Coverys report shows areas at greatest need for clinical care improvement and risk management.
Surgeries and diagnoses generate the most medical malpractice claims, a recent report on a decade of malpractice data says.
Despite advances in patient safety since the publication of the landmark reportTo Err Is Human: Building a Safer Health System more than 20 years ago, medical errors continue to draw thousands of malpractice claims annually. The recent report, which was published by Coverys, says malpractice claims that the company handled over the past decade show the quest to improve patient safety is far from over.
"Change is not happening as quickly and collectively as it needs to. Our data shows improvement in select areas such as increased patient engagement, flattened hierarchies and the ability for staff at all levels to raise concerns, increased teamwork, and better sharing of information. However, many areas remain largely unchanged," the Coverys report says.
The report features data collected from more than 20,000 closed claims at Coverys from 2010 to 2019. The report includes several key data points.
Average indemnity paid in malpractice claims increased from $342,581 in 2010 to $411,053 in 2019.
The Top 5 malpractice allegations were surgery or procedure-related (29.2%), diagnosis-related (27.3%), medical treatment-related (12.5%), medication-related (8.8%), and patient environment safety (6.0%).
The Top 5 complaints related to surgery and procedure events were surgical team performance (78.2%); retained object (7.1%); unnecessary surgeries (3.5%); wrong side, site, or patient (3.4%); and delayed surgery (2.7%).
The Top 5 complaints related to diagnosis events were evaluation of patients including history and physical (32.0%), interpretation of tests (23.9%), ordering diagnostic or lab tests (23.5%), referral management (7.5%), and doctor follow-up with patients (5.0%).
Most diagnosis-related events occurred in physician offices (34.6%) or emergency departments (24.9%).
Cancer was the top medical condition for diagnosis-related events, at 28.5%.
"We were somewhat surprised and even disappointed that we did not see improvement in some of the key areas. Certainly, failure to diagnose and surgical error were areas that remained at high levels, with many of the same issues that we saw in the early days of patient safety improvement," Bob Hanscom, JD, vice president of business analysis at Coverys, told HealthLeaders.
Improving surgery and procedures
To improve surgery and procedures, healthcare organizations should focus on the top two risk management factors, technical skill and clinical judgement, Ann Lambrecht, RN, BSN, JD, a senior risk specialist at Coverys, told HealthLeaders.
"Embedded in clinical judgment are patient assessment and diagnosis of that clinical condition. Those factor very heavily in the clinical judgment. Evaluation of surgical outcomes with feedback provided to the practitioner is part of ongoing performance evaluation and that ongoing focus is critical in addressing technical skill and improving surgical outcomes. We think this is not always happening—it is not happening on a consistent basis and it is not happening periodically," she says.
Training and building experience also are important to improving surgery and procedures, she says. "Ongoing training and being able to perform a certain volume of procedures is essential to maintaining technical proficiency. In anything we do, the more we do it, the better we get at it and the less variation."
There are three primary ways to improve surgery and procedures, Hanscom says.
Although surgical safety checklists were enthusiastically received in certain parts of the country and across Europe, they need to be implemented broadly across the United States.
Technical skill has shown improvement and less variation when organizations have invested in simulation and skills labs, where surgeons can practice procedures and be safe in making mistakes.
Health systems and hospitals need to make reducing distractions in operating rooms a priority.
Improving diagnosis
Lambrecht says efforts to improve diagnosis should focus on the three top risk management categories: clinical judgment, clinical systems, and communication.
"Certainly, use of clinical decision support tools could assist in the clinical judgment arena—they help address issues of hidden bias and narrow diagnostic focus. Clear consultation policies that define when a consultation must occur and how consultants' findings are communicated add another layer to improve diagnostic accuracy. Finally, you should have a chain of command to escalate issues when differences in care arise," she says.
To improve diagnosis, healthcare organizations should address process variability and cognitive variability, Hanscom says.
"The standardization of processes that support high reliability and at least make sure that you are taking all of the steps to reach the right diagnosis is critical. It goes from the initial evaluation of the patient, all the way through to referral management and follow-up with patients. What is the process and how do we make sure things do not fall through the cracks?" he says.
