our board of directors set a goal to make measurable outcome improvements and reduce safety events that reach patients. We started to focus on our methodology. We understand that most errors that reach a patient are because of system and process design flaws. No one goes into healthcare to harm people—it is about poorly designed systems. So, we spent a lot of time building our management structure and training our leaders in the theory of lean management. Then we spent time getting input from our 20,000 team members to develop a lean management system that connected our frontline team members to our CEO every day," he says.
The results have been impressive.
WellSpan Chambersburg Hospital: more than 260 days central line-associated bloodstream infection (CLABSI) free
WellSpan Waynesboro Hospital: last CLABSI was prior to 2012
WellSpan Gettysburg Hospital: more than 250 days CLABSI free and more than 100 days catheter-associated urinary tract infection (CAUTI) free
WellSpan Ephrata Community Hospital: more than 980 days CLABSI free
WellSpan Good Samaritan Hospital: more than 830 days CLABSI free
At WellSpan York Hospital, the Open Heart ICU and Surgical ICU have been both CAUTI free for the past year
Safety event reporting
WellSpan has committed to having an extensive tiered-huddle system, where every team member huddles every morning, Seim says. "Every team member is engaged in some type of huddle, where any safety event, harm event, or near miss gets elevated upto our CEO. We trained all 20,000 team members in patient safety and in recognizing risk or harm to patients. We trained all team members in problem solving and root-cause problem solving. The concept is that everyone owns patient safety in our health system."
The frontline huddles are connected to the entire management team, he says. "The second tier of huddles is managers and directors, who elevate concerns from the frontline team members. Then our regional vice presidents huddle; and, ultimately, the vice presidents' huddle reports to our CEO huddle. Every day, we connect any safety concern that a frontline team member identifies all the way up to our CEO."
The health system also has a revamped formal reporting system for patient safety, Seim says. "We rebranded our patient safety process to remove any punitive characteristics for team members—we wanted them to feel psychological safety. We rebranded to putting safety first and called the reporting system "Safety First." We are striving to get the number of events that our team members identify to increase in our Safety First system. We wanted them to not only report errors but also proactively report areas where someone could be potentially harmed."
In 2020, there were 20,000 safety events reported. Over the past year, 42,000 Safety First events have been reported, he says.
Team members can also find out what has happened after they report a safety issue, Seim says. "We created an opportunity for team members to request feedback on how we resolved an issue. A lot of times, team members had felt it was not worth putting in a report because it just went into a black box and disappeared. In the new process, team members can request follow-up from the manager of a unit to find out what we have done to prevent an error from reaching a patient."
Promoting a culture of safety
WellSpan has promoted a culture of safety, with active involvement of the leadership team, Seim says. "Our board sets our annual plan goals, including zero harm to patients and zero harm to team members. We use the lean methodology of sharing data openly. Every two weeks, we have a leadership review of our annual plan goals, which includes patient harm. We have a weekly call every Monday with every manager in the organization where we share information about safety."
The health system has created a culture where patient safety catches are celebrated, he says. "We have what we call a Heads Up, Speak Up Award, where we recognize team members who stop the line for a potential harm event before it reaches a patient. We have had national recalls for products when our team members have stopped the line because there was a safety issue. One was with a fall mat that was slippery when wet. We celebrate the best catches of the year during our annual quality forum. We talk about quality and safety, and we celebrate opportunities to improve patient safety and quality."
The experience of two healthcare worker well-being programs implemented during the coronavirus pandemic generates recommendations.
The architects of two healthcare worker well-being programs launched at the beginning of the coronavirus pandemic share lessons learned in a new journal article.
Healthcare workers nationwide were already showing signs of distress and burnout before the pandemic. Earlier research showed that physicians experiencing at least one burnout symptom rose from 38.2% in 2020 to 62.8% in 2021.
The new journal article, which was published by JAMA Psychiatry, focuses on well-being programs launched by Columbia University Irving Medical Center (CopeColumbia) and the University of California-San Francisco (UCSF Cope).
CopeColumbia and UCSF Cope shared several characteristics such as being led by departments of psychiatry. CopeColumbia featured a model of peer support and education. UCSF Cope provided triage, assessment, and treatment services to all workers at the health system.
