In addition to Black physicians being underrepresented, there is an income disparity between Black and White physicians, U.S. Census data shows.
There has been a modest increase in the percentage of Black physicians in the healthcare workforce for more than a century and Black physicians remain underrepresented, a new journal article says.
Earlier research has shown benefits from racial diversity in the physician workforce. For example, a study published in 2019 found that patients are more likely to undergo preventive services when under the care of racially concordant clinicians.
The new journal article, which was published in the Journal of General Internal Medicine, is based on U.S. Census Bureau data. The journal article features several key data points.
In 1900, Blacks accounted for 11.6% of the U.S. population and 1.3% of physicians were Black.
In 1940, Blacks accounted for 9.7% of the population and 2.8% of physicians were Black. Only 0.1% of physicians were Black women.
In 2018, Blacks accounted for 12.8% of the population and 5.4% of physicians were Black. The percentage of physicians who were Black women was 2.8%
The data shows a significant racial income disparity between Black and White male physicians. In 2018 dollars, the income gap was about $68,000 in 1960 and $50,000 in 2018.
The author of the journal article wrote that the proportion of Black physicians has remained low for more than a century and a racial income disparity has persisted.
"Little progress has been made in increasing the representativeness of the physician workforce and in achieving racial equity in physician pay. The proportion of physicians who are Black has increased by only 4 percentage points over the course of 120 years. The proportion of physicians who are Black men remains essentially unchanged since 1940, with the increase since then in proportion of physicians who are Black coming from an increase in Black women," wrote Dan Ly, MD, PhD, MPP, an assistant professor at the David Geffen School of Medicine at UCLA.
Ly told HealthLeaders the lack of progress in increasing the proportion of Black physicians is concerning. "If we care about the health of the U.S. population, particularly the health of Black patients, we should care about how few Black physicians we have and the glacial progress we have made as a medical system in increasing that number," he said.
Medical education is a key factor in increasing the representation of Black physicians in the profession, Ly said. "That takes medical leadership, starting with leadership at medical schools."
Culture plays a pivotal role in essential areas such as physician enterprise and patient safety, Tower Health executive says.
A physician leader at Tower Health says helping to build an effective culture at the health system will be among the keys to success in her new roles.
Suzanne Wenderoth, MD, was recently promoted from senior vice president and chief clinical officer of Tower Health Medical Group to executive vice president, CEO of physician enterprise, and interim chief medical officer of Tower Health. The West Reading, Pennsylvania-based health system features seven hospitals and about 14,000 employees.
Prior to joining Tower Health in 2018, Wenderoth worked in four roles at Reading Health System, including medical director of the patient-centered medical home primary care service line and vice president of ambulatory clinical initiatives.
Wenderoth recently talked with HealthLeaders about a range of issues such as physician enterprise, quality improvement, and patient safety. Following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of being a successful physician enterprise leader?
Suzanne Wenderoth: At the most basic level, physician enterprise leadership is about establishing a common cultural foundation. You need to establish a common mission, principles, and values. You need to let individual physicians know—regardless of where they work—that we are all aligned toward the same goals.
Another piece is that it is not only the physician component of the enterprise. It is important that we identify and align our goals with the other legs of the stool, including nursing and operations. We must establish coordination together.
Fundamentally, you must achieve aligned goals; and, often, physicians measure that through compensation. So, whether it is shared savings arrangements or other incentives, you must be able to deliver not only on the mission but also on the compensation.
Finally, one goal for physician enterprise leadership is to alleviate some of the physician frustrations. Whether it is with the electronic medical record or complex processes—alleviating frustrations is a critical part of the journey as well.
HL: Give a specific example of unifying physicians under one mission or culture.
Wenderoth: If you think about always putting the patient at the center of what you do, that is a simple value to remember. It also aligns us. If we pick any of our individual goals on a scorecard, if you always look at it from the patient-centered perspective, that is an example of a core value.
If you think about the mission as being patient-centered, you can take any one of your measures such as falls prevention and look at it from the patient perspective. You do not want to prevent patients from getting out of bed; rather, you can provide them with assistive devices and use remote monitoring to help them be mobile in a safe way.
HL: What are the primary elements of physician alignment?
Wenderoth: It is tricky because you need to know what you are aligning to. You need to align physicians and the health system, but you also need to align physicians and compensation.
No. 1, you need to match people's expectations with the strategy and the goals. Then you must share data transparently and ask physicians for their insights. You also need to match incentives to what is being reimbursed. We all have lots of great ideas in medicine, but if incentives are not matched with how we are being paid, that creates misalignment.
HL: What are the primary components of successful quality initiatives?
Wenderoth: The most important piece is to go to the frontline, which is where the work is really happening. You need to have those folks identify the most critical issues.
Then, you must have a fixed goal. It could be aspirational, and you might be concerned that you will not hit it, but that's OK. You must have a set goal, with a finite number or metric in mind. The goal also must come with a deadline or timeline. Then, as you design activities and measure improvement, you must give feedback in a regular fashion, with a cadence so that people can react to it.