Cognitive variability is significant because clinicians with less and less time on their hands succumb to their own biases, Hanscom says. "They think they know what the condition is and they are going after that—they are not necessarily doing the rule-outs that they were taught to do in medical school because they don't have time to do it."
Technology has a role to play in reducing cognitive variability in diagnosis, he says. "This is where innovation needs to step up in terms of bringing artificial intelligence to the decision-making process."
Improving the evaluation of patients—including patient history and physicals—is essential to achieving effective diagnoses, Lambrecht says.
"One key component is having an experienced provider conduct the initial evaluation that all future assessments will be compared to. This is seldomly done. Typically, it is a resident or an advanced practice provider who conducts the initial evaluation. So, when the initial assessment does not catch even a small issue, that one oversight can trigger a cascade of events that is very difficult to reverse," she says.
Patient engagement plays a crucial role in diagnosis, Hanscom says. "Patients should be participating. They should be reporting their symptoms in the most accurate way possible. They should be encouraged to ask questions. They should be talking about their family history. Patients need to be involved. That should carry through every step of the diagnostic process."
Telehealth has experienced explosive growth during the coronavirus pandemic, with telehealth claims lines increasing 3,552% from August 2019 to August 2020, according to FAIR Health.
There has been unprecedented year-over-year growth in telehealth insurance claims, and the growth was sustained from July to August, according to FAIR Health's Monthly Telehealth Regional Tracker.
In March, when the coronavirus pandemic took hold in the United States, telehealth visits increased 50%, according to Frost and Sullivan. With in-person medical visits associated with the risk of coronavirus infection, virtual visits emerged as a safe and effective way for patients to meet with their doctors in many circumstances.
FAIR Health's Monthly Telehealth Regional Tracker, which was launched as a free service in May, follows telehealth insurance claims lines for commercial payers across the country. The data accounts for about 75% of commercially insured claims.
The August data includes several key data points:
Nationally, telehealth claims lines increased 3,552% from August 2019 to August 2020, increasing from 0.17% of medical claims lines in August 2019 to 6.07% in August 2020.
From July to August 2020, telehealth claims lines were relatively stable, increasing 1.2% from 6.00% of medical claims lines in July to 6.07% in August.
All four regions of the country followed by the telehealth tracker—Midwest, Northeast, South and West—experienced large year-over-year increases in volume of telehealth claims lines from August 2019 to August 2020.
Mental health conditions—the top telehealth diagnosis since March 2020—increased as a share of all telehealth diagnoses from July to August, rising from 45.39% to 48.93%.
Respiratory diseases were the fourth most common telehealth diagnosis in August 2020 at 2.32%. In August 2019, respiratory diseases accounted for 17.63% of telehealth diagnoses, with the year-over-year decrease linked to the diversity of other diagnoses that became more common in telehealth due to the pandemic.
Interpreting the data
The telehealth tracker has documented utilization trends for telemedicine during the pandemic, FAIR Health President Robin Gelburd, JD, told HealthLeaders.
"Beginning in March, there was a great increase in telehealth claim lines as a percentage of all medical claim lines in 2020 nationally and in every region compared to the same months in 2019. April 2020 showed even more growth than March 2020. From April to July, there was a relatively small month-to-month decline. August showed signs of stabilization," she says.
Mental health conditions are a common telehealth diagnosis that has become more prevalent during the pandemic, Gelburd says.
"We can say that even before the COVID-19 pandemic, mental health was a prominent area of telehealth, but mental health conditions have continued to rise as a share of all telehealth diagnoses throughout the pandemic. The increase may be due to stress and anxiety caused by the pandemic or by the fact that, as patients begin to return to medical offices and facilities for non-emergent care, mental health diagnoses constitute a larger proportion of the telehealth diagnoses," she says.
Telehealth has been used for a wider variety of conditions throughout the pandemic, Gelburd says. "For example, hypertension became one of the top five telehealth diagnoses nationally in March 2020 whereas it was not in March 2019 or in February 2020. In the Midwest, diabetes mellitus appeared as one of the top five diagnoses in April 2020, a position it had not occupied in April 2019. In May 2020, developmental disorders ranked among the top five telehealth diagnoses in all regions and nationally; whereas, in May 2019, it was not in the top five in any region."
The new patient action plan stresses leadership, patient and family engagement, workforce safety, and learning systems.