The new journal article offers nine lessons learned from the well-being programs.
1. Prepare for a future crisis: Healthcare organizations should prepare now for future crises, the journal article's co-authors wrote. "In addition to building a robust well-being program, healthcare systems must incorporate explicit plans for supporting mental health into future disaster preparedness. These plans require investment in a mental health workforce that has capacity and flexibility to respond during disasters."
2. Embrace structural change: Healthcare organizations should enact structural changes to boost well-being, the journal article's co-authors wrote. "Workplace well-being is largely dependent on structural factors. After the initial shock of managing the fear and uncertainty of a novel deadly virus, we found that sessions emphasizing individual well-being and coping strategies without adequately addressing (or at least acknowledging) structural barriers to wellness evoked negative responses. For example, the impact of lack of childcare resources clearly impacted healthcare worker experience of burnout during the pandemic."
3. Promote compassionate leadership: Healthcare organizations need compassionate leadership to achieve positive cultural change, the journal article's co-authors wrote. "The central role of leadership in creating a sense of safety and shared purpose was repeatedly highlighted—not only at the top but across all layers of administration. … We believe that leaders should obtain training in compassionate leadership following the principles of trauma-informed care: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, and attention to culture, historical, and gender issues. We believe that leaders should be evaluated by their ability to prioritize well-being and mental health, in addition to productivity."
4. Deploy dedicated resources: Healthcare organizations need to have dedicated resources to address healthcare worker well-being such as financial and personnel resources, the journal article's co-authors wrote. "Both systems in the initial phase of the crisis mobilized clinicians eager to volunteer time to support their colleagues to rapidly create these programs. However, as our medical centers reopened, it became clear that meeting the varied needs of workers across complex health systems requires ongoing investment from the larger institution, rather than relying on individual volunteers or departmental resources."
5. Address equity and justice: Healthcare organizations need to address equity and justice to boost healthcare worker well-being, the journal article's co-authors wrote. "The disproportionate toll of the COVID-19 pandemic on historically racialized and economically marginalized populations is well documented. Clinicians caring for these populations are faced with the consequences of societal inequities that limit their ability to care optimally for patients and contribute significantly to moral injury. Within the healthcare workforce, the stresses of the pandemic were also unequally experienced. For example, productivity declined among women compared with men in academia."
6. Importance of psychiatry leadership: Well-being program leadership teams should include psychiatry professionals, the journal article's co-authors wrote. "We strongly believe that psychiatry should hold a formal role within any system-wide well-being effort in healthcare. Because well-being exists along a spectrum, our programs benefited from psychiatry leadership who could facilitate consideration of the range of mental health issues that often co-occur with significant work stressors and burnout, integrate evidence-based therapeutic approaches into well-being efforts, and facilitate access to clinical care."
7. Partnerships are pivotal: Well-being programs should be built on partnerships and trust, the journal article's co-authors wrote. "Human resources groups were key partners in both institutions and must be engaged early in any crisis response. Collaboration between departments and units, such as Faculty Affairs, the Office of Work Life, employee assistance programs, as well as between academic and hospital programs that have historically functioned in silos, were critical to our successful efforts to support well-being, build trust, and overcome stigma."
8. Craft worker-focused opportunities: In addition to individual treatment, well-being programs should offer a range of resources for self-help and stress management, the journal article's co-authors wrote. "To increase employee access to mental health services in ways that provide reassurance about confidentiality, institutions should consider contracting with insurance providers with robust mental health coverage and/or partnering with companies that have remote telemental health and facilitate care for employees and their family members to be delivered both within and outside the medical center."
9. Address mental health stigma: Healthcare organizations should strive to reduce the stigma associated with mental health support and treatment, the journal article's co-authors wrote. "Many interventions intentionally focus on burnout—rather than mental health—to avoid the stigma associated with mental illness. … We recommend that institutions launch mental health destigmatization campaigns to encourage all staff to seek treatment when needed, connected with scalable low-resource interventions. Hospital privilege processes should not include any questions regarding mental illnesses or treatment, but rather focus on current ability to perform occupational duties."