You want to create standard processes that people can predict and anticipate.
HL: What are the primary components of successful patient safety initiatives?
Wenderoth: Here at Tower Health, we embody and embrace just culture. The idea is that humans are fallible. We are all going to make mistakes, but we need to be willing to talk about our near misses and our errors. As a culture, we need to be willing to address near misses and errors while not being shamed by them or embarrassed. Then, we need to be preoccupied with fixing problems.
You need to have an effective incident reporting system. We have a reporting system called RL Solutions that is quite transparent and nonpunitive.
A few years ago, we did not have nearly as many safety reports being placed as one would have expected or hoped. Since reporting is foundational to patient safety, it is important that you get enough people reporting. We realized that there were so many steps to the reporting process that we were creating a barrier for our employees. So, we initiated a process improvement effort and cut the number of reporting steps in half, and our reporting numbers went way up.
Another key to success in patient safety is building policies and processes that address errors. Without guiderails, people will continue to make errors.
Lastly, you need proactive education. You must tell friends and colleagues what you have learned, so everyone can capitalize on the knowledge.
HL: How can health systems and hospitals move toward zero harm in patient safety?
Wenderoth: So much of this is culture. Every healthcare worker must decide that patient safety is a fundamental component of how they will do their work throughout the day.
At Tower Health, we have taken a serious approach to change management. It is one thing to say you want to engage in change, but it is another thing to focus on the science of change management. You need to look at the number of people who are necessary to move change, and you must figure out how you are going to move culture. Changing culture is the first step to achieving zero harm.
Another factor is having an optimal learning system, so you can mine data and understand what your trends look like.
Then you must look at designing care improvement. One area that will be exciting in coming years is around engaging patients. The co-design of care can move you to high reliability and zero harm. You must have patient experience, patient committees, and patient voice in the co-design of care.
Decrease of service volumes during the pandemic and signs of rebound are driving changes in physician practice finances.
The coronavirus pandemic had a tumultuous impact on physician practices in 2020, but there are signs of recovery in 2021, according to the April Physician Flash Report from Kaufman Hall & Associates LLC.
Physician practices experienced reduced service volumes in 2020 as patients reacted to lockdowns and shunned in-person visits due to fears of coronavirus infection in healthcare settings. The reduced in-person visits were partially offset by increased utilization of telemedicine.
The April Physician Flash Report includes three key data points.
1. Investment per physician
In 2020, there was a 6.8% annual increase in median investment/subsidy per physician full-time equivalent (FTE) compared to 2019, according to the report.
A co-author of the Physician Flash Report explained the drivers of the increase in investment per physician FTE to HealthLeaders. "We saw a lot of health systems holding physician compensation whole during the pandemic—that was a deliberate choice to hold physicians harmless for changes in the market. So, overall, with a reduction in utilization and revenue, and constant compensation for physicians, the net impact was that the investment per physician increased," said Cynthia Arnold, MBA, BA, a senior vice president at Kaufman Hall.
Health systems and physician practices will have to address investment per physician, she said. "The investment per physician numbers have increased so much that it is impossible to ignore them going forward. For us to deal with the economic pressures of this increased subsidy, health systems are going to need to pull in their physician groups and work more closely with physician group leadership."
2. Net revenue per physician
Net revenue per physician FTE declined slightly from Q3 to Q4 2020 after hitting a low in Q2 of 2020, according to the report.
The decline in net revenue per physician FTE could be a negative trend this year, Arnold said. "We do not think this bodes well for 2021."
The decline in revenue is going to put pressure on physician practices to cut costs, she said. "There is going to be more pressure for automation. At the front desk, we are going to see practices using bots to take care of repetitive tasks. Automation to reduce administrative costs will happen relatively quickly. It will be harder to replace clinical providers such as nurses and medical assistants, but all of this is going to be up for consideration as we move forward."
3. Total direct expense per physician
Total direct expense per physician FTE fell 4.9% from 2019 to 2020, according to the report.
Reductions in front-office staff during the pandemic were a primary driver of the decrease in total direct expense per physician FTE, Arnold said.
"This is an important workforce question. At most health systems, the entry level for lower-income individuals is at physician practices. So, getting a job at the front desk gets you into a health system and let's you apply for other jobs. But we are not seeing the availability of that workforce, and they are not coming back very quickly," she said.
A 0.9% increase in total direct expense per physician FTE from Q3 to Q4 in 2020 reflects a rise in patient visit volumes at the end of last year, Erik Swanson, MPH, MS, BS, a senior vice president at Kaufman Hall, told HealthLeaders.
"As volumes return, you see some of the support staff starting to come back to work. We certainly expect total direct expense per physician FTE to increase as the volumes increase. It is going to be critical for organizations to monitor these types of trends on a more real-time basis, so that they can potentially adjust what those rates of return of expense will be over time," he said.
Forecasting the future
Last year was transformational for physician practices, which face a new operational and financial landscape, Arnold said.
