A practicing family medicine physician from South Carolina becomes 176th president of the American Medical Association.
The new president of the American Medical Association says physicians have a key role to play in the lives of their patients.
Gerald Harmon, MD, is a practicing family medicine physician based in South Carolina. He has been a member of the AMA board since 2013 and served as board chair from 2017 to 2018. Before his election to the AMA board, Harmon served on the AMA Council on Medical Service.
Harmon is a clinical professor at two South Carolina medical schools. He also is a member of the clinical faculty at the Tidelands Health MUSC Family Medicine residency program.
Harmon was inaugurated as the 176th president of the AMA in June, succeeding Susan Bailey, MD. He recently talked with HealthLeaders about a range of healthcare topics, including the pandemic, health equity, and physician burnout. The following is a lightly edited transcript of that conversation.
HealthLeaders: At this stage of the stage of the coronavirus pandemic, what is the primary pandemic-related challenge facing physicians?
Gerald Harmon: Physicians have always been shown to be one of the most trusted sources of information for patients. The patients get direct advice and recommendations from their physicians. Now, physicians need to encourage vaccine confidence and encourage improved access to vaccines.
Vaccine administration has slowed because it is not quite top of mind for a lot of folks. So now, it is critical for physicians to have the vaccines available to vaccinate their patients. We know physicians have been eager to vaccinate patients, and we are still trying to make sure that physician offices across the country have a vaccine supply.
So, it is important for physicians to serve as a source of vaccine information and encourage their patients to receive the vaccine, but it is also important for vaccine suppliers to get vaccines into physician offices and practices so they can give those vaccines to patients and reduce the spread of COVID.
HL: What can physicians say to their patients to increase confidence in the vaccines?
Harmon: There is some misinformation in the media and social media. I try to offer to my patients that there are proper vaccine protocols. I say these vaccines were developed rapidly but not by missing any scientific hurdles.
The messenger RNA and adenovirus technology was taken off the shelf. We did not have to go through funding hoops because the federal government applied funding upfront. The absolute rigor of the scientific process was followed, and these vaccines are among the safest and most effective ever developed. Patients should have every confidence that these vaccines are safe.
HL: How can physicians help to advance health equity?
Harmon: One of the things I get to be is the spokesperson for the AMA's health equity accelerator. Part of our mission statement is advancing the art and science of medicine and the betterment of public health. It is hard to do that without advancing health equity and addressing healthcare disparities. So, health equity is critical to our mission statement.
We released a plan in May with different actions on health equity. We want to promote equity and racial justice in the AMA itself. We want to expand the capacity to understand and implement anti-racism and equity strategies. We want to build alliances with other stakeholders. We want to look upstream to social determinants of health and root causes of inequities. We want to ensure there are equitable structures for providing healthcare such as broadband expansion into underserved and rural communities. Finally, we want to foster some pathways for truth, education, reconciliation, and transformation for AMA's past racial inequities.
It is a big deal. We have had policies established by the AMA House of Delegates establishing that race is a social determinant of health.
HL: Assess the impact of the coronavirus pandemic on physician burnout.
Physician burnout has worsened. Physicians and others absolutely stepped up during the pandemic. They had taken an oath to take care of people. They risked their lives and even the lives of their families by taking care of COVID patients.
A factor that has limited burnout during the pandemic is a renewed sense of purpose. We have done some surveys at the AMA during the pandemic that found that as many as 48% of doctors felt a renewed sense of purpose. They realized that the practice of medicine was a calling. We have had some psychological, emotional, and physical burnout, but we have had a renewed sense of purpose.
Now that the adrenaline is pulling back and we are getting into a post-pandemic steady state where we do not have the overwhelming burden of COVID disease, we still have barriers to physician satisfaction.
We have the barrier of electronic records not talking with each other. We have statistics that physicians spend many hours per year just waiting to log on to an electronic record. We also know that for every hour of direct patient care, physicians spend up to two hours documenting what they did—so it is a very inefficient system. Then we have the barrier of prior authorization, whether it is a prescription drug, a referral to a specialist, or an imaging procedure. We know that the average doctor has almost 40 prior authorizations to process every week. We consider prior authorizations to be barriers to care. We have a lot of disincentives for physician morale to stay high.
HL: What are some of the primary solutions for physician burnout?
The AMA has some prescriptions for physician burnout. If you have an energized and engaged workforce of physicians that is resilient, it is essential for achieving national health goals. We also know that burnout it is not only a physician workforce issue—a healthcare organization must become resilient itself.
For example, if I work for a large health system, I want the organization to develop a resiliency policy. The health system cannot just say that doctors need to be more resilient and work harder. Healthcare organizations can take a more systemic approach. They can focus on staffing and scheduling. They can focus on giving physicians the right tools. They can focus on getting better vendor support for electronic records. They can work with physicians to reduce the burden of credentialling. These irritators can be reduced without reducing quality of care.
HL: What advice would you offer to new physicians who are just beginning to practice medicine?
Harmon: Remember your opportunity to be a doctor. If you are a new doctor now, you have been given a gift. You can treat your fellow human with a level of trust that you have never had before.
To get to be a practicing doctor today, you have climbed a steep hill. You have gone through education in the twelve grades, then you qualified for a college-based degree, then you qualified for medical school. You have met all kinds of successful standards—you can take data, analyze it, and come up with a meaningful application to benefit humankind. You are an extraordinarily gifted person if you are a young doctor. Take that to heart without getting an artificial sense of self-importance. Apply your gift.
Whether it is me as a family medicine physician, an emergency room physician, a researcher, a pathologist, and all manner of physicians in practice, it is such an honor to be a doctor. I recommend to every doctor—take advantage of that honor and be proud of being a physician.
