The patients featured in a new research article underwent Rous-en-Y gastric bypass or sleeve gastrectomy—two of the most common kinds of bariatric surgery.
Compared to the general U.S. population, adults who are not married and get weight-loss surgery are more than twice as likely to get married within five years, and adults who are married and get bariatric surgery are more than twice as likely to get divorced, a new research article found.
The primary motivations for bariatric surgery are weight loss and decreasing the risk of potentially deadly weight-related conditions such as heart disease, stroke, and high blood pressure, according to Mayo Clinic. However, preoperative patients have also reported having bariatric surgery for reasons related to romantic relationships such as improving intimacy and finding a life partner.
"Weight loss is generally the goal of bariatric surgery, but people have a variety of motivators for wanting to lose weight—for example, remission of Type 2 diabetes and improvement in joint pain," the lead author of the new research article, Wendy King, PhD, said in a prepared statement. "Patients have also described the desire for romantic partnership or improving relationships as important motivators. Before this study, we had no quantitative data in the U.S. on how marital status changes after bariatric surgery—are patients more likely to get married, divorced, find romantic stability?"
King is an associate professor in the Department of Epidemiology at the University of Pittsburgh Graduate School of Public Health.
The new research article, which was published by Annals of Surgery Open, is based on data collected from more than 1,400 U.S. adults who were enrolled in the National Institutes Health-funded Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. The patients examined in the new research article underwent Rous-en-Y gastric bypass or sleeve gastrectomy—two of the most common kinds of bariatric surgery—from 2006 to 2009.
The new research article features several key data points.
The relationship status of most of the LABS-2 participants did not change in the five years they were followed after surgery, with 81% of married participants staying married and 70% of always-single participants staying single.
However, 18% of unmarried LABS-2 participants got married, compared to 7% of the general U.S. population during the same five-year time period; and 8% of the married participants got divorced, compared to 4% of the general U.S. population.
Cohabitating or being separated versus always single, younger age, having a college degree versus a high school education, lower body mass index, and lower Beck Depression Inventory score before surgery were associated with an increased likelihood of marriage after surgery.
Among LABS-2 participants who were not married before surgery, two of 16 pre- to postoperative changes evaluated in the new research article were associated with being married after surgery: improvement in physical health and an increase versus no change in household income.
Female sex, younger age, household income under $25,000 versus greater than or equal to $100,000, smoking, alcohol problems, and having sexual desire greater than once a week versus never were associated with an increased likelihood of separation or divorce after surgery.
Four pre- to postoperative changes were associated with being divorced or separated after surgery: greater weight loss, decrease versus no change in household income, starting psychiatric medication versus no preoperative or postoperative use, and increase versus no change in sexual desire.
"These estimates of change in marital status are higher than expected based on the percentage of U.S. adults who were married and the reported marriage and divorce rates from the same timeframe in the U.S. general adult population. Several preoperative predictors of marriage and of separation or divorce were identified, many of which have been identified in the general population. Greater weight loss was related to a higher chance of postoperative separation or divorce but not marriage," King and her co-authors wrote.
Interpreting the data
Lifestyle changes after surgery associated with weight loss likely contributed to higher rates of divorce and separation, King said. "This could indicate that a patient's changing lifestyle post-surgery put them out of sync with their spouse. It can be really hard when one spouse changes what they eat and how active they are, and desires more sexual activity, while the other doesn't. That can put significant strain on a marriage. It may be important for couples to consider this and have strategies to maintain their connection after surgery."
The new research article's findings about weight loss after bariatric surgery and its association with divorce were similar to the results of a Swedish study, King and her co-authors wrote. "The positive association between weight loss and divorce was also seen in the Swedish cohort and may reflect improved self-image and self-confidence that increase motivation or strength to leave an unhealthy marriage."
King and her co-authors offered other interpretations of the divorce data. "Additionally, partners of adults who undergo bariatric surgery may feel greater jealousy over their partner's weight loss and attractiveness or feel that they are no longer needed. Household income likely decreased as a function of the separation or divorce. Likewise, factors that prompted starting psychiatric medication may have stemmed from, rather than contributed to, separation or divorce."
King and her co-authors speculated on why an improvement in physical health and an increase in household income were associated with being married after weight-loss surgery. "Whereas improved physical functioning may have led to behaviors that increased the chance of marriage, household income likely increased as a function of marriage."
For primary care physicians, a capitation model risk adjusted for age and sex generates the smallest physician gender pay gap, researchers found.
For primary care physicians, the gender pay gap among clinicians varies by compensation model, a new research article found.
Earlier research has shown that male physicians receive higher compensation than female physicians, with one study estimating that male physicians earn an average adjusted gross income that is about $2 million higher than female physicians over a simulated 40-year career. Another study found that in productivity-based compensation models female physicians earn less compensation than male physicians because they spend more time with patients and conduct fewer patient visits.
The new research article, which was published by Annals of Internal Medicine, features data collected from 1,435 matched primary care physicians (PCPs)—881 male clinicians and 554 female clinicians. The study has several key data points.