AdventHealth expects Central Florida population growth of about 6% over the next four to five years, with a related increase in demand for healthcare services.
Meeting the challenge of population growth in Central Florida is the top priority of the new chief clinical officer of the AdventHealth Central Florida Division South Region.
In March, Victor Herrera, MD, became chief clinical officer and senior vice president for AdventHealth Central Florida Division South Region, which features 10 hospitals. His prior positions at AdventHealth include serving as chief medical officer and vice president of AdventHealth Orlando, the flagship hospital of the Altamonte Springs, Florida-based health system. He also served as medical director of continuing education at the health system.
HealthLeaders recently talked with Herrera about a range of issues, including medical education, quality improvement initiatives, and change management. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What is your top priority in serving as chief clinical officer of AdventHealth Central Florida Division South Region?
Victor Herrera: The population in Central Florida is growing. In the next four to five years, we anticipate that we will have about 6% population growth. We estimate that will be 150,000 to 200,000 new people in this area. I see getting ready for this population growth as our top priority. From a healthcare perspective, we expect an increase in demand for healthcare services.
The population growth will bring pressure in terms of building our access points, creating an infrastructure that meets the needs of that growth, and thinking about our workforce. Coming out of the coronavirus pandemic, there have been constraints related to workforce, and we are in the process of thinking through our pipeline for providers. We need to not only hire more people but also change the way people work, so we can take care of more patients without increasing the burden on care teams in a way that is unsustainable.
HL: How do you plan to rise to the challenge of making sure you have the workforce to serve this growing population?
Herrera: We will have to pursue innovation in how we deliver care. We anticipate that we are going to do more things outside of the hospitals. We are going to see more care at home. When it comes to the care model, it is going to look very different five years from now. We are going to redefine hospital care—it is the only way that we can match the demand for services.
Obviously, technology is going to have to be one of the tools that we are going to have to leverage as part of this transformation. There is the potential to use artificial intelligence and machine learning. We need to remove the burden that is associated with tasks that are tedious and take a lot of time for our workforce. We can probably automate many of these tasks, which will free up time for frontline healthcare workers to deliver care. It can also improve satisfaction in the workforce.
Currently, nurses spend up to 40% of their time documenting and doing tasks that we believe we can automate. So, it's not just about adding more people. It is about changing the work of the people we have already, so they have the capacity to see more patients.
Victor Herrera, MD, chief clinical officer and senior vice president for AdventHealth Central Florida Division South Region. Photo courtesy of AdventHealth.
HL: You have experience in medical education. What are the primary qualities of a good medical educator?
Herrera: We have a large medical education footprint in our health system, and we continue to grow it. We are training the next generation of physicians, and our goal is that most of those physicians will stay with us. When it comes to the key qualities of a good medical educator, things have changed a lot. If I go back to when I was a medical student, most of the knowledge that I was acquiring came from attending physicians and faculty. I would ask them questions, and that is how I learned.
The world has changed. There is so much information now that we need to know and be able to find. We cannot just rely on individual educators to pass along that knowledge. We need to teach our trainees how to use the tools that exist, so they can go on their own and find information. In 2023, a good medical educator understands what information tools exist and focuses their training of students and residents on how to use those tools to find information. In addition, a good medical educator teaches clinical judgment, which continues to be a core area.
HL: What are the primary elements of advancing population health?
Herrera: We need to leverage artificial intelligence and machine learning to characterize the populations that we serve. We need to have access to data and focus on the outcomes we are trying to influence. We need to focus on the predictors of outcomes. Artificial intelligence and machine learning will give us the ability to process data and find signals that were not obvious to us in the past. This will take us to a new level of delivering on the promise of population health. This is a big opportunity—how we can leverage technology to understand data to have predictive value for our patients.
HL: What are the keys to success in quality improvement initiatives?
Herrera: When we talk about quality improvement, we need to go beyond a particular care team and saying their quality needs to be better. As leaders, we need to get to the root cause of why we are getting the results that we are getting. Sometimes, we fail to think that way. If we are not getting the results we are hoping for, there is a reason for that. There are drivers or incentives that prevent you from achieving what you want to achieve.