The new joint venture in North Carolina will help independent physician practices by easing administrative burdens and bolstering value-based care capabilities.
A new joint venture in North Carolina that pairs a payer with a management services company is designed to support independent physician practices during the shift to value-based care.
In today's market, independent physician practices face a range of challenges to maintain their operations. In particular, independent physician practices must deal with burdensome administrative functions and develop new capabilities to achieve success in value-based care contracts.
The joint venture is being formed by Blue Cross and Blue Shield of North Carolina (Blue Cross NC) and New York, New York-based Deerfield Management Company. Von Nguyen, MD, MPH, senior vice president and CMO of Blue Cross NC says the payer entered the joint venture for two reasons.
"First, we are very much aligned upon providing options for physician practices to remain independent. The other reason we are doing this is as we look at healthcare, we fundamentally believe that value-based care is the future. When you look beyond the day-to-day administrative tasks, there is an opportunity through people, processes, and technologies to bring new opportunities and new ideas to smaller practices. It can be really challenging to run a practice and learn new capabilities, so this the joint venture is a way to support physician practices as they grow in this new value-based care environment," he says.
Nguyen says there are three broad categories where the joint venture will support independent physician practices—people, processes, and technologies.
"For people, we can help with the staffing of mainly the nonclinical staff. We want to bring in the right staff to support providers at scale. You can imagine that one provider might not need a pharmacist but having a pharmacist across multiple physician practices might make a lot of sense," he says.
"For processes, there is an opportunity to learn from each other. During the COVID pandemic, physician practices were trying to figure out new ways to see patients and keep them safe. You can imagine that through the joint venture, a provider could quickly call and inquire about keeping patients safe, maintaining social distancing, and scheduling appropriately between visits," he says.
"For technology, COVID provides another good example of the potential of the joint venture. Telehealth was all the rage during the pandemic, but there are many platforms for providing telehealth, including Zoom, Skype, WebEx, and Teams. The joint venture can help physician practices choose the right virtual solution," he says.
A primary goal of the joint venture is helping independent physician practices cope with administrative burdens, Nguyen says.
"As we think about this joint venture with Deerfield, it offers an opportunity to get providers out of a cycle where they can focus on their job of providing quality care to patients and leave administrative tasks to a different organization—an organization that is run by this joint venture. This new organization can take care of everything from scheduling, to hiring staff, to making sure rent is paid. All of those administrative tasks are handled—allowing the provider to spend time with patients," he says.
Supporting adoption of value-based care
Another top goal of the joint venture is supporting independent physician practices in the shift to value-based care, Nguyen says.
"In value-based care, you need to think about new capabilities that you need to bring to bear. You need to make sure that you have enough dollars in the bank for when you have bad years. You need to think about care coordination differently. You need to think about keeping patients healthy—you do not make money by seeing patients in the clinic, you make money by keeping patients out of the clinic. Providers need to think about the tools they need to keep patients healthy at home," he says.
The joint venture will support independent physician practices in their journey to adopting value-based care, says Adam Grossman, MBA, a partner at Deerfield. "This is a multi-year process that requires a lot of infrastructure to support practices as they adopt new tools and resources to make the transition to value-based care. So, whether it is helping practices to evaluate the right technology tools, helping practices with relationships in the provider community, or helping practices with contracting, there are several areas where support is needed."
Applying Deerfield's resources
Deerfield has two assets that will play key roles in the joint venture, Grossman says.
"One, we have the Deerfield Institute, which has been in existence for about 15 years. The institute has a lot of capabilities. For example, we can help practices understand different geographies, we can help practices understand market access, and we have an epidemiology team. There are a lot of capabilities within the Deerfield Institute that the joint venture can leverage over time."
"The second component is the Deerfield operations team. That is a group focused on building businesses. This team can help the joint venture figure out accounting and financial management, or information technology, or human resources and talent acquisition. A lot of the business building that is required for the joint venture will be supported by the operations team," he says.
A chief quality and clinical transformation officer shares insights on checklists, value-based care, high reliability, workforce safety, and telehealth.
To advance value-based care, health systems and hospitals need to eliminate "defects in achieving value," a top executive at Cleveland-based University Hospitals says.
Peter Pronovost, MD, PhD, is the chief quality and clinical transformation officer at University Hospitals. The critical care physician has a global reputation as a patient safety champion, including life-saving work developing checklists to reduce central line–associated bloodstream infections. He is a prolific researcher, with more than 800 articles published in peer-reviewed journals.
HealthLeaders interviewed Pronovost recently to discuss a range of topics, including checklists, value-based care, workforce safety, and his vision for telehealth after the coronavirus pandemic has passed. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of a good checklist for clinical care?
Peter Pronovost: The main element of a good checklist is that the checklist helps to ensure that the task that it is intended to occur actually occurs. In other words, the check list is a means to doing something.
There are a few things that guide a good checklist.
One, is that you are crystal clear about what you are trying to accomplish with the checklist. You need to be clear about the behavior you are seeking to change. Two, is that you co-create a checklist with the people who will be using it. In other words, if you impose a checklist on people, it is often wrong and not adopted. Three, is that you ruthlessly try to reduce ambiguity. If you look at one of the main reasons why checklists are not used, it is unclear who is to do what, where, when, and how. Finally, you need to have a mechanism to review and evolve a checklist because, like any tool, the initial draft of a checklist is often wrong. As you use a new checklist with patients, within a short period of time you should have a well-vetted checklist.
HL: What are the primary opportunities to improve the value of clinical care at health systems and hospitals?