Female PCPs conducted fewer patient visits than their male counterparts on an annual basis (1,210.3 versus 1,477.7)
Under a productivity-based fee-for-service compensation model, median estimated annual compensation was $285,397 for male physicians and $225,276 for female physicians, for a difference of $58,829
The gender pay gap was similar under a capitation model that was not risk adjusted, with a difference of $58,723
The gender pay gap was larger under a capitation model risk adjusted for age alone, with a difference of $74,695
The gender pay gap was largest under a capitation model risk adjusted for diagnosis-based scores alone, with a difference of $89,974
The gender pay gap was smallest under a capitation model risk adjusted for age and sex, with a difference of $36,631
"We observe a 21% gender wage gap between matched male and female PCPs in the same practices under productivity-based primary care payment that is similar under unadjusted capitation, larger under capitation risk-adjusted for age alone and for diagnosis-based risk scores, and smaller when accounting for patient age and sex," the study's co-authors wrote.
Interpreting the data
Female PCPs conducting fewer patient visits contributed to the gender pay gap under the productivity-based compensation model, the study's co-authors wrote. "We found that despite female PCPs likely working similar hours to or even more hours than their male counterparts, female PCPs received less compensation under productivity-based payment due to conducting fewer visits. These lower visit rates may be explained by female PCPs spending more time per visit, or being less likely to work with nurse practitioners or physician assistants billing under their [National Provider Identifiers], for example, when performing female preventive visits involving pelvic examinations."
This gender pay gap under unadjusted capitated payment was likely due to female physicians having smaller attributed patient panels, the study's co-authors wrote.
Capitation with diagnosis-based risk adjustment may exacerbate the gender pay gap, the study's co-authors wrote. "We found that male physicians' patients had higher mean diagnosis-based risk scores than those of female physicians (and although male patients of female PCPs had the highest [Hierarchical Condition Category] scores of any group, this was offset by female PCPs having majority female patients with lower HCC scores)."
Adoption of a capitation model risk adjusted for age and sex may be well-suited to primary care, the study's co-authors wrote. "Going forward, an alternative payment model such as age- and sex-adjusted capitation that minimizes the gender wage gap, or future models that more directly capture primary care effort, may be beneficial not only from an equity standpoint but also for retention of the increasingly female primary care workforce that is already disproportionately subject to burnout. Sustaining these workforce members may mitigate primary care capacity constraints and, in turn, support better health outcomes at lower cost."
The findings of a new research article could indicate significant improvements in patient safety.
In the past decade, the annual rates for in-hospital adverse events decreased for acute myocardial infarction, heart failure, pneumonia, major surgical procedures, and all other conditions, a new research article found.
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. Despite two decades of attention, estimates of annual patient deaths due to medical errors rose steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The new research article, which was published in the Journal of the American Medical Association, is based on data collected from more than 244,000 adult patients hospitalized in 3,256 hospitals from 2010 to 2019. The study used data from the Medicare Patient Safety Monitoring System, which features 21 measures from four kinds of adverse events—adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events (hospital-acquired pressure ulcers and falls).
The study generated several key data points.
From 2010 to 2019, adverse events for acute myocardial infarction decreased from 218 to 139 per 1,000 hospital discharges
From 2010 to 2019, adverse events for heart failure decreased from 168 to 116 per 1,000 hospital discharges
From 2010 to 2019, adverse events for pneumonia decreased from 195 to 119 per 1,000 hospital discharges
From 2010 to 2019, adverse events for major surgical procedures decreased from 204 to 130 per 1,000 hospital discharges
From 2012 to 2019, adverse events for all other conditions were unchanged at 70 adverse events per 1,000 hospitals discharges
After adjustment for patient and hospital characteristics, there was a significant decrease in the relative risk of adverse events for all other conditions from 2012 to 2019
For acute myocardial infarction, heart failure, pneumonia, and major surgical procedures, overall observed in-hospital mortality declined from 4.6% in 2010 to 2.7% in 2019
For the all other conditions group, overall observed in-hospital mortality increased from 1.2% in 2012 to 2.2% in 2016, with the rate at 1.7% in 2019
"In the U.S. between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures, and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions," the study's co-authors wrote.
Interpreting the data
Although the trends reported in the study do not definitely point to improvement in patient safety, the Medicare Patient Safety Monitoring System was designed to monitor adverse events, the study's co-authors wrote. Two other factors indicate the trends reflect an improvement in patient safety, they wrote. "The basis for the estimates is a highly structured and reproducible medical record abstraction process conducted at a central location by specialists in this work, and the definitions and measurement protocols were consistent over the study period."
The positive trends in adverse events are also consistent with major patient safety improvement initiatives launched during the study period such as the Partnership for Patients program as well as programs at the Centers for Medicare & Medicaid Services that target acute myocardial infarction, heart failure, and pneumonia, the study's co-authors wrote. Other factors could have improved patient safety, they wrote. "New technologies to support safety also were implemented along with new initiatives to increase person and family engagement in safety efforts. … Other factors such as spread of safer processes of care may also have played a role. Advances in care not directly attributable to patient safety efforts also may have contributed to the improvements (e.g., the widespread adoption of minimally invasive surgical techniques)."
The co-authors speculated on the cause of the only increase in adverse event rates reported in the study. "The only increase in adverse event rates was in the general adverse events domain for the all other conditions patient group in 2014 to 2019, and this finding may indicate a special need for new initiatives related to prevention of pressure ulcers and inpatient falls."