"We are not returning to normal; we are moving to a new normal. We are going to need to be much more tuned into our patients and recognize that they are consumers. Our patients need to have choices. We are going to need to reconfigure our physician networks. Resizing the employed physician groups will be a big part of the change going forward, but we will also have to align physician leadership so that it can be much more helpful in understanding how the work gets done," she said.
The Physician Flash Report provides essential insights into physician practice economics, Swanson said.
"Number One, it informs the economic equation at play for physician groups and what level of investment is ultimately going to be acceptable to organizations. In addition, it informs investment and what you are getting for it. In this report, with the decreases in the patient volumes, some of those decreased volumes may not be returning because consumers have different choices. Organizations need to be thinking about how to reconfigure, rethink, and innovate," he said.
Work-life challenges have implications for retention off staff and trainees, survey finds.
The coronavirus pandemic has led many healthcare workers, particularly women with children, to consider leaving the workforce or reducing work hours, a recent study found.
In March 2020, 42% of U.S. workers transitioned to working from home. It is likely that employed women faced greater burdens because they spend 22% more time on household and care work compared to men. Studies have shown that healthcare workers have faced higher stress levels during the pandemic than before the pandemic.
The recent study, which was published by JAMA Network Open, features survey data collected in August 2020 from more than 5,000 faculty, staff, and trainees at University of Utah Health. The research includes several key data points.
49% of parents said that parenting was a stressor during the pandemic and 50% of parents said helping children with virtual education was a stressor
21% of survey respondents reported considering leaving the workforce and 30% reported considering reduced work hours
55% of faculty and 60% of trainees reported perceived decreased productivity
47% of survey respondents reported concern that the pandemic would impact their career development, with 64% of trainees reporting a high level of concern
81% of survey respondents said balancing childcare and work responsibilities was somewhat or extremely difficult
60% of survey respondents reported that continued opportunity to work from home was very or extremely helpful
68% of survey respondents reported that scheduling flexibility was very or extremely helpful
61% of survey respondents reported that knowing a work or training schedule one month in advance was very or extremely helpful
57% of survey respondents reported that have a supervisor who had a good understanding of work-life struggles was very or extremely helpful
"In this survey study, most participants with children did not have childcare fully available and many considered leaving the workforce and were worried about their career. Being female with children or having a clinical job role was associated with consideration for leaving the workforce and reducing hours," the study's co-authors wrote.
Health systems can take actions to address their workers' stress related to the pandemic, they wrote. "Health systems must develop effective strategies to ensure that the workplace acknowledges and supports employees during this unprecedented time, not only within the work environment, but also in managing unanticipated childcare responsibilities due to lack of childcare or in-person school. In doing so, health systems will improve the likelihood of retaining generations of well-trained clinicians, scientists, and staff."
Interpreting the data
One of the study's co-authors told HealthLeaders that two findings of the research were most concerning.
"We are particularly troubled by the fact that so many faculty members who have dedicated five-to-10 years of their life training to become physicians or scientists were considering leaving the workforce. Additionally, almost 50% of faculty and 64% of trainees (students, residents, and fellows) were worried that the pandemic had negatively impacted their career," said Angela Fagerlin, PhD, chair of the Department of Population Health Sciences at University of Utah.
There are three primary actions that health systems can take to support healthcare workers during the pandemic, she said.
Setting clinical schedules as far ahead of time as possible so healthcare workers can make childcare plans more effectively
Allowing for flexible work schedules as much as possible such as working from home and working sporadically through the day while making up time-off hours
Having supervisors better understand work-life struggles
Several factors are likely linked to those in clinical job roles considering leaving the workforce and reducing hours, Fagerlin said. "I imagine the lack of flexibility or the ability to stay home with children may have contributed. Non-clinicians such as PhD faculty had the flexibility to stay home, although as a PhD-scientist mother of three kids who only all went back to school recently, working while virtual-schooling is a different type of stress. Another feasible reason is the incredible stress resulting from caring for patients during COVID and the risks associated with that care."
The Toledo, Ohio-based health system is addressing social determinants of health directly and through partnerships.
ProMedica is on a quest to become one of the leading health systems in the county in addressing social determinants of health.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOH and working with partners, healthcare organizations can help their patients in profound ways beyond clinical care.
The ProMedica National Social Determinants of Health Institute recently published its 2020 Impact Report. The report includes several key data points.
In all ProMedica care settings, patients were asked to self-identify social needs in 14 categories: 85% of patients completed the survey before seeing their provider, 43% of patients identified a social need, and 16% of patients had social needs in four or more categories.
More than 18,000 connections were made to ProMedica's food clinics, financial coaching, social programming, educational opportunities, and other SDOH interventions.
The top three SDOH risks identified in primary care settings were social isolation (34%), financial (22%), and food insecurity (15%).
HealthLeaders recently spoke with ProMedica President and CEO Randy Oostra, DM, about the health system's approach to SDOH and most recent SDOH partnership with Fresno, California-based Bitwise Industries. Following is a lightly edited transcript of that conversation.