Pronovost: Everybody talks about value from a theoretical perspective. Much like checklists, if we cannot get down to the defects in value, we will never be able to achieve it.
I have developed a checklist for value that has three domains: defects in helping people stay well such as not performing cancer screenings, not helping people get well such as poorly managing chronic diseases, and defects in helping people to get better such as mistreating an acute illness. Defects in helping people to get better include making sure that inpatient care is coordinated with primary care, making sure that recommended care is optimal because a significant percentage of every procedure is not needed based on objective criteria, making sure the site of care is optimal at achieving the best outcome at the lowest cost, and eliminating harm such as using checklists to eliminate infections.
At University Hospitals, we have done research that shows defects in achieving value cost the healthcare system $1.4 trillion—it is a third of the annual healthcare spend. But most of these defects are invisible to healthcare providers. At University Hospitals, we have been able to reduce the annual healthcare spend for Medicare patients by 9% in 2018 to 2019 and another 13% in 2019 to 2020. We achieved this by systematically making defects in value visible, then designing systems to eliminate them.
HL: What are the primary opportunities to achieve high reliability in clinical care?
Pronovost: Healthcare is riddled with mindless variation and has too little mindful variation.
Mindless variation is variation that exists either because we have not taken the time to create a standard for high reliability or because someone in a position of power just wants to do something their way. In healthcare, we must make enhanced efforts to reduce mindless variation because it is harmful to patients.
Mindless variation exists in all three domains of defects in value-based care. It exists in preventive care, where we are not making sure people get the right kind of preventive care. It exists in management of chronic disease—there is variation in diagnosis, there is variation in how we treat people, and there is variation in controlling chronic illnesses. And in acute illness there is variation in several areas such as having care in an emergency department that could be provided in a lower cost setting.
A lot of what I just talked about were the technical aspects of high reliability, but there are also tremendous opportunities to achieve high reliability in our teamwork. We do not have highly reliable ways of communicating with each other. For example, most hospitals have people suffering harm because a code will go off and there is an order to call anesthesia, but the code does not say who should make the call. Predictably, five minutes later, somebody says, "Where's anesthesia?" Nobody took responsibility for calling anesthesia. This is a simple example of low-reliability systems in healthcare that need to change.
HL: What are the main areas of workforce safety at health systems and hospitals?
Pronovost: Right now, with COVID, we are seeing a tremendous uptick in assaults and aggressive behavior among patients. It is quite alarming. It is likely due to the impact of COVID and the stresses on people. The issue of assault—especially in our emergency departments and behavioral health units—is troubling and an opportunity for improvement.
A second issue is burnout and the emotional safety of healthcare workers. The past year has been enormously stressful, and staff have witnessed immense suffering. We need to make sure that we heal our healers.
In addition, needlestick injuries are a big issue along with back injuries.
HL: What is your vision for telehealth after the coronavirus pandemic has passed?
Pronovost: The most exciting piece of telehealth is the idea of combining technologies to enhance value.
For example, in our health system, we are combining several individual technologies that generate enormous value. We are doing what we call triggering, which means if you are a patient and you have gone a while without being seen or not having a required test, we can automatically notify you and your provider to come in. With that outreach, we include smart chatting, so there is a chatbot that can educate the patient about diabetes or the importance of mammograms. The outreach includes self-scheduling. And the outreach includes navigating, so you can speak to a nurse or schedule a telehealth visit.
Telehealth is great, but if the people who most need in-person visits are not coming in, we will have a defect in value. By combining technologies, we are creating what I call a web of well-being, where we can identify people in need of health services and provide them with the services that best meet their needs. A chatbot might meet someone's needs, or scheduling a primary care visit might meet someone's needs, or a telehealth visit might meet someone's needs, or speaking to a nurse on a call line might meet someone's needs.
HL: How can leadership drive change at health systems and hospitals?
Pronovost: Most importantly, it is by the narratives that we tell. Stories are the most potent source for change because they define how we act. I learned this in my central line–associated bloodstream infection work.
After we saw a 90% reduction in CLABSI across the country, we interviewed clinicians to ask what was different about this CLABSI effort. We wanted to know if it was just the checklist. Our hunch was it was not the checklist—it was something deeper. When we interviewed clinicians, what we found was they all said, "We changed the narrative." They started the effort thinking that these infections were inevitable, but they got to zero when they thought these infections were preventable and they were capable of doing something about it.
Physicians may be uncomfortable discussing end-of-life issues and avoid having the conversations.
In the outpatient setting, a significant number of oncologists miss opportunities to have end-of-life (EOL) discussions with their patients, a recent research article found.
EOL treatment that does not align with patient goals is a major public health problem that can have a negative impact on patients and families. For oncology patients, EOL treatment that does not align with patient goals includes chemotherapy during the last 14 days of life, ICU care during the last 30 days of life, and late referral to hospice.
The recent research article, which was published by JAMA Network Open, is based on an analysis of more than 400 outpatient encounters at two academic medical centers. The patients had stage IV malignant neoplasm and were expected to be admitted to an ICU or to die within one year.
The study features two key data points.
In 423 outpatient encounters, only 21 (5%) included EOL discussions
In a random sample of 93 of the outpatient encounters, 35 (38%) included missed opportunities for EOL discussions
"Opportunities for EOL discussions were rarely realized, and missed opportunities for these discussions were common, a trend that seemed to mirror oncologists' treatment style," the research article's co-authors wrote.
There were three kinds of missed opportunities to hold EOL discussions, according to the research article.