The co-authors also speculated about why there was a relatively low decrease in adverse events for the all other conditions category. "The lower overall rate of decline in adverse event rates in the all other conditions group, compared with the acute myocardial infarction, heart failure, pneumonia, and major surgical procedures groups, might be due to the quality improvement efforts targeted at the latter 4 conditions, whereas similar interventions did not occur for most of the conditions represented in the all other conditions group. Furthermore, the baseline adverse event rates were much lower in the all other conditions group, potentially leaving less opportunity to achieve improvement."
Jack Resneck Jr. shares the agenda for his American Medical Association presidency and prescriptions for some of the biggest challenges facing physicians.
A top priority for the new president of the American Medical Association is a recovery plan for the nation's physicians.
Jack Resneck Jr., MD, was recently inaugurated as the 177th president of the AMA. He is a practicing dermatologist in the San Francisco Bay Area and is the first dermatologist to serve as AMA president since 1925.
Resneck was elected to the AMA Board of Trustees in 2014, and he was board chair from 2018 to 2019. Before being elected to the AMA Board of Trustees, he served as chair of the AMA Council on Legislation and as a delegate to the AMA House of Delegates. Resneck has held several other leadership positions, including serving as the president of the California Society for Dermatology and Dermatologic Surgery.
HealthLeaders recently talked with Resneck about issues related to his AMA presidency, including his agenda, physicians and the coronavirus pandemic, and how physicians can address health equity. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: Physicians have been on the frontline of the pandemic for more than two years. What concerns should we have for physicians at this point in the pandemic?
Jack Resneck Jr.: First, I have never been prouder to be a physician as I look at my colleagues across the country and watch what they have endured and what they have done to support the country the past couple of years. They have put their lives on the line. Early in the pandemic, doctors were sleeping in their garages or tents to protect their families.
In terms of concerns, physicians have been holding together a health system that has been stretched too thin and tested by the pandemic. I have an enormous amount of concern about physician attrition and retirements. The AMA led a study that showed about one-in-five of physicians and about two-in-five of nurses intend to leave their professions in the next two years. On the physician side, we know that replacement costs are substantial. For organizations that employ physicians, the replacement costs are between $250,000 to $1 million per physician. The aggregate costs of physicians reducing their work time due to burnout alone is estimated to be $4.6 billion a year in the United States.
HL: What are the top agenda items for your AMA presidency?
Resneck: We have already talked about COVID stretching the healthcare system to the brink and furthering burnout among physicians. I feel strongly that our nation must renew its commitment to physicians and the patients they serve.
The Recovery Plan for America's Physicians has several points. One of them is addressing burnout and destigmatizing mental health issues for physicians. Another point is removing dysfunction from the healthcare system, which goes hand-in-hand with addressing burnout because dysfunction is a major driver of burnout. Prior authorization is a good example—it has grown out of control in the past few years. I have been a practicing physician for about two decades, and I remember a time when prior authorization was focused on a few expensive medications or tests. I now have to do prior authorizations for generic topical creams that have been around since the 1960s.
A third pillar of the Recovery Plan is stabilizing Medicare payments. We have seen two decades of nearly frozen payments as practice costs have gone up and inflation is now accelerating. Whether you are a large health system or a small physician practice, that is just unsustainable. In order for health systems and physicians to be able to invest in the future of healthcare, Medicare payments have to get fixed.
Fourth, the AMA is also focused on team-based care and making sure physicians are recognized for their expertise at the top of those teams. And fifth, we are focused on innovation and continuing to further telehealth and other innovations that help physicians move forward.
In terms of other top agenda items, I want to focus on a couple of other things. One is innovation more broadly. It has been a priority of mine for several years that when we have seen innovation go wrong in healthcare—such as lousy electronic health record products—it has been because physicians were not in the room in the early stages when the building blocks were being created. So now, with digital health and artificial intelligence, the AMA is working hard to bring physician values to the table.
Second, I want to keep politicians out of exam rooms. In reproductive health, transgender care, and other areas, we have seen states inserting politicians into the decision-making process that should be between doctors and patients.
Finally, I want to advance health equity. There are shameful inequities in our healthcare system for Black, Brown, Indigenous, and other marginalized patient populations.
HL: What can physicians do to address health equity?
Resneck: At the AMA, we created a Center for Health Equity a few years ago. In 2021, we released a plan to embed racial justice and advance health equity at the AMA and in healthcare. We are committed to eliminating longstanding health inequities and improving outcomes for historically marginalized populations.
There are many pieces to this work. One piece that is very important is reckoning with our own history at the AMA. We have been around for a long time and have done things in the past that have exacerbated inequities. Ultimately, addressing health equity is about embedding this work across the entirety of our organization, whether it's in how we think about chronic disease, whether it's thinking about medical education and having a pipeline of future physicians that looks like the patients we serve, whether it's in advocacy, litigation, or innovation. The effort needs to be on all fronts—it is not siloed work.
As physicians inside the AMA and nationally as a profession, we have an important role to play. This is part of our medical ethics and important to do for the patients we serve.
As individuals and groups, there are several steps physicians can take to address health equity. First is just being committed to doing the work. You must call it out and make it clear that this is something that you are committed to.
We have to have the education and training to shift our norms and practices. We need to be working in medical education to make sure we are producing physicians who are prepared to do this work. We must do the reading of the research so that we know the steps that we need to take.