HealthLeaders: Why has ProMedica decided to play an active role in addressing SDOH?
Randy Oostra: About a decade ago, we were doing some community needs assessment work around obesity, and we started an educational program in the schools. The folks who were doing the training asked for a meeting; and at the meeting, we expected to hear great things about the work we were doing. But the trainers said, "We have a problem—these kids are hungry. It is difficult to talk about nutrition when the students are hungry."
We got more and more impressed that if all we did was take care of people clinically, we really were not addressing their health and wellbeing. We started looking at the social determinants of health. We knew that 20% of a person's health is related to what we do clinically and 80% is related to other factors—primarily social determinants of health.
We needed to look at total health and wellbeing. So, we started screening for hunger. Then we started screening for more than a dozen social determinants of health. Then we realized that if the screening was good for our patients, it should be good for our employees. So, we started screening our employees for social determinants of health, and our efforts kept building from there.
What we found among our employees was that they had tremendous social needs, and it impacted recruitment, retention, productivity, and healthcare costs.
HL: What are the primary social determinants of health initiatives at ProMedica?
Oostra: We have partnered with a company in Ann Arbor, Michigan, called Kumanu that we made an investment in. They have a screening tool that looks at social determinants and personal determinants of health such as resilience and a sense of purpose.
We were fortunate enough to get a large gift from a philanthropist that helped us establish the Ebeid Neighborhood Promise program, where we built an inner-city neighborhood grocery store and have financial opportunity counselors.
We have built out a team of folks who live across the country, and the idea is to have intervention specialists in all of the social determinant areas. So, what started out as a passion around health and wellbeing has been built out to specialists who can support people who want to do interventions. We just helped another nonprofit grocery store to open, so we are doing consulting work in that area.
We work with a data analytics company called Socially Determined. We have a loan pool for minority- and women-owned businesses. We work with the Local Initiatives Support Corporation, which is a community development financing institution based in New York. Community development financing institutions are organizations that can help you invest where banks will typically not help you invest.
We have a lot of initiatives around housing. We are doing some specific fundraising for housing in neighborhoods such as the Junction Neighborhood in Toledo.
We are spending a lot of time on education, not only in pre-K but also in tutoring and programs that give people help in going to college. We are starting a science, technology, engineering, and math high school in the fall with the Toledo Public Schools.
Our view is that we should not only be involved in social determinants of health but also be accountable in addressing and leading in social determinant causes in our communities. Who is better at looking at a comprehensive model for health and wellbeing than healthcare institutions?
HL: ProMedica recently announced a partnership with Bitwise Industries to open an innovation center in Toledo. Why did the health system decide to enter this partnership?
Oostra: Regarding the Bitwise partnership, if you can get a person a good job, you can change their entire life.
Bitwise teaches individuals who have not been in the technology industry tech skills such as coding and software, so that they can go and get tech jobs. Their targets are primarily women, minorities, and the LGBTQ community. They are in four communities in California, and Toledo is their first site outside of California. They go to underdog cities and create careers for people who have been underrepresented.
In Toledo, Bitwise is hoping to create 500 tech jobs within three years. That has been their track record in California. When you think about it from the perspectives of economic development, changing people's lives, and giving people opportunity who have not had opportunity, the Bitwise partnership fits perfectly in that space.
We made a $2 million investment in Bitwise.
HL: Will the innovation center help fill positions at ProMedica?
Oostra: Yes. We are already in discussions with Bitwise about their software capabilities that can help us. They will provide an employment pipeline for us, especially in our innovation group because we have several startups that are tech-based. They also will help us fill a lot of IT jobs.
HL: How do you plan to measure the return on investment for the innovation center?
Oostra: There are a couple of ways that we will measure the ROI. We will not only measure ROI by job growth but also measure it by the number of startups that come out of the innovation center.
This kind of project does not necessarily get us a financial ROI, but it will get us a social, health, and wellbeing ROI, which our board has been very comfortable to invest in. We do not have endless resources, but we make purposeful investments in projects that are good for social determinants, personal determinants, and anchor institution strategies.
The survey data compares importance of online reviews to word-of-mouth recommendations.
When selecting a physician, online reviews are considered very important nearly as much as word-of-mouth recommendations among older patients, according to survey data.
Online reviews have become an important element of consumerism in healthcare. Online reviews of physicians are available on healthcare provider websites and commercial websites such as Google and Yelp.
The survey data of adults aged 50 to 80 years, which was reported this week in Annals of Internal Medicine, was collected from the University of Michigan National Poll on Health Aging. The survey data includes the following key points.
In selecting a doctor, online physician ratings and reviews were considered very important among 20.3% of survey respondents
In selecting a doctor, word-of-mouth recommendations from family and friends were considered very important among 23.0% of survey respondents
Where a physician trained or attended medical school was considered very important when selecting a physician for 17.4% of survey respondents
The top three factors that older adults rated as very important when selecting a physician were whether the physician accepted their health insurance (93.0% of survey respondents), how long it takes to get an appointment (61.2%), and convenience of office location (58.7%).