1. An inadequate response to patient concerns about disease progression: "When patients or caregivers expressed concern over disease progression or dying, they were often met with partial, avoidant, or absent responses from their oncologists. When oncologists did respond, they often deflected concerns, rather than using them as openings to explore patients' goals, values, or preferences for care, according to best practice in patient-practitioner communication," the research article's co-authors wrote.
2. Engaging in optimistic future talk: "Optimistic future talk describes oncologists' responses to patients' concerns regarding disease progression or dying. Instead of addressing patients' concerns directly, oncologists often shared anecdotes of patients who exceeded average life expectancy," the co-authors wrote.
3. Concern of discontinuation of treatment: "Oncologists frequently expressed concern over treatment discontinuation, often referred to as a holiday or break. … Often, oncologists folded statements of concern about discontinuation into discussions of future treatment, leaving no room to discuss discontinuation," the co-authors wrote.
The co-authors speculated about the reasons why oncologists avoid EOL discussions. "Evidence suggests that physicians may be uncomfortable discussing EOL topics and, thus, avoid them. In addition, emotional distancing due to physician stress or burnout may decrease the likelihood that physicians pick up subtle cues from patients regarding concerns about their disease," they wrote.
"It is also possible some oncologists believed they were sparing patients from conversations they were not yet ready to have, or preserving hope—albeit, potentially to the patient's detriment—of continuing treatment. In this vein, some oncologists may have felt a sense of denial as to their patients' disease progression, particularly after developing close relationships with their patients," they wrote.
Despite decades of effort to improve oncologists' EOL discussions, more work is needed, the co-authors wrote. "Future efforts must address barriers, such as oncologists' fear of upsetting patients and discomfort engaging in EOL discussions, and challenges inherent to providing a time-sensitive prognosis, in tandem with the need to respond to patient emotions and express empathy."
A new report shows an increase in acquisitions of independent physician practices during the pandemic.
During the coronavirus pandemic, there have been upticks in independent physicians becoming employees and acquisitions of independent physician practices, a new report shows.
The trends of physicians leaving private practice for employment at corporate entities such as hospitals and acquisitions of independent physician practices by corporate entities have been going on for years. These trends have raised concerns, including a loss of autonomy in clinical practice and increased costs associated with physician practice consolidation.
The new report was prepared for the Washington, DC-based Physicians Advocacy Institute by Avalere Health. The study examined data from January 1, 2019, to January 1, 2021.
The report features several key data points:
18,600 physicians left independent practice to become employees at health systems or hospitals, with 11,400 of those physicians changing employment after the start of the coronavirus pandemic
Health systems and hospitals acquired 3,200 independent physician practices during the study period, representing an 8% increase
29,800 physicians left independent practice to become employees of other corporate entities such as health plans and venture capital firms, with 11,300 of those physicians changing employment after the start of the pandemic
The percentage of physicians employed at other corporate entities increased 31% during the study period
Other corporate entities acquired 17,700 independent physician practices during the study period, representing a 32% increase
There was a 3.1% increase in the growth rate of physicians employed at health systems and hospitals after the start of the pandemic
There was a 3.9% increase in the growth rate of physicians employed at other corporate entities after the start of the pandemic
As of January 2021, 69.3% of physicians were employed at health systems, hospitals, or other corporate entities
"These trends are part of a greater shift towards consolidation within the healthcare marketplace, which has dramatically reshaped the practice landscape for physicians. Understanding the extent and impact of these trends is important for all healthcare system stakeholders, given the implications on healthcare spending and, in many cases, the continuity of the patient-physician relationship," the report says.
Interpreting the data
Although the report does not have data for 2021, the pandemic appears to have accelerated the pace of physicians leaving independent practice and physician practice acquisitions, Kelly Kenney, JD, CEO of the Physicians Advocacy Institute, told HealthLeaders.
"You cannot dispute the fact that there was a bump up nationally. There were 48,400 additional physicians who left independent practice during the two-year study period and became employees. And 22,700 of those physicians left independent practice in the last six months of 2020. That is a significant increase during the pandemic. We saw this upward trend reflected in both the physician employment and the practice acquisitions analysis. So, it appears to be a consistent upward trend," she says.
The report provides insights into the acquisition of independent physician practices by corporate entities such as health plans and venture capital firms, Kenney says.
"The trend of health system and hospital acquisition of practices has been going on for more than a decade, but this is the first time we have been able to look at acquisitions by other corporate entities such as private equity entities and health insurers. Given the financial model of some of these corporate entities, there are some inherent concerns that we should look at. We need to pay close attention to how these other corporate entities approach key patient issues such as access to a personal physician and access to clinically indicated care. These other corporate entities have different financial incentives than independent physician practices," she says.
Transparency is a concern related to practice acquisitions by other corporate entities, Kenney says.
"We need to look at the level of transparency around other corporate entities that are purchasing independent physician practices. We need to make sure there is enough transparency and regulatory oversight to ensure that onerous or restrictive policies are not in place. There is not a lot of scrutiny for these other corporate entities, and we need to make sure there are safeguards in place. There are patients attached to these practices, and we need to make sure those patients are not in worst shape than they were pre-acquisition," she says.
The report's data reflects the difficulty of operating an independent physician practice, Kenney says.
"It is difficult to maintain an independent physician practice, and a conversation needs to occur about whether that is something we are ready to give up as a nation. Many of us feel that we want the choice of having a physician in a practice that is run independently. We need to continue to push for that and need to support physicians who choose to remain independent. Physician practices that are independent need to be viable from a financial perspective, and they should not be overloaded with regulatory and administrative burdens that make it impossible to practice independently," she says.