Within our practices and organizations, we must analyze data to understand where inequities exist and are emerging. We need to develop a clear vision and goals within our practices and our communities. We need to do the work by launching targeted improvement efforts and measuring our progress as we go.
HL: How can healthcare organizations address physician burnout?
Resneck: We know that burnout can be reduced or even prevented with intentional organizational initiatives. The return on investment for organizations that address burnout can be substantial.
Since 2012, the AMA has been a leader in the national conversation on the physician burnout crisis. We have approached burnout in a data-driven way—both in terms of identifying what the problems are and what the solutions are.
Burnout manifests in individuals, but we think it originates in systems, and physicians cannot solve this crisis on their own. Addressing burnout requires a comprehensive strategy and investment to target barriers and burdens. Addressing burnout is not about yoga classes, dinners with leadership, and resiliency training, which are all lovely add-ons, but they are not at the core of what is going to solve burnout. If anything, they send the wrong message, which is the problem is with the physician as opposed to being with the system.
There are three things that systems must do to address burnout. First, measure burnout with validated tools such as the Mayo Clinic Well-Being Index and the Stanford Professional Fulfillment Index. Knowing where you are starting is important. Second, for healthcare organizations, addressing burnout must be an organizational value. It must be on the leadership dashboard and resourced. Third, the changes must be real. Physicians need real help with tasks that do not need to be done by physicians. For example, the in-basket in electronic medical records requires a team-based approach.
HL: What advice do you have to offer to new physicians entering the field?
Resneck: Given the challenges of the past two years, it would be easy for new physicians to be hesitant about the field. But I love my job—whether it is the part of my job that involves going into an exam room and working one-on-one with a patient or whether it is getting involved in policy and advocating on behalf of physicians.
I love what I do. So, I hope young physicians can be optimistic about the future that is ahead because we still have one of the coolest jobs possible. Physicians are incredibly lucky and privileged to do our work.
Survey data finds that 21% of healthcare workers experience childcare stress.
For healthcare workers, childcare stress during the coronavirus pandemic is associated with higher rates of burnout, intent to reduce work hours, and intent to leave jobs, a new research article says.
The pandemic has worsened preexisting childcare accessibility problems and disparities. Before the pandemic, the annual cost of full-time childcare for an infant was $21,700, which is more than one-quarter of an average hospital nurse's salary and more than two-thirds of an average nursing assistant's salary. Childcare is in short supply, with childcare desert designationsin three of five rural areas. In addition, it is difficult for healthcare workers to find care outside typical hourssuch as nights and weekends.
The new research article, which was published by JAMA Network Open, is based on survey data collected from 58,000 healthcare workers, including 15,700 physicians and 11,400 nurses. The study has several key data points.
Childcare stress (CSS) was reported in 21% of healthcare workers
CSS was more common in women than men (21.1% versus 17.9%)
Compared to healthcare workers without CCS, those with CCS had 115% greater odds of anxiety or depression
Compared to healthcare workers without CCS, those with CCS had 80% greater odds of burnout
High CCS was linked to 91% greater odds of intent to reduce work hours (ITR) and 28% greater odds of intent to leave jobs (ITL)
CCS was more common among racial and ethnic minority healthcare workers than White survey respondents
"The COVID-19 pandemic has had a myriad of effects on [healthcare workers] that put our workforce at risk. These data show an association between CCS and burnout, anxiety and depression, and ITL and ITR. Institutional interventions supporting childcare resources for [healthcare workers] may attenuate burnout, anxiety, depression, ITR, or ITL," the study's co-authors wrote.
Interpreting the data
Efforts to address CCS in healthcare workers should include interventions targeting racial and ethnic minority employees, the study's co-authors wrote. "Recovery based on racial equity needs to include collecting data, involving racial and ethnic minority communities in the process, and increasing access to childcare going forward. Without these efforts, individuals from minoritized groups will probably experience reduced participation in the workforce."
The study's findings also have important implications for female and male healthcare workers, the co-authors wrote. "Attending to CCS may help lower burnout rates for women, who historically have higher burnout rates than men. Given the increased burden women face at home, removing barriers for men in their participation in home duties is critical. Recognizing that men who are experiencing high CCS have strong odds of reporting anxiety and depression is important in discussing ways to support removing CCS burden from both male and female [healthcare workers]."
Childcare considerations should be a priority at healthcare organizations, the co-authors wrote. "We propose a more intentional approach in the health care workplace to assessing and addressing childcare concerns when worker assignments are made. Workplaces that can accommodate change on short notice, provide on-site care for ill children or on-site schools, and are aware of worker concerns about their children will be better positioned to show workers they are a caring environment, one that, we hope, workers would be more likely to remain with rather than leaving for shift work in other settings, a scenario that is currently occurring in large numbers."
Healthcare organizations should consider offering their own childcare services, they wrote. "Work-affiliated childcare reduces CCS and would be a reasonable strategy to mitigate the impact of childcare stress on ITL or ITR."
Merritt Hawkins, which is the largest physician search firm in the country, shows strong starting salaries and rising demand for physicians in latest annual report.
After being suppressed during the first year of the coronavirus pandemic, the job market and starting salaries for physicians appear to be rebounding, according to an annual report from AMN Healthcare and its physician search division, Merritt Hawkins.