The root causes are often not obvious, and sometimes we jump into quality improvement initiatives without understanding those drivers. Understanding root causes is the key to quality improvement.
HL: What are the keys to success in change management?
Herrera: It is similar to quality improvement. You need to understand the drivers of what you want to change. In addition, you need to have good communication with everyone who is involved. You need to get to the front line and determine why we are doing what we are doing. So, you need to find root causes and establish communication all the way to the front lines.
HL: What is your approach to team leadership?
Herrera: You need to create psychological safety among your team members. You need to create an environment where people feel comfortable telling you what they think. In healthcare, we take care of patients, and taking care of patients comes with a high bar in terms of expectations. We are always trying to achieve excellence in everything that we do. At the same time, we need to create an environment where people feel it is OK to fail. If we are not getting the results that we need right away, my leadership style is to say that is OK; otherwise, you will stop innovating. If you are going to innovate, you need to feel comfortable with the idea that innovations may not work the first time.
My leadership style is to push my team to think outside the box, to try new things, and to innovate. You are not going to get your team to innovate if you do not create psychological safety.
The increase in physician turnover was greatest from 2010 to 2014, rising from 5.3% to 7.2%.
The annual physician turnover rate increased significantly between 2010 and 2018, according to a recently published journal article.
Physician turnover was defined as physicians moving to a new practice or leaving the practice of medicine. Physician turnover has several negative consequences, including the cost of replacing physicians who leave a practice, interruption of continuity of care, and reducing access to care such as for rural patients.
The recent journal article, which was published by Annals of Internal Medicine, is based on a new method of gauging physician turnover through Medicare billing records. The analysis compared turnover rates by physician, practice, and patient characteristics.
The journal article features several key data points.
The annual physician turnover rate rose from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and rose to 7.6% in 2018
From 2010 to 2014, most of the increased turnover rate was due to physicians who stopped practicing, with an increase from 1.6% to 3.1%
Younger physicians were more likely to move to a new practice, with 5.6% of physicians between 35 years old and 44 years old moving in a given year, and 2.6% of physicians 65 years old or older moving in a given year
Older physicians were significantly more likely to leave practice, with 9.8% of physicians 65 years old or older leaving practice compared to 1.4% of physicians 35 to 44 years old leaving practice
Physicians in rural areas were more likely to move than physicians in urban areas (5.1% vs. 3.9%) and more likely to leave practice (3.3% vs. 2.7%)
Female physicians were more likely to move and leave practice than male physicians
Compared to physicians in larger practices, physicians in solo or 2-physician practices were less likely to move or leave practice
Physicians seeing a higher proportion of dual-eligible (Medicare and Medicaid) patients were more likely to move (top vs. bottom quartile: 4.2% vs. 3.9%) and more likely to leave practice (top vs. bottom quartile: 3.5% vs. 2.9%)
Among specialties, hospitalists had the highest annual moving rate (5.4%), followed by surgical specialists (4.5%) and primary care physicians (4.0%)
Among specialties, obstetrician-gynecologists had the lowest annual moving rate (3.5%)
Among specialties, hospitalists had the highest annual rate of leaving practice (3.6%), followed by primary care physicians, obstetrics-gynecology, and hospital-based physicians (ranging from 3.1% to 3.2%)
Among specialties, medical specialists (2.0%) and surgical specialists (2.4%) had the lowest annual rates of leaving practice
The increase in turnover rates between 2010 and 2018 is significant, and it poses challenges for healthcare providers and patients, study co-author Lawrence Casalino, MD, PhD, emeritus professor of public health, Department of Population Health Studies, Weill Cornell Medical College, told HealthLeaders.
"You have to look at the percentage change and the absolute numbers. The change in the absolute numbers—5.3% to 7.6%—does not seem that large, but it is still one out of 13 physicians leaving medicine or moving to another practice. That is fairly high, and it is close to the other studies that have looked at physician turnover. It is expensive for a practice or a health system if a physician leaves. When they have to look for a new physician, there are several costs involved. It is also bad for patient care, particularly for patients who have had a physician for a long time," he said.