Easing regulatory burdens is crucial to the future of independent physician practices, Richele Taylor, JD, CEO and chief legal officer of the South Carolina Medical Association, told HealthLeaders. "The regulatory burdens are important because it is hard for a new physician to start a practice, and you want to keep independent practices viable especially in rural and underserved areas. It has got to be something they can do. They have got to be able to run a practice while practicing medicine."
New policies such as lifting the moratorium on physician-owned hospitals need to be adopted to ensure independent physician practices do not become a relic of the past, Kenney says. "We certainly hope we are not seeing the end of independent practice. We think there are commonsense policies to put into place to protect that option for physicians and patients."
It is unlikely that independent physician practices will disappear, Taylor says. "Physicians are service-oriented, and they will always look for where they can serve. So, the independent physician practice model will always be around because physicians are going to gravitate to it. But it is our job to help protect independent physician practices to make sure that when physicians look for those kinds of opportunities, they will be available."
Scout by Sutter Health combines downloadable information with human nonclinical guides to help young people with anxiety, depression, and stress.
Sutter Health has launched a digitally driven tool matched with nonclinical guides to support youth and young adults who are struggling with anxiety, depression, and stress.
Access to behavioral health services is a challenge for many people afflicted with mental illness. In 2016, about 16.5% of school-aged children had been diagnosed with a mental health disorder. During the coronavirus pandemic, a larger than average share (56%) of people between 18 and 24 have reported symptoms of anxiety and/or depressive disorder.
Scout by Sutter Health was launched as a pilot program in July 2020. The program was launched at scale in April 2021. Scout is a 12-week, nonclinical program targeted at youth and young adults aged 12 to 26.
"Scout is a nonclinical tool—it is not a substitute for treatment. Rather, Scout is a tool to build youth and caregiver resilience. It helps youth manage their symptoms and helps them in their everyday lives in managing a variety of life challenges while they are having depression, anxiety, or stress," says Larry Marx, MD, director of integrated care for the mental health and addiction team at Sutter Health.
Pediatricians or clinicians working with young people and/or their families can refer patients or caregivers to Scout if there are concerns around stress, anxiety, or depression.
Scout has four primary elements:
1. Weekly virtual screenings
After young people enroll in Scout, they are screened weekly for anxiety and depression, says Vandana Pant, MA, director of strategic initiatives for the health design and innovation team at Sutter Health. "For a young person who uses Scout, they sign up, then they receive weekly screeners. Those weekly screeners are based on evidence-based tools that measure both anxiety and depression—the GAD-7 and PHQ-9. Based on the young person's responses to the screeners every week, they receive personalized content."
The screeners rate a young person's symptoms from mild, to moderate, to severe. When a rating reaches the moderate level, the young person automatically gets outreach from a nonclinical guide. Reaching out to a clinician is recommended for additional support, she says. "We are very conscious of directing young people back into care if their scores are showing that they are at a level that may require clinical care. That provides a safety net."
2. Digital modules of educational and supportive materials
Downloadable information that Scout provides falls into two categories: young people received personalized information based on responses to the screeners, and young people and their caregivers receive standard digital information modules on a weekly basis.
The standard digital information modules can be educational about anxiety and depression or address other topics such as communication skills, Pant says.
"When a caregiver signs up for Scout, the main difference is that the young person has a highly personalized experience with the screeners. If you sign up as a caregiver such as a parent, modules are sent out on a weekly basis that parallel the modules that the young people receive. For example, if a young person receives an educational module on anxiety, their caregiver will receive the same module of content. For the caregiver, the goal is to build resilience through building knowledge," she says.
An example of personalized information is making it age-specific, Pant says.
"A lot of people in their early 20s are in the workforce, and we have tools that are valid for that age group like isolation at work, communication with peers, living successfully with roommates, managing finances, and the stress of dating. So, there is a host of content that is not necessarily clinical but addresses things that form the basis of people's everyday anxieties. On the younger end of the spectrum, we have content modules that address things like talking with friends about mental health, having a healthy diet, tips for getting to bed on time, and tips for settling the mind," she says.
3. Exercises
Scout has been designed to not be directive or prescriptive. For example, exercises linked to the information modules provide options for young people, Marx says.
"As the youth or the young adult goes through the different modules, there is a variety of different exercises that they can choose to participate in. There are no dictates or prescribing in the tool—there are just helpful suggestions. If someone decides to do one of the exercises, Scout checks on how they feel after the exercise to give some insight into whether a particular practice improves overall well-being. Because Scout is not a clinical tool, youth can pick and choose exercises or material that are going to be meaningful to them. There is no monitoring of what material or exercise has been used, so young people are completely autonomous," he says.
4. Nonclinical guides
A unique aspect of Scout is the use of nonclinical guides provided by Boston-based Docent Health to engage young people, Pant says.
"The core of the program and what really differentiates it is that we support the experience that young people go through for 12 weeks with nonclinical guides. Docent Health provides the nonclinical guides—they essentially guide the experience. For example, in addition to my weekly screener, I can text additional concerns. In that case, a Docent guide will step in and give a personalized response. That boosts the support because young people know that they can reach out if they want to," she says.
The nonclinical guides play a key role in Scout, Pant says. "Once you are enrolled in the program, you receive the screeners in an automated way, but you are welcomed into the program by a nonclinical guide. That nonclinical guide also keeps checking in with you through the course of the program. The nonclinical guide is also available via text as a source of support and engagement."
Sutter Health decided to include a human touch in Scout because of design-stage feedback from young people and the project's youth advisory group, she says. "Across the board, from age 12 to 26 and in the youth advisory group, we heard that one of the key challenges that young people face when they are feeling depressed or anxious is that they feel isolated. We responded to that need for human connection by creating a program that had an opportunity for nonclinical, human guide support."