Demand for physicians slumped in 2020, as health systems and hospitals suspended elective surgeries to accommodate COVID-19 surges and patients avoided healthcare settings because of fear of coronavirus infection. Downward pressure was exerted on physician compensation, and some physicians faced furloughs or reduction in working hours.
AMN Healthcare's newly released 2022Review of Physician and Advanced Practitioner Recruiting Incentives indicates the worst impacts of the pandemic on physician demand and compensation may be over. "Demand for physicians, and the salaries they are offered, have rebounded dramatically from the height of COVID-19," Tom Florence, president of physician permanent placement for AMN Healthcare, said in a prepared statement. "Virtually every hospital and large medical group in the country is looking to add physicians."
The 2022 Review is based on a representative sample of 2,695 permanent physician and advanced practitioner search engagements that AMN Healthcare and Merritt Hawkins had ongoing or conducted from April 1, 2022, to March 31, 2022. The report has several key findings.
Physician starting salaries show a rebound from the downward pressures of the first year of the pandemic, with the starting salaries of 14 physician specialties up year-over-year and only three down.
Orthopedic surgeons were offered the highest starting salary for physicians at $565,000.
Pediatricians were offered the lowest starting salary for physicians at $232,000.
Signing bonuses increased compared to the 2021 Review, with the average signing bonus for physicians rising from $29,656 to $31,000 and the average signing bonus for nurse practitioners (NPs) and physician assistants (PAs) rising from $7,233 to $9,000.
For the second year in a row, NPs were the most requested search engagement, which reflects a shift from physician office primary care delivery settings toward more convenient settings such as urgent care centers, retail clinics and telemedicine that employ advanced practitioners.
Nineteen percent of search engagements were for advanced practitioners such as NPs and PAs, which was up from 18% in the 2021 Review and 13% in the 2020 Review. This reflects higher demand for nonphysician clinicians.
Primary care physicians accounted for only 17% of search engagements, down from 18% in the 2021 Review and 20% in the 2020 Review. This reflects the shift from physician office primary care delivery settings toward more convenient settings.
Nearly two-thirds of search engagements were for physician specialists such as cardiologists, neurologists, and oncologists. This likely reflects the impact of an aging population that requires specialty care.
The combined categories of anesthesia providers (anesthesiologists and certified registered nurse anesthetists) accounted for the third highest requested search engagements. This indicates that the number of medical procedures requiring anesthesia, which declined in the first year of the pandemic, is rebounding.
Psychiatrists accounted for the fourth highest search engagements. This reflects the longtime shortage of behavioral health clinicians, which has been exacerbated by the pandemic.
Demand for telemedicine clinicians was strong, with 18% of radiology search engagements for teleradiologists and 15% of psychiatrist search engagements for telepsychiatrists.
Interpreting the data and trends
The increasing number of specialist search engagements relative to primary care physician search engagements represents a significant trend, Florence said. "The market has done a complete about-face. Several years ago, primary care physicians were the priority for most hospitals and medical groups. While many still seek them, the emphasis has shifted to specialists."
After slumping in the first year of the pandemic, demand for clinicians is surging, the 2022 Review says. "During the initial months of the pandemic, the number of search assignments Merritt Hawkins was engaged to conduct declined by 30% year-over-year. For the first time in over 33 years of providing physician search services, we saw a significant number of physicians laid off or furloughed, while some physicians were unable to find jobs coming out of residency. The contrast between then and the completion of our 2022Review could not be more pronounced. In the last quarter of 2021, Merritt Hawkins was retained to conduct more search engagements than in any other quarter in our history."
The number of physicians expected to leave the profession is alarming, the 2022 Review says. "The U.S. already faced a physician 'retirement cliff' before the pandemic, as close to 30% of active physicians are 60 years old or older. The fallout from COVID-19 is likely to accelerate physician retirements and otherwise drive exits from medicine as physicians become part of the 'Great Resignation' that has seen workers of all kinds leave their jobs."
Market disruptors such as retail clinics, insurance companies, and private investor groups are increasing demand for physicians and are likely to exacerbate physician workforce shortages, the 2022 Review says.
For example, CVS Health, which already has 1,500 Minute Clinics staffed mainly by NPs, is planning to open 1,500 HealthHubs that will shift from the episodic care provided at Minute Clinics to longitudinal care. "CVS has the stated aim of becoming the physician employer of choice, taking advantage of physician burnout and workplace disaffection to attract physicians seeking a more favorable practice model," the 2022 Review says.
The findings of new research point to ways to promote diversity among medical students.
Medical students are more likely to leave medical school if they are underrepresented in medicine by race and ethnicity, have low income, or come from underresourced neighborhoods, a new research article found.
Earlier research has shown that several racial and ethnic groups such as Blacks and Hispanics are underrepresented in the physician workforce compared to the demographics of the U.S. population. The lack of diversity in the healthcare workforce has a negative effect on patients of color, according to a report published earlier this year.
The new research article, which was published by JAMA Internal Medicine, features data collected from more than 33,000 allopathic doctor of medicine medical school students. The primary outcome examined by the researchers was medical student attrition, which was defined as withdrawal or dismissal from medical school for any reason.
The study has several key data points.