The prevalence of use of online ratings and reviews was higher among women (48.2%) versus men (37.1%)
The prevalence of use of online ratings and reviews was higher among survey respondents with a bachelor's degree or higher (49.0%) versus respondents with high school or less (33.2%)
The prevalence of use of online ratings and reviews was higher among survey respondents with at least one chronic condition (45.2%) versus respondents with no chronic conditions (38.5%)
When selecting a physician, the relative importance of online reviews and ratings compared to word-of-mouth recommendations for older adults is highly significant, the lead author of the survey report told HealthLeaders.
"This finding is very significant, as word of mouth recommendations from family and friends have historically been one of the most important sources of information about doctors. Further, we found that online ratings and reviews were considered very important more often than other parts of a physician's background, such as where they trained or attended medical school," said Jeffrey Kullgren, MD, MS, MPH, an associate professor of internal medicine at University of Michigan.
Kullgren also speculated on the prevalence of use of online ratings and reviews by survey respondents' gender, education, and whether they had a chronic condition.
"Because women often play an essential role in healthcare decisions for their families and frequently have unique healthcare needs, it is perhaps not surprising that they would use online ratings and reviews differently than men. It is possible that people with higher levels of education are more engaged in decisions about their healthcare and thus more likely to use available information about physicians. People with chronic conditions often need more healthcare and need to see more physicians longitudinally than people without chronic conditions. As a result, patients with chronic conditions may have more opportunities to choose physicians as well as a strong incentive to select physicians that will best meet their needs over the long-term," he said.
Considerations for selling a medical practice depend on whether the seller is retiring, financially distressed, or making a strategic move.
There are successful strategies to employ and key steps to be taken when selling a medical practice.
In the short-term, the coronavirus pandemic has placed many medical practices in dire financial straits and selling a practice may be unavoidable. In the long-term, small medical practices have been selling to larger medical groups and health systems for years, and that trend is likely to continue.
The considerations for selling a practice depend on the seller, says Barry Posner, JD, BS, a partner at Kudman Trachten Aloe Posner LLP in New York City. "There are three kinds of sellers: there is the seller who is retiring, there is the seller who is in distress, and there is the seller who is selling into growth or selling strategically."
Succession is a primary consideration for the sellers who are retiring, he says. "For retiring doctors, if it is a one-physician practice, more than likely they are going to pass the practice to a successor or somebody who they have trained. But those situations are getting more and more rare."
For distressed sellers, they can either align themselves with a buyer that can make them more profitable, or they can become employees or contractors of a larger practice group, Posner says. "It often comes down to cost savings. They may have high-cost equipment. They may have high-cost rent. Selling the practice relieves distressed doctors of those burdens. That way, they can get back to practicing medicine and let other people deal with the business of medicine."
More commonly, there are practices that just are not as profitable as they used to be, and they want to make a strategic move to become more profitable, he says. "The way you achieve more profitability by selling to large practice groups or health systems is by getting cheaper purchasing by volume, sharing high-cost equipment such as CT scans, and lowering back-office costs through centralized billing and collections."
Determining the value of practices
Revenue is a pivotal element of a medical practice's valuation for sale, Posner says.
"Medical practices are generally valued off a multiple or fraction of revenue. The most common general practices would be in the 0.5 to 0.7 times their annual revenue range. As you get to higher end specialties, you can go to 0.8 to 1.0 times annualized revenue. The 0.5 or 50% of revenue valuation would be typical for an internist, podiatrist, and general practitioners. As you get to shorter supply specialties such as neuroradiology and oncology, you can get to a higher multiple," he says.
For example, if a practice was crafting a deal on a calendar-year basis for 2020, and the practice had $2 million in revenue, and the negotiated percentage was 70%, the value of the practice would be $1.4 million.
Avoiding the biggest pitfall
The most daunting pitfall when selling a medical practice is avoiding buyers that have weak financial standing, Posner says. "There are some very fine health systems and large practice groups that are well-funded and well-sponsored either through private equity firms or physicians who have been very successful over the years. I have seen examples that go the other way."
To avoid a financially troubled buyer, owners of medical practices that are up for sale need to have a strong team in place to help them, he says. "The biggest pitfall is ensuring that the medical group that you are selling into is financially sound. Due diligence is critically important. And the way to conduct due diligence is by getting your accountant, your lawyer, and business broker or banker involved in the process as early as possible."
Prepping a practice for sale
To sell a medical practice successfully, physicians need to lay solid groundwork for the sale, Posner says.
"Prepare, prepare, prepare. Get your lawyers and accountants lined up early. Get your documentation together—whether it is your payer contracts for reimbursement, your licenses, or your financial statements. All the documents that would be typically requested by a buyer should be prepared and at your fingertips. When you are asked, you should be able to hand over documents immediately," he says.