Interpreting the data
The finding that physician turnover is higher in rural areas than urban areas is concerning, Casalino said. "Rural areas are already short on physicians in primary care and specialties. In addition, people in rural areas are usually poorer and sicker than people in urban areas."
The finding the physicians with higher proportions of dual-eligible patients have relatively high turnover rates is also concerning, he said. "To the extent that dual-eligible and poorer patients are sicker, they need their doctors even more."
Financial and clinical pressures likely contribute to the physician turnover rates of physicians with higher proportions of dual-eligible patients, Casalino said. "It's common knowledge that practices that have high percentages of dual-eligible or otherwise poor patients have lower revenue than other practices. So, they take in less money, but to provide good care for poorer and sicker patients, it takes more time and money for physicians to provide that care. There is more financial and clinical pressure on physicians in practices that have a high poor patient mix."
Multiple factors likely explain why physician turnover is higher for women than men, he said. "On average, female physicians are younger than male physicians, and younger physicians are more likely to move to another practice. Women also are involved in more care of children and elderly parents, and they may not be as tied to a particular practice as men. They may have to leave because they cannot make their schedule of caring for other people work with their practice, and they have to go somewhere else that has the schedule they need."
The COVID-19 pandemic exposed several weaknesses in public health emergency preparedness such as insufficient centralized coordination at the federal level.
The frequency of pandemics on the scale of the COVID-19 pandemic is likely to increase and preparedness planning needs to improve, according to a position paper from the American College of Physicians (ACP).
The COVID-19 pandemic exposed several weaknesses in public health emergency preparedness, the position paper says. At the federal level, those weaknesses included insufficient centralized coordination, inadequately defined responsibilities, and an under-resourced national stockpile of supplies such as personal protective equipment. Other weaknesses included the failure to have a widespread testing and tracing system to contain the outbreak.
The ACP position paper, which was published today in Annals of Internal Medicine, makes 13 recommendations to improve public health emergency preparedness.
1. The federal government should have a comprehensive pandemic preparedness and response plan that is evidence-based and includes input from qualified professionals. Congress should provide adequate funding for pandemic preparedness.
2. Health equity should be a top priority for policy makers and public health officials in pandemic planning to diminish health disparities.
3. Federal and state agencies should have consistent and timely communication about risk and evidence-based strategies to address a pandemic as recommended in the ACP's earlier position paper, "Modernizing the United States' Public Health Infrastructure." Physicians have a key role to play in communicating evidence-based prevention and treatment strategies, and they should contribute to pandemic communications at the federal, state, tribal, and local levels. Efforts must be made to dispel misinformation and to boost trust in the healthcare system.
4. There should be a congressionally funded national public health data infrastructure that can support real-time data sharing between public and private public health stakeholders.
5. Efforts should be undertaken to secure and improve the healthcare supply chain. There should be funding to have sufficient personal protective equipment and other essential supplies in the Strategic National Stockpile.
6. Public policy should promote first-responder capacity and training as well as surge capacity at healthcare facilities. Education and training is needed to bolster the healthcare workforce, including physicians, nurses, and public health practitioners. Federal, state, and private agencies involved in licensing or work visas should be prepared to use volunteer physicians and other healthcare workers to meet labor demand during public health emergencies.
7. There should be a reserve of healthcare workers including physicians and public health professionals in healthcare settings to counsel, diagnose, treat, and monitor patients during a public health emergency.
8. Safety and well-being should be promoted during public health emergencies. Government agencies and medical institutions should partner to craft emergency preparedness plans that foster patient health, safety, and welfare. Government agencies and medical institutions should protect the safety and well-being of healthcare workers during a public health emergency.
9. Public and private payers should provide financial support to healthcare providers during public health emergencies, particularly in underserved communities. This financial support is essential because of increased costs and decreased revenues during pandemics.
10. Efforts should be made to decrease infection in workplaces, especially for essential workers. There should be federal mandates for workplace protections for essential workers during public health emergencies.
11. There should be universal access to sick leave with paid time off to allow workers to address personal or family illnesses, injury, or other medical conditions.
12. There should be public-private partnerships to speed vaccine development and distribution during a pandemic. Clinical trials should include all populations such as racial minorities and children.