Among the 33,389 MD students in the study, 2.8% experienced attrition from medical school
Compared to non-Hispanic White students, students without low income, and students who did not grow up in underresourced neighborhoods, students who were underrepresented in medicine such as Blacks and Hispanics, students who had low income, and students who grew up in underresourced neighborhoods were more likely to experience attrition from medical school
Students that had all three marginalization characteristics (underrepresented in medicine, low income, and growing up in an underresourced neighborhood) had an attrition rate 3.7 times higher than students who were not underrepresented in medicine, did not have low income, and were not from an underresourced neighborhood
Students who were underrepresented in medicine experienced about twice the rate of attrition as non-Hispanic White students (5.6% versus 2.3%)
Students who had low income experienced about twice the rate of attrition as students without low income (4.2% versus 2.3%)
Students who grew up in underresourced neighborhoods experienced about twice the rate of attrition as students who did not grow up in underresourced neighborhoods (4.6% versus 2.4%)
"This retrospective cohort study demonstrated a significant association of medical student attrition with individual (race and ethnicity and family income) and structural (growing up in an underresourced neighborhood) measures of marginalization. The findings highlight a need to retain students from marginalized groups in medical school," the study's co-authors wrote.
Interpreting the data and conducting interventions
Earlier research has shown that medical students who are underrepresented in medicine are exposed disproportionately to interpersonal and structural barriers that affect their medical school experience. These students have other experiences that contribute to medical school attrition, the study's co-authors wrote.
"These students also often lack identity-concordant mentors and role models, are frequently burdened with instances of minority tax (similar to the disparity in responsibility for underrepresented faculty), and commonly experience microaggressions and discrimination, including exposure to bigoted remarks by patients and faculty, bias in evaluations, and inequities in the receipt of academic awards. These experiences of social isolation, racism, and discrimination have been associated with burnout, depression, and attrition and highlight the need for medical schools to adopt a more proactive antiracism strategy," they wrote.
The data from students with low income and students who grew up in underresourced neighborhoods indicate an important finding, the study's co-authors wrote. "Poverty and growing up in an underresourced neighborhood may have long-term consequences that are accentuated in medical training, such as lack of social and cultural capital to navigate medicine's hidden curricula, social isolation from affluent majority peers, and financial stress, which may be associated with attrition among students with low income."
Medical schools should consider conducting three interventions to reduce attrition among marginalized students, the study's co-authors wrote:
"Given the higher attrition rate among marginalized student groups, medical schools should consider reforms that dismantle structural inequities in medical culture and training that equate privilege with merit and physicians as an elite class of citizens. These reforms may begin with tuition and debt reform and purposeful partnership and support of local and national underresourced communities."
"Reforms could include robust financial and administrative support for diversity, equity, and inclusion offices and affinity groups representing marginalized groups. These offices should be populated with staff who are trained in critical race theory, health equity, and inclusive pedagogy and should be resourced to facilitate students' preclinical and clinical curriculum, offering programming for students, faculty, and staff on implicit bias, structural competency, and civil discourse."
"As medical schools strive to create an inclusive and equitable learning environment, [another] consideration could be an aggressive effort to hire faculty from diverse backgrounds, who may offer critical mentorship opportunities for all medical students. In addition, interactions between medical students and a diverse faculty have been shown to be associated with reductions in implicit bias in the learning environment."
The proposed behavioral health hospital would increase access to inpatient and intensive outpatient care in the Greater Boston area.
Tufts Medicine and Acadia Healthcare have formed a joint venture to build a 144-bed behavioral health facility on the site of the former Malden Hospital in Malden, Massachusetts.
The joint venture is designed to increase access to behavioral health inpatient and intensive outpatient care in the Greater Boston area. Access to care is one of the biggest challenges in behavioral health nationwide, with mental health patients boarded in hospital emergency departments for days or weeks awaiting the availability of inpatient beds.
"There is a critical need for capacity in behavioral health in the Commonwealth. Our plans to redevelop the Malden Hospital site into a state-of-the-art behavioral health hospital will help address the constraints on access to care that our healthcare providers and our patients and families face every day," Michael Dandorph, president and CEO of the Burlington, Massachusetts-based health system said in a prepared statement. "We are proud of the services that MelroseWakefield Hospital and Lawrence Memorial Hospital have provided and these plans expand upon the legacy of high-quality, compassionate care they have long delivered to patients."
The project faces local and regulatory review. Once the new facility opens in two to three years, MelroseWakefield Hospital and Lawrence Memorial Hospital in Medford will consolidate their inpatient behavioral health services at the new hospital. There will be a net gain of 86 inpatient beds.
The new behavioral health hospital represents a $65 million investment and will replace the former Malden Hospital, with a smaller footprint than the existing structure. Tufts Medicine and Acadia Healthcare are both contributing to the investment. The project will create 9 acres of conservation land and open space.
The top executive of Franklin, Tennessee-based Acadia Healthcare hailed the partnership with Tufts Medicine. "Acadia is extremely pleased to be partnering with a premier integrated healthcare system like Tufts Medicine, who shares in our mission and values," Acadia Healthcare CEO Christopher Hunter said in a prepared statement. "We look forward to creating this modern, patient-centered facility that will provide life-saving services to individuals and families throughout the region. The new hospital will also be a center of excellence for teaching the next generation of clinicians and staff so we can serve the community for many years to come."
Information about community engagement for the project is available online. A community meeting about the project is scheduled for July 19 at 6 p.m. in Malden City Hall.