Delays due to ill-prepared sellers can have adverse consequences, Posner says. "I am a believer that time kills deals, and the quicker you can respond to due diligence questions from a prospective buyer, the better off you are."
The health system has supported healthcare workers, adopted new modalities of care, improved communication, and boosted emergency preparedness.
By multiple measures, COVID-19 has challenged healthcare providers more than any other public health crisis since the 1918 influenza pandemic. As the coronavirus pandemic enters its second year, many health systems, hospitals, and physician practices remain in crisis mode.
A pair of physician leaders at Cincinnati-based UC Health recently spoke with HealthLeaders to discuss how the health system has grappled with COVID-19. Following are four primary lessons learned from the coronavirus pandemic.
1. Strain on healthcare workforce
Healthcare workers have risen to the challenge, says Dustin Calhoun, MD, medical director of emergency management at UC Health.
"In emergency management, there is a concept that in a major disaster such as this pandemic only 50% to 60% of your healthcare workers will show up for work. In the face of personal danger to themselves and their families, a significant number of healthcare workers would stay home. We had always planned based on that concept, but that turned out to be very much not true," he says.
Particularly at the start of the pandemic, UC Health's workforce faced daunting uncertainty, Calhoun says. "The amount of willingness of healthcare workers to put themselves in danger has been remarkable. Our personal protective equipment practices are excellent now and our supplies are excellent now, but we did not know that in the beginning."
"When the pandemic started, we did not know a lot about the virus. In the first few months, there were educated guesses at best. Yet, healthcare workers took those educated guesses, put the PPE on, and took care of the patients. For most healthcare workers, this is probably the first time in their career that doing their job put them at significantly more risk than they anticipated when they went into the field. We all knew there were risks in healthcare such as needle sticks. But in the beginning of the pandemic, the perceived risk of personal danger was high," he says.
Huddles have played a pivotal role in supporting healthcare workers during the pandemic, says Jennifer Forrester, MD, associate chief medical officer and an infectious disease specialist at UC Health.
"We started having huddles before work shifts prior to the pandemic and that was one of the things that was helpful for the staff over the past year. Instead of coming to work, getting your assignment, and doing your job, you come to work, and everybody meets before the shift begins. Some of the people from the prior shift meet with the people from the new shift," she says.
"During these huddles, you not only talk about patients but also talk about what is going on in the bigger picture. You discuss what everybody needs for their shift. And the huddles are not limited to the micro level of a clinic or a unit. We made a system that allows concerns raised in the huddles to escalate to the executives, including employee well-being, which is one of the things stressed in the huddles," Forrester says.
The health system's employee assistance program (EAP) has also been critically important to supporting healthcare workers, Calhoun says.
"The employee assistance program pushed out their availability. We know that among healthcare workers and the entire population that psychiatric illness from the very mild to the more severe has certainly been more pronounced during the pandemic. The EAP made sure that there were programs available for employees who were experiencing the effects of serious stressors," he says.
2. Unconventional treatment modalities and new ways of providing care
Adoption of telehealth has been a transformative change at UC Health, Forrester says.
"Probably the biggest new way of providing care has been the use of telehealth. It was up and coming at the beginning of the pandemic—mostly used by primary care physicians, but most of us in specialty care were not using it routinely. The pandemic skyrocketed the use of telehealth, which is great for patients. Telehealth is excellent for patients in rural areas, especially for accessing subspecialists at an academic center. It can be a two-hour drive for a visit, which is a lot to ask of patients," she says.
Proning of seriously ill coronavirus patients is a great example of unconventional treatment techniques utilized during the coronavirus pandemic, Calhoun says.
"When I went through medical school, ventilatory proning—the idea of venting a patient while they were laying on their stomach—was an extraordinary technique that we only used with super sick patients in the ICU. It was found out early in the pandemic that the pathology that occurs in the lungs due to COVID is responsive to the proning technique of ventilating. We began invasively proning patients in the emergency department as well as proning patients who were still breathing spontaneously and not on a ventilator. We just positioned them in ways that made it easier for their lungs to function," he says.
Proning was initiated early in the pandemic, Calhoun says. "We started proning in mid-March of last year. Our intensivists, our pulmonologists, and our infectious disease doctors were very aggressive at recognizing that this was a useful procedure."
3. Improving communication
Effective communication strategies have been pivotal during the pandemic, Calhoun says.
"We have learned a tremendous amount about the most efficient methods of communicating with our clinical staff, our employees, and our patients as well as communicating with the community in general. We have utilized trusted partners in the community to communicate with particular groups. Even though we like to think of ourselves as being very trusted by the community because we are healthcare workers and our purpose is to help the community, there are barriers sometimes. Standing beside another trusted partner significantly improves our ability to communicate with particular groups," he says.
For internal communications, UC Health has ramped up utilization of an online resource that was in place before the pandemic, Calhoun says.
"An internal communications tool called The Link has had a major impact during the pandemic. It is essentially an internal communication online tool that is intended to be the source of truth for UC Health's healthcare workers. The amount of use of The Link now is tremendous. Early in the pandemic, our marketing and communications team very adeptly put The Link at the center of our pandemic communications. We put our protocols on The Link—it became where you looked for answers," he says.