Measuring Scout's impact
Sutter Health and Docent Health created a dashboard for Scout that has metrics on the population health and individual level.
On the population health level, week-over-week aggregate scores on the anxiety and depression screeners measure whether participants are trending in a positive or negative direction.
Engagement level is also measured week over week. Engagement is measured by how many people are completing the screeners and how many people are texting the nonclinical guides.
So far, the numbers look good, Pant says. "We have had about 510 users over the past three months: 40% of them are caregivers and 60% of them are young people. On an aggregate basis, we have seen a 1.7% improvement in anxiety scores; so, week-over-week, we are seeing improvement in anxiety at the population health level. About 95% of the users say they are finding the modules meaningful."
More faculty at a Texas academic medical center are considering quitting or scaling back to part-time employment during the pandemic.
Faculty at an urban academic medical center are more likely to quit or move to part-time employment during the coronavirus pandemic, a recent research article found.
Clinician burnout was already at high levels before the coronavirus pandemic began in spring 2020. It is widely believed that work-life integration and burnout have worsened during the pandemic.
The recent research article, which was published by JAMA Network Open, features survey data collected from more than 1,000 medical, graduate, and health professional school faculty at the University of Texas Southwestern in Dallas. The survey was conducted in September 2020.
The study includes several key data points.
After the coronavirus pandemic began, faculty were more likely to consider quitting or scaling back to part-time employment than before the pandemic (quitting 23% versus 14% and scaling back to part time 29% versus 22%)
After the coronavirus pandemic began, female faculty were more likely to consider quitting or scaling back to part-time employment compared to male faculty than before the pandemic (quitting 28% versus 15% and scaling back to part time 40% versus 13%)
After the coronavirus pandemic began, faculty with children were more likely to consider quitting or scaling back to part-time employment than before the pandemic (quitting 29% versus 17% and scaling back to part time 40% versus 24%)
After the coronavirus pandemic began, female faculty with children were more likely to consider quitting than female faculty without children than before the pandemic (quitting 35% versus 17%)
"In this survey study, the perceived stressors associated with work-life integration were higher in women than men, were highest in women with children, and have been exacerbated by the COVID-19 pandemic. The association of both gender and parenting with increased perceived work-life stress may disproportionately decrease the long-term retention and promotion of junior and midcareer women faculty," the research article's co-authors wrote.
Interpreting the data
Raising children is a major stressor for female faculty regardless of the pandemic, the research article's co-authors wrote. "In our study, faculty who were mothers were more likely to consider leaving or already had or were considering reducing their employment to part time both before and since the pandemic compared with faculty women without children, highlighting the universal stress of caregiving independent of the pandemic."
Working part time can exacerbate existing gender gaps at academic medical centers, the research article's co-authors wrote. "In our study, women were 3 times more likely than men to consider or already be employed part time both before and since the pandemic. Part-time faculty perceive that they perform more unpaid work, have fewer research opportunities, a slower career trajectory, and may be less likely to take on leadership appointments."
Academic medical centers should take actions to improve work-life integration, particularly for female faculty, the research article's co-authors wrote.
"Better support of working parents, specifically working mothers, through flexible work policies, improved childcare and parental leave programs, more equitable sharing of unpaid care hours between women and men, and active acknowledgment of the effects of work-life conflict on academic productivity and fulfillment are paramount to ensuring academic medicine does not lose talented faculty and proactively combats gender inequity and gender-based advancement regression," they wrote.
Although verbal threats were the most common kind of workplace abuse reported by survey respondents, 34% of the ED healthcare workers also reported physical assaults by patients.
Violence toward emergency department healthcare workers is prevalent and underreported, and victimized ED healthcare workers experience emotional injury during and after assaults, a new research article found.
Earlier research has shown that EDs are a hotbed for workplace violence. A New York City study found that 97% of emergency medicine resident physicians had experienced verbal harassment in an ED. A study published in 2016 found that 78% of ED healthcare workers had reported a violent assault in the prior year.
The new research article, which was published by Annals of Emergency Medicine, is based on survey data collected from 123 ED healthcare workers at an academic medical center in North Carolina. The survey respondents included 27 resident physicians, who were hypothesized to be at greater risk of workplace violence than their older colleagues.
"Residents are in training, are often young, and frequently have minimal experience with such encounters. They may lack the skills or training needed to prevent, manage, or process incidents of abuse," the research article's co-authors wrote.
The research article includes several key data points.
Among all survey respondents, 80% reported at least one verbal assault in the prior year. Among residents, 89% reported at least one verbal assault in the prior year.
Among all survey respondents, 70% reported experiencing verbal assault multiple times. Among residents, 74% reported experiencing verbal assault multiple times.
Among all survey respondents, 34% reported one incident of physical assault. Among residents, 22% reported one incident of physical assault.
Among all survey respondents, 9% reported multiple physical assaults. No residents reported multiple physical assaults, which the researchers said was likely due to the clinicians working in the ED for less than 2.5 years.
Among all survey respondents, 63% reported feeling unsafe in the workplace. Among residents, 67% reported feeling unsafe in the workplace.
Among residents, 96% discussed workplace abuse only with a colleague or no one at all. None of the residents filed formal incident or police reports.
The healthcare workers were asked whether there were specific reasons that led perpetrators to commit acts of violence or abuse. Among healthcare workers who experienced assault, 22% said they believed the incident was motivated by race or ethnicity, 21% said they believed the incident was related to their sex or gender identity, and 21% said they believed the incident was related to their age.