For Forge Health patients with behavioral health and/or substance use conditions, if there is a comorbid physical condition that is included in the care plan.
New York City-based Forge Health, which provides a range of outpatient behavioral health services, takes a "full-person" approach to care, including physical health and social determinants of health.
Millions of Americans have both a physical health and a behavioral health or substance use conditions, according to the National Alliance on Mental Illness. Integrating care for behavioral health and physical health decreases fragmentation in care, and fragmentation is linked to poor health outcomes.
Forge Health offers outpatient behavioral health services and substance abuse services via telehealth and at offices located in Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, and Virginia.
Forge Health has been able to drive down utilization of medical services such as emergency room visits because the organization's care model is focused on both mental and physical health, says co-founder and CEO Eric Frieman.
"We have the ability to drive down utilization on the physical health side because we have a unified, full-person approach to care. In a treatment plan for one of our patients, just improving their mental health condition or their substance abuse symptoms is important, but it is not everything. If they have a comorbid medical condition, we include that as part of the treatment plan. For example, if one of our patients has diabetes, we make sure they are seeing an endocrinologist. If they are seeing an endocrinologist, they are adhering to the treatment plan; if they don't, it is time for a clinical intervention," he says.
Forge Health care model
Multidisciplinary teams are a cornerstone of the Forge Health care model, Frieman says. "We don't let any of our providers work in a vacuum or work alone. The multidisciplinary care team includes licensed mental health therapists as well as a psychiatrist or a psychiatric nurse practitioner. We also have care coordinators who helps patients coordinate their care with physical health providers and address social determinants of health. The care team works together on each patient's care. There are weekly clinical rounds and care team members are available to discuss and coordinate care for patients."
The care coordinator plays an essential role, says John Rodolico, PhD, chief science officer at Forge Health. "The therapists and psychiatrists on the multidisciplinary team cover a lot of bases, but they cannot cover everything. The care coordinator coordinates anything that falls outside the main hub of the team."
The clinicians and care coordinators share the responsibility of addressing the social determinants of health for patients, Frieman says. "We have community partners. We have a vetted list in each of our markets of nonprofits, community organizations, and government agencies. We assist our patients in getting connected to the right service."
Data analytics are an essential element of the Forge Health care model, Frieman says. "Everything that we do is electronic. So, we have the ability to track data such as progression of treatment. We have standard evaluation tools that allow us to track a patient's symptoms such as their depressive symptoms, their trauma symptoms, and their addiction symptoms. We can look at that data and see how a patient's condition progresses over time. Based off that evaluation and tracking of data, we can re-evaluate our treatment plans if necessary."
Forge Health uses four primary patient assessment tools: the BAM or Brief Addiction Monitor for substance use disorder, the PHQ-9 for depression, the PCL-5 for trauma, and the GAD-7 for anxiety.
The data analytics associated with these patient assessment tools are helpful both internally and with external healthcare provider partners, Rodolico says. "These are analytics that are used across the field, particularly the PHQ-9, PCL-5, and GAD-7, which are used across many organizations. So, these analytics can be used not only internally but also externally with other providers. For example, a first-responder can come in and be very high on the PCL-5. They go through the Forge Health program. At the end of that care, they can have a dip in their PCL-5 score, but they still need to be monitored. If everyone signs off, we can give the PCL-5 data to the clinician to whom we have handed off the patient. That way, the new clinician can see the improvement and where the patient needs to go in care."
Unique aspects of Forge Health
Streamlined care delivery is a hallmark of Forge Health, Frieman says.
"The behavioral health care industry is filled with point solutions, which is not how our model works. We have created a one-stop-shop for behavioral health. So, if a patient comes to us and they have a mental health issue and a substance use disorder, we can effectively treat that patient for both conditions without having to coordinate care with outside providers. With other providers, they may only be able to treat mental health conditions and have to coordinate with a substance abuse provider. With our multidisciplinary care teams, we have the ability to provide psychotherapy as well as evaluation and medication management services. We do it all in-house," he says.
Forge Health has a mature approach to virtual care, Rodolico says. "Forge Health has been ahead of the curve on virtual care. Many behavioral health organizations have adopted virtual care since the beginning of the coronavirus pandemic because they were forced to operate virtually. Our executive group has been looking to the future, and we were doing virtual care long before COVID-19 struck us."
Having the ability to provide high-quality care in-person or virtually is important at Forge Health, Frieman says. "The ability to have a hybrid model is critical for us. Patients can receive care in-person or via telehealth modalities. Having the ability to do both is a somewhat unique offering at Forge Health. Sometimes, patients want visits in-person; sometimes, patients want hybrid visits; sometimes, patients only want to be virtual."
Unlike many behavioral health organizations, Forge Health does not rely on grant funding to finance care, Frieman says. "We are in-network with every major health insurance company. We take Medicaid, Medicare, Veterans Affairs benefits, and TRICARE for active-duty military. There are no grants and no self-pay. All services are paid by someone's health insurance. In general, we are fee-for-service, but we also have value-based arrangements."
At the AdventHealth Post-COVID Clinic, new patients are evaluated by primary care, behavioral health, and physical therapy staff.
An extensive patient evaluation process is one of the distinguishing characteristics of a new long COVID clinic at Central Florida-based AdventHealth.