Email also has been an effective internal communication strategy, Forrester says.
"We set up dedicated email addresses to answer questions about certain things. Employees can just send an email to a COVID-19 address and ask questions. For example, employees can ask questions about personal protective equipment. When the vaccines became available for our employees, we set up a dedicated email for the vaccines; so, if staff had questions about vaccination scheduling or side effects, they could get reliable information. These dedicated email addresses link our employees to the right people," she says.
Externally, taking a multi-faceted approach to communication has been successful, Forrester says.
"From a community standpoint, the multipronged approach of meeting people where they are was critical, whether it be on television, social media, or our website. The different ways to communicate have been expanded during the pandemic. Particularly with the vaccine, we want to reach as many people as possible, and we will do that in any way possible. In this area, working with our community groups and leaders has been very important," she says.
4. Honing emergency preparedness
Improving emergency preparedness at UC Health has been one of the silver linings of the pandemic, Calhoun says.
"Unlike the 2014 Ebola outbreak, which was relatively short-lived, the prolonged nature of the coronavirus pandemic has taught us what really is and is not important. We have made emergency management part of our daily plan. There are few times in my career when I have seen emergency management become part of daily healthcare operations. That is when emergency management works really well—when it is truly integrated into operations. The duration of the pandemic has forced that integration," he says.
The coronavirus pandemic also has impacted a major emergency department renovation at UC Health, Calhoun says.
"We are renovating a very old emergency department. After seeing what we went through with Ebola and seeing what we have been going through with the pandemic, we saw the need for integration of capabilities. For example, we have taken a second look at how many negative pressure rooms we are going to have and how much 'blow out' space we need to expand capacity when necessary. The pandemic demonstrated the importance of integrating those kinds of things into the design of this new emergency department. The timing of the pandemic in this remodeling process will benefit the community significantly," he says.
Survey data shows at least half of critical care physicians experienced emotional distress in the first nine months of the COVID-19 crisis.
In the critical care setting, emotional distress and staffing shortages have persisted during the coronavirus pandemic, a recent survey report says.
Critical care physicians are essential caregivers for seriously ill COVID-19 patients. They are not only well-positioned to assess emotional distress and shortages in the critical care setting but also pivotal personnel who can have a negative impact if they become burned out.
The survey report, which was published by Critical Care Medicine, is based on data collected from more than 2,300 critical care physicians in the spring of 2020 and more than 1,300 critical care physicians in the fall of 2020. The survey report has several key findings.
In the spring survey, 67.6% of critical care physicians reported moderate or high levels of emotional distress. In the fall survey, 50.7% of critical care physicians reported moderate or high levels of emotional distress.
Compared to their male counterparts, female physicians reported higher levels of emotional distress in both the spring and the fall surveys. In the spring survey, 75.0% of female physicians reported moderate or high emotional distress. In the fall survey, 67.7% of female physicians reported moderate or high emotional distress.
Reported critical care staff shortages were nearly unchanged in the spring and fall surveys, with 48.3% of survey respondents reporting staff shortages in the spring and 46.5% reporting staff shortages in the fall.
The worst staff shortage was among ICU-trained nurses, with 34.2% of survey respondents reporting ICU-trained nurse shortages in the spring and 33.1% of survey respondents reporting shortages in the fall.
Reported shortages of personal protective equipment fell by more than half from the spring survey to the fall survey. In the spring survey, 52.7% of respondents reported PPE shortages. In the fall survey, 21.9% of respondents reported PPE shortages.
"Stress, staffing, and, to a lesser degree, personal protective equipment shortages faced by U.S. critical care physicians remain high. Stress levels were higher among women. Considering the persistence of these findings, rising levels of infection nationally raise concerns about the capacity of the U.S. critical care system to meet ongoing and future demands," the survey report's co-authors wrote.
Interpreting the data
The lead author of the survey report told HealthLeaders that the persistent moderate or high levels of emotional distress are troubling.
"It is very concerning, especially since this survey was conducted just at the start of the winter surge. We also found that this distress was similar across hotspots. This suggests that, at least in part, emotional distress is global and cumulative. As we face a new surge this is even more of a concern. That said, at least to some degree a contributor to emotional distress was risk to self. As many physicians are being vaccinated, this might help mitigate distress a little. However, there are other contributors to stress that are not affected by vaccines," said Bradley Gray, PhD, senior health services researcher at the American Board of Internal Medicine.
Having nearly half of critical care physicians reporting staff shortages is another area of concern, he said. "This finding was for ICU-trained staffing shortages. This is concerning because these are the people who really know what they are doing and not having enough of these specialized workers adds to the emotional distress of physicians and we presume other ICU-trained staff."