13. Vaccines should be used based on recommendations from the Centers for Disease Control and Prevention as well as the agency's Advisory Committee on Immunization Practices. Vaccines should be distributed equitably, with priority place on high-risk people such as healthcare workers. Physicians should promote vaccination among their patients.
There is an urgent need to improve pandemic preparedness, the co-authors of the ACP position paper wrote. "As our global society continues to be ever more interconnected, and climate change is worsening, evidence suggests that more frequent and severe pandemics are on the horizon. Now is the time to take action and make preparations before the next pandemic happens. Policymakers must learn from the experience of the U.S. with COVID-19—both the good and the bad—and draw from it to inform a robust, comprehensive, and unified national pandemic preparedness plan."
Although men account for the majority of physicians, the proportion of female physicians in the workforce increased from 30% in 2010 to 37% in 2022.
The U.S. physician workforce increased 23% from 2010 to 2022, according to a census conducted by the Federation of State Medical Boards (FSMB).
The census, which was published this week by the Journal of Medical Regulation, is the seventh biennial census conducted by the FSMB. The census features data on physician workforce trends, including the number of licensed physicians, medical degree type, specialty certification, sex, and age.
Census data was drawn from the FSMB's Physician Data Center. The census covers physicians with full unrestricted licenses to practice in the 50 states and the District of Columbia in 2022.
The census includes several key data points.
The number of physicians has increased from 850,085 physicians in 2010 to 1,044,734 physicians in 2022. The physician-to-population ratio has increased from 277 physicians per 100,000 people in 2010 to 313 physicians per 100,000 people in 2022.
Most physicians (89%) have a Doctor of Medicine (MD) degree, with 11% of physicians having a Doctor of Osteopathic Medicine (DO) degree. From 2010 to 2022, the number of physicians with a DO degree increased 89%, compared to an 18% increase in the number of physicians with an MD degree.
Physicians holding specialty certifications has increased, with 77% of physicians board-certified in 2010 and 85% of physicians board-certified in 2022.
In 2022, physicians had graduated from 2,200 medical schools in 169 countries. Most physicians (77%) graduated from U.S. or Canadian medical schools. The largest percentage of international medical graduates attended medical schools in India (21%).
Although men account for the majority of physicians, the proportion of female physicians in the workforce increased from 30% in 2010 to 37% in 2022.
The mean age of physicians has increased from 50.7 years old in 2010 to 51.9 years old in 2022. From 2010 to 2022, there was a 54% increase in the number of physicians aged 60 years and older.
In 2022, female physicians were younger than male physicians: 31% of female physicians were under 40 compared to 20% of male physicians, and 19% of female physicians were 60 or older compared to 38% of male physicians.
Interpreting the data
The new census report shows significant changes in the physician workforce, Humayun Chaudhry, DO, president and CEO of the FSMB, said in a prepared statement. "The data in the 2022 census illustrates how dramatically the physician population has grown and diversified since 2010. The FSMB census continues to be an important tool in helping medical regulators and healthcare policymakers stay informed of physician workforce trends as they consider ways to encourage public safety and physician wellness."
The census and demographic data highlight concerning trends, the co-authors of the Journal of Medical Regulation article wrote. "The nation's healthcare system faced several hurdles during the COVID-19 pandemic and prolonged challenges remain as aging in the general and physician populations create increased demand for healthcare resources and amplify workforce supply concerns."
However, the journal article's co-authors identified several "reasons to be cautiously optimistic."
The country is at the forefront of advances in medical technology and more students are enrolling in medical schools.
During the coronavirus pandemic, many physicians and other clinicians showed resilience and an ability to adapt to changing circumstances.
Also during the pandemic, medical licensing boards demonstrated the ability to respond to a crisis such as through expedited licensure.
The expansion of telehealth since the beginning of the pandemic has boosted access to healthcare services.
The U.S. healthcare system will have to rise to daunting challenges in the years ahead, the co-authors of the journal article wrote. "As the nation progresses through the demographic and digital transformations ahead, striking a balance between meeting the healthcare needs of an aging population and the wellness concerns of an often-overworked physician will be difficult but essential."