There are coronavirus "long haulers" among COVID-19 patients who have experienced mild, moderate, and severe infections. In one study of COVID-19 patients hospitalized with severe acute respiratory infection, functional impairment was found in 53.8% of patients four months after hospital discharge. Long COVID symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, and fatigue.
AdventHealth opened the health system’s Post-COVID Clinic in March. Determining whether patients have long COVID and characterizing their symptomology requires an exhaustive evaluation process, says Dwayne Gordon, MD, an AdventHealth Medical Group internal medicine physician and lead physician of the Post-COVID Clinic, which is based at AdventHealth Orlando.
"These patients are universally difficult to diagnosis. You have to determine whether a patient has long COVID, which is not a crystal-clear condition. With long COVID, a patient can present in numerous ways. It can be weakness. It can be forgetfulness. It can be shortness of breath. It can be a chronic cough. It can be anxiety, depression, or insomnia. A key question is: Did your symptoms start before or after you had COVID? So, delineating the timeline is part of diagnosing long COVID. We try to determine whether someone has had onset of new symptoms or significant worsening of chronic symptoms after COVID. Some people had anxiety before they contracted COVID, but it can get significantly worse after COVID," he said.
To qualify for care at the Post-COVID Clinic, a patient must have a confirmed COVID diagnosis and coronavirus symptoms for at least three months.
The patient evaluation process at the clinic is conducted in two phases—an intake telephone call with a registered nurse followed by a 90-minute in-person evaluation, Gordon says. "We conduct an intake interview before patients come to the clinic. That intake includes getting basic information about when the patient was diagnosed with COVID, their initial symptoms, and their current symptoms."
If the intake interview indicates a patient probably has long COVID, an in-person visit is scheduled, he says.
"For example, a patient could have been infected with COVID in 2020. We would ask about presenting symptoms, we would ask whether they were vaccinated before infection, we would ask whether the patient was hospitalized, we would ask whether they required oxygen, we would ask whether they required inpatient rehabilitation, and we would ask whether they required home oxygen. Then we would talk about their current symptoms. We also have a couple of forms for patients to fill out—the GAD-7 for general anxiety disorder screening and the PHQ-9 for depression screening. We get a SLUMS score to see whether there is evidence of memory loss or dementia. We screen all of our patients to see whether they have sleep-related disorders such as insomnia and obstructive sleep apnea. We go over their past medical history in detail, including medications and past surgeries. We also talk about their social history. Are they currently employed? Are they unemployed because of long COVID symptoms?"
The in-person evaluation also includes a complete physical therapy screening.
The evaluation process helps to establish a care plan, Gordon says. "After patients get evaluated by physical therapy, behavioral health, and myself, then we establish a comprehensive care plan. Many patients require physical therapy for generalized weakness. They might require occupational therapy because they are dropping things or are unable to do activities of daily living such as bathing, cooking, and dressing."
Staffing, referrals, and research
It is crucial for long COVID clinics to have multidisciplinary care teams, Gordon says. "When it comes to being multidisciplinary, we have a primary care physician, a behavioral health team, and a physical therapist. Patients get a comprehensive evaluation by all three of those disciplines. We also partner with subspecialists who we can make referrals to—we have AdventHealth pulmonologists and cardiologists. We also have a registered nurse, who helps with social work, and a practice manager."
Having a multidisciplinary clinic is a key to success, he says. "One thing we have learned, and we talk about regularly is the involvement of multiple departments—everything from marketing to research to behavioral health to primary care to physical therapy and beyond. We have all of these departments represented at a weekly meeting because long COVID is complex. You have to have a social worker, you have to have a nurse, you have to have medical assistants, you have to have doctors, you have to have your physical therapists. If you do not have those components, then you are going to fall short because these patients take a significant amount of time and resources."
The Post-COVID Clinic is conducting research to increase the understanding of long COVID with the AdventHealth Transitional Research Institute. One study that is already underway is examining how long COVID affects patients with diabetes. Researchers will observe changes to organs, such as the heart, lungs, liver, kidney, pancreas, and spleen following a COVID diagnosis in people with and without diabetes to determine how COVID and any related inflammation may impact organ function in diabetics.
Behavioral health dimension
Behavioral health services are an important element of the Post-COVID Clinic, Gordon says. "Some people have significant anxiety and depression. They not only require counseling but also may require medications. They can get counseling from us, then we transition them to outpatient counseling for modalities such as cognitive behavioral therapy, where they get help coping with the stressors of long COVID."
Insomnia is common among coronavirus long haulers, he says. "There can be multiple reasons for insomnia, including sleep disorders such as sleep apnea. They might get two or three hours of sleep per night. For these patients, we work on a medication regimen, and we work on sleep hygiene counseling that includes handouts for best practices to get a restful night."
Insomnia contributes to brain fog among long COVID patients, Gordon says. "It is well known that if you have insomnia, then your ability to think clearly is going to be impaired."
Forgetfulness and dementia are being observed in relatively young coronavirus long haulers, he says. "The majority of patients who are scoring for memory loss and dementia in the SLUMS evaluation are between 30 and 55 years old. It is highly unusual to see the scores that we are seeing in that age range. It is uncommon to do a SLUMS evaluation for people in this age range—this evaluation is typically done in the elderly population because that is when you tend to see forgetfulness."