The relatively large reported shortage of ICU-trained nurses is likely having negative consequences, Gray said. "This is a major concern because ICU-trained nurses and critical care physicians play a pivotal role in the ICU. ICU-trained staff in general are the best equipped at dealing with COVID patients. Also, the degree to which non-ICU-trained nurses are being utilized taxes the ICU-trained staff including physicians because they likely must supervise and assist the non-ICU-trained nurses. That results in the ICU-trained nurses feeling a double burden."
The survey report found that at least half of critical care physicians experienced moderate or high levels of emotional distress for the first nine months of the pandemic. If this problem continues deep into 2021, the impact could be dramatic, he said.
"Bright red is my level of concern. Many states are experiencing increased hospitalization rates, and this will shoot up as the spring 2021 surge builds. Again, the emotional distress seems cumulative. When you look at what physicians are telling us, many are saying that the loosening of COVID restrictions in the face of a new surge is one factor that adds to emotional distress. I think these docs get frustrated that the only thing that seems to move the state policy needle is death and hospitalizations. We know the wave is coming, why can't we take steps now to reduce future deaths and hospitalizations?"
The new study corroborates earlier research that found sexism and racial/ethnic bias are common in surgical settings.
Sexist and racial/ethnic microaggressions against female and racial/ethnic minority surgeons and anesthesiologists are common and linked to physician burnout, a new study finds.
Burnout is one of the most vexing challenges facing physicians and other healthcare workers nationwide. Research published in September 2018 indicates that nearly half of physicians nationwide were experiencing burnout symptoms. Female physicians tend to experience burnout more than their male counterparts—a Medscape report published in January found that 51% of female physicians were burned out and 36% of male physicians were burned out.
The new study, which was published by JAMA Surgery, is based on survey data collected from nearly 600 surgeons and anesthesiologists at Southern California Permanente Medical Group. The study includes several key data points.
94% of female survey respondents reported experiencing sexist microaggressions
81% of racial/ethnic survey respondents reported experiencing racial/ethnic microaggressions
47% of survey respondents reported physician burnout
The odds of experiencing physician burnout were high for female physicians (odds ratio 1.60) and racial/ethnic minority physicians (odds ratio 2.08)
The likelihood of burnout was high for female physicians who experienced sexist microaggressions (odds ratio 1.84 for racial/ethnic minority female physicians and odds ratio 1.99 for White female physicians)
The likelihood of burnout was high for racial/ethnic minority female physicians who experienced racial microaggressions (odds ratio 1.86)
The likelihood of burnout was high for racial-ethnic minority female physicians who experienced both sexist and racial/ethnic microaggressions (odds ratio 2.05)
"In this survey study, there was a high prevalence of sexist and racial/ethnic microaggressions against surgeons and anesthesiologists. Racial/ethnic minority female physicians, specifically [Black, Hispanic, and Hawaiian/Pacific Islander] physicians, experience the highest prevalence and severity. Furthermore, sexist and racial/ethnic microaggressions were associated with physician burnout," the researchers wrote.
Interpreting the data
The lead author of the new study told HealthLeaders that sexist and racial/ethnic microaggressions are one of several factors that contribute to physician burnout.
"The cause of physician burnout is multifactorial and has been described as chronic work-related stress that leads to a constellation of emotional exhaustion, depersonalization, and low personal achievement. We know that microaggressions negatively impact one's morale and psychological well-being. The extra energy required to address these microaggressions, the responsibilities of being a physician, and our essential roles directly contribute to burnout," said Neha Sudol, MD, a member of the Department of Obstetrics and Gynecology at Southern California Permanente Medical Group and UC Irvine Medical Center.
Sexist and racial/ethnic microaggressions likely impact all three dimensions of physician burnout, she said. "We hypothesize that repetitive microaggressions in the workplace specifically contribute to emotional exhaustion and, perhaps, the other components of burnout to a lesser degree."
With sexist and racial/ethnic microaggressions, there is an intersection of sex, race/ethnicity, and physician burnout, Sudol said. "We found that female and all racial/ethnic-minority surgeons and anesthesiologists were more likely to experience burnout compared to White, male colleagues. We then identified an intersection between microaggression experience and physician burnout whereby female racial/ethnic-minority physicians who experienced microaggressions were more likely to experience burnout compared to their White, male colleagues."
Sexist and racial microaggressions contribute to pervasive workplace inequity faced by female and racial/ethnic surgeons and anesthesiologists, she said. "Workplace inequity, by definition, is rooted in bias and unfair circumstance. Microaggressions are acts of discrimination toward marginalized groups and, thus, directly contribute to inequity. Our findings, that female and racial/ethnic minority surgeons and anesthesiologists experience microaggressions at a high prevalence, corroborate previously published reports that surgical environments are wrought with sexism and racial/ethnic bias."
The are actions that can be taken at the individual and institutional levels to address sexist and racial/ethnic microaggressions, Sudol said. "At an individual level, value and respect should be placed on addressing microaggressions in a non-accusatory manner and holding each other accountable. From a larger institutional standpoint, the data highlights the importance of establishing codes of conduct and other initiatives that empower marginalized groups and encourage allyship."