"Although verbal assault is most common, 34% of healthcare workers in this academic ED also reported incidents of physical assault by patients. Consistent with prior studies, only 20% of respondents filed formal incident reports or police reports, and when looking specifically at resident responses, there were no formal reports filed," the research article's co-authors wrote.
The survey responses generated 24 narratives about workplace violence and abuse. The narratives featured four themes: comments on assaults and threats, feeling unsafe, resignation, and influence on care. The following are examples of comments that fell into these four themes.
Assaults and threats: "A patient was verbally assaulting. After many minutes of being yelled at, the patient hit me and swung at another nurse demanding IV pain medicine, then proceeding to scream that this was our fault, and threatening to kill us and our families."
Feeling unsafe: "I was punched in the eye by a psych patient, did not file a police report because the officer made me feel like I contributed to the incident. I missed three days of work. Now I always feel unsafe on my job."
Resignation: "Workplace violence is unfortunately part of the job. It's concerning that charges can be filed against a healthcare professional for too much force but nothing can be done when a patient punches, kicks, bites, scratches, pulls hair, or generally assaults you. I'm not here to get beaten up. This culture needs to change before a nurse gets killed by a patient."
Influence on care: "I've experienced multiple encounters with intoxicated patients being verbally abusive and threatening. It has definitely impacted my ability to provide care."
Research insights
Verbal and physical abuse of healthcare workers takes an emotional toll, one of the research article's co-authors told HealthLeaders.
"The experience of abuse in the workplace can certainly contribute to burnout, lower job satisfaction, stress, and disengagement. In the worst cases, when there are physical threats, it can even lead to fear and a change in behavior such as canceling social media accounts or not driving directly home," said Christina Shenvi, MD, PhD, an associate professor of emergency medicine at the University of North Carolina School of Medicine in Chapel Hill, North Carolina.
An effective incident reporting system is crucial to addressing workplace violence in healthcare settings, she said. "It is important that healthcare workers know that if they report concerns, that action will be taken to help keep them safe and prevent future incidents."
Healthcare organizations should have a set of essential interventions and responses in place to address workplace violence, Shenvi said. "Institutions should have a process for assessing the reports and events, provide legal support when needed, and create policies and procedures to prevent future abusive episodes. In addition, institutions should have a means of providing emotional and personal support to healthcare workers to facilitate emotional recovery."
MercyOne's new chief medical executive says he is positioned to be a primary leader in the health system's efforts to achieve health equity.
A chief medical executive has a key role to play in addressing health equity, the new chief medical executive at Clive, Iowa—based MercyOne says.
Hijinio Carreon, DO, was recently named to the newly created position of chief medical executive at the MercyOne health system. An emergency medicine physician, Carreon previously served as chief medical officer of MercyOne Des Moines Medical Center.
Carreon recently talked with HealthLeaders about a range of issues, including health equity, physician engagement, and his vision for telehealth after the coronavirus pandemic has passed. The following is a lightly edited transcript of that discussion.
HealthLeaders: What is the role of the chief medical executive in addressing health equity?
Hijinio Carreon: As the chief medical executive, I should promote and ensure responsibility across all disciplines in terms of health equity. I should be in the forefront in addressing health disparities. In this role, I find myself as an essential leader of the hospitals and need to make sure that I create an equitable environment for our diverse population.
COVID-19 has resulted in a lot of changes and identified many weaknesses in our healthcare delivery system—whether those are related to social determinants or how we manage chronic illnesses. From my perspective, it is extremely vital to address health equity. I must ensure that I am implementing effective education programs for our clinicians to address their unconscious biases and to garner patient trust.
My immediate objectives related to health equity and personalized care are a digital strategy to create avenues to improve access to care and ensuring that we continue to move to a value-based care model. We currently utilize health coaches and community health workers to identify the social determinants that exist in our communities. We do not want to just address social determinants but also tie them into the resources that exist within the communities, so that we are addressing the fundamental reasons for why people are not seeking medical care or why people are unable to make an appointment that has been scheduled.
HL: What are the primary elements of personalizing patient care?
Carreon: There has been a lack of personalized care for a long time. Healthcare has struggled to gather patient information necessary to tailor care because of the disparate electronic health records that exist even within some health systems. This creates a great deal of frustration for not only patients but also physicians.
When you break down personalized care, it spans multiple dimensions. There is a partnership between the clinician and the patient. At MercyOne, we want to ensure that we create adequate healthcare access points. We want to ensure that we have effective methods of communicating across the continuum of care.
In my role as chief medical executive, being that chief clinical person over both the ambulatory and inpatient sides means being able to see both sides and not just have physicians focused on the ambulatory side or the inpatient side. I need to oversee the operation from both avenues to ensure that we are fulfilling patient needs across the continuum of care. I want to ensure that patient data is accessible and viewable across the delivery models—whether that is ambulatory, subspecialty services, or the inpatient setting.
HL: What are the primary elements to success in physician engagement?
Carreon: The keys to physician engagement are transparency, alignment of our goals, physician empowerment, teamwork and collaboration, and allowing physicians to lead.
In terms of transparency, at times, the belief is that the physician is the frontline worker and may not have a vested interest in the finances and payer issues that may be occurring in healthcare industries. In reality, physicians developing an understanding of how reimbursement is done, what the current finances are, and where the opportunities exist helps create alignment. With alignment, the goal of the organization's success should align with the goals of the practicing clinicians. So, if their goals are improvement of patient care and improvement of patient access, they should align with the organization's goals.
HL: What is your vision for telehealth after the coronavirus pandemic has passed?
Carreon: I have a strong belief in telehealth. In the initial months of COVID-19, about 25% of our patient visits were performed virtually. As we continue to reopen our clinics safely, digital health still maintains a significant objective for us.
When it comes to accessibility, I cannot emphasize enough that telehealth is one of the strategies to improve accessibility, especially in a state like ours where we have a lot of rural communities. There is not a hospital in every town. There is not a clinic in every town. So, we must have different modalities for patients to access us. Versus a trip of several hours, telehealth offers an opportunity for patients to stay in their homes and access care.
If patients need a higher level of care, telehealth can direct patients to the appropriate location to get whatever additional care they may require.
There are concerns about access to broadband as well as insurance and reimbursement issues that may prevent patients from accessing virtual services. We need to make reimbursement transparent for the consumer to ensure that they know what they are going to have to pay out of pocket and what their insurance is going to cover.
From the patient's perspective, we must create a seamless telehealth experience.
HL: What are the primary measures for the performance of a chief medical executive?
Carreon: Physician and advanced practice provider engagement is extremely important. Quality outcomes—specifically around hospital-acquired conditions and mortality—are extremely important. Then there is improvement in the equity of care in the communities we serve. Health equity must be more than a nice statement that is said—it must be embedded in the belief of the frontline physicians that they believe there is an opportunity to improve equity in care. If people understand the importance and value of keeping our communities healthy, that engenders trust in the patients who we serve.
Population growth and aging are expected to be the primary drivers of demand for physicians through 2034, a healthcare workforce report says.
By 2034, there will be a shortage of physicians ranging from 37,800 to 124,000, according to a recent report prepared for the Association of American Medical Colleges.
The AAMC has published seven annual supply and demand reports on the physician workforce since 2015. Projected shortages of physicians pose several implications, including limiting access to care, stymying efforts to achieve health equity, and eroding clinician well-being.
The projected physician shortage is a complex challenge that requires urgent action, AAMC President and CEO David Skorton, MD, said in a prepared statement.
"Addressing the physician shortage requires a multipronged solution that starts with educating and training enough physicians to meet America's needs and includes improving access to care, diversifying the physician workforce, and ensuring our nation is prepared to address current and future public health crises. Now more than ever, the nation must make a long-term investment in the healthcare workforce. The time to act is now," he said.
This year's AAMC physician workforce report was prepared by the Life Science division of IHS Markit, a global information company. The analysis was conducted before the onset of the coronavirus pandemic and was updated with trends in healthcare delivery and the physician workforce such as physician work hours and retirement trends.
The report features five key findings.
1. Projected physician shortage by 2034
Demand for physicians is projected to grow faster than supply for more than a decade, with the physician shortage by 2034 set to range from 37,800 to 124,000, the workforce report says.
The shortfall of primary care physicians is projected from 17,800 to 48,000 by 2034.
The shortfall of specialty physicians is projected from 21,000 to 77,100 by 2034, including the following three categories:
Surgical specialties shortfall from 15,800 to 30,200
Medical specialties shortfall from 3,800 to 13,400
Shortage in other specialties ranging from 10,300 to 35,600
2. Demographic drivers
Population growth and aging of the U.S. population are expected to be the primary drivers of demand for physicians from 2019 to 2034, the workforce report says.
"During this period, the U.S. population is projected to grow by 10.6%, from about 328.2 million to 363.0 million. The population under age 18 is projected to grow by 5.6%, which portends low growth in demand for pediatric specialties. The population aged 65 and older is projected to grow by 42.4% — primarily due to the 74.0% growth in size of the population age 75 and older. This trend portends high growth in demand for physician specialties that predominantly care for older Americans," the report says.
3. Aging workforce
Many physicians are approaching retirement age, and trends in retirement decisions will have a significant impact on the supply of physicians, the workforce report says.
"More than two of five currently active physicians will be 65 or older within the next decade. Shifts in retirement patterns over that time could have large implications for physician supply. Growing concerns about physician burnout, documented in the literature and exacerbated by COVID-19, suggest physicians will be more likely to accelerate than delay retirement. On the other hand, economic uncertainty and any detrimental effect on physician wealth could contribute to delaying retirement," the report says.
4. Impact of increasing care access
The coronavirus pandemic has heightened concern over health equity and care access, the workforce report says. "COVID-19 has raised awareness of the disparities in health and access to care by minority populations, people living in rural communities, and people without medical insurance."
If these concerns are addressed, demand for physicians will increase significantly, the report says. "If underserved populations had healthcare use patterns like populations with fewer access barriers, demand would rise such that the nation would be short by about 102,400 (13%) to 180,400 (22%) physicians relative to the current supply. Improving access to care is a national imperative."
5. Impact of the coronavirus pandemic
COVID-19 will likely impact both supply and demand for physicians, but the effects will be hard to determine for years, the workforce report says.
"The current pandemic has demonstrated that to better ameliorate the morbidity, mortality, and economic impacts of future pandemics, we will need to train (or cross-train) more physicians to alleviate shortages in crucial specialties and settings; approach this ramp-up within a context of equity, diversity, and inclusion; focus on the well-being of the healthcare workforce so that our providers are healthy enough to provide high-quality care to patients; and improve the effectiveness and efficiency of care delivery by using promising technologies and team-based care," the report says.
The pandemic has exposed weaknesses in the healthcare system and placed a spotlight on the importance of physicians in U.S. medicine, Skorton said.
"The COVID-19 pandemic has highlighted many of the deepest disparities in health and access to healthcare services and exposed vulnerabilities in the healthcare system. The pandemic also has underscored the vital role that physicians and other healthcare providers play in our nation's healthcare infrastructure and the need to ensure we have enough physicians to meet America's needs," he said.