A new "action plan" to advance patient safety addresses fundamental elements of improving safety at healthcare organizations, a leader of the initiative says.
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 have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The new initiative is detailed in an action plan published on September 14. The document was crafted by the National Steering Committee for Patient Safety, which was formed in May 2018. There were 27 organizations represented on the steering committee from the following groups: healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies.
Jeffrey Brady, MD, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality, and co-chair of the National Steering Committee for Patient Safety, recently shared his perspectives on the four focal points of the action plan with HealthLeaders.
1. Culture, leadership, and governance
The action plan calls on healthcare leaders, governance bodies, and policymakers to demonstrate a commitment to safety as a core value and to foster cultures of safety.
Healthcare organization leaders play a pivotal role in improving patient safety, Brady says. "Culture, leadership, and governance are one of the foundational areas of the action plan. Any healthcare organization leadership is integral to patient safety."
The action plan provides a patient safety improvement road map to healthcare organization leaders, he says.
"In terms of how we envision the action plan, we view it as being helpful to healthcare organization leaders who play a critical role in establishing, maintaining, and promoting a culture of safety. Over the years of our work on patient safety at AHRQ, patient safety starts at the top. The leadership establishes the culture, and they enable resources to flow to the things that set a safe environment for patients and the healthcare workforce."
2. Patient and family engagement
The action plan calls for propagation of effective patient and family engagement. Specifically, healthcare organizations should include patients, families, and care partners in the design and delivery of care.
"The research shows us that when patients are engaged in their healthcare it can lead to measurable improvements in safety and quality. If a patient or family is paying attention, they are more likely to see something that could be a problem. That is one aspect of patient and family engagement—enlisting patients to help be watchful and mindful of potential safety hazards," Brady says.
Patient and family engagement also provides healthcare organizations with an opportunity to redesign care to be more patient-centric, he says. "Another aspect of patient and family engagement begins even before care is provided. It is the idea of co-production of care with patients and families. This aspect addresses the best ways to organize care, plan care, and structure care. You talk with patients and families about the best way to set up care and how to make it easier for them."
3. Workforce safety
The action plan says patient safety and workforce safety are linked closely. To boost workforce safety, healthcare organizations should take a unified and total-systems approach, the action plan says.
Healthcare workforce safety and patient safety go hand in hand, Brady says. "It is hard to ask anyone who themselves do not feel safe to focus on making sure someone else is safe. When someone does not feel safe, they are understandably distracted by that. If you have a healthcare worker in a situation that does not feel safe to them, even if it is subtle, you want them to feel supported, you want them to feel safe, and you want them to feel someone cares about them."
Healthcare organization leaders are essential to achieving workforce safety, he says. "We state in the action plan that workforce safety is a duty of healthcare leaders. They need to engage in continuous improvement of workforce safety. Because of the potential for distraction, healthcare workforce safety is a precondition for advancing patient safety."
"When we talk in the action plan about the safety of the healthcare workforce, we include not only physical harms such as falls and back injuries from moving patients but also psychological harm, which has been magnified during the coronavirus pandemic. There are risks to everyone in healthcare associated with this new infection. Those threats are not only physical but also psychological—there is a dark cloud of risk associated with the virus."
4. Learning system
The action plan calls on healthcare organizations to foster networked and continuous learning such as promoting the sharing of information and improvement efforts.
Learning systems harness data, Brady says. "Learning systems are more than just about the data—this is where the quantitative understanding of patient safety comes alive. These are reporting systems, data systems, and analytical systems."
Building learning systems help healthcare organizations understand their patient safety challenges and boost sharing of best practices between organizations, he says.
"These systems help healthcare organizations understand what is happening in their own organization such as how many safety events they are having and what is the most common problem. Every organization needs to have a learning system that informs them about safety risks in their own organization. In addition, organizations need to look outside—across the field—to peer organizations from which they can learn."
Learning systems generate benefits beyond boosting patient safety, Brady says.
"The nice thing is we have some efficiencies to be gained through learning systems. The resources, technical requirements, and organizational competencies that are needed for learning systems can be applied to multiple problems. For example, these data systems can be adapted to new problems such as COVID-19. What we can expect is that investment in learning systems will reap additional benefits over time as they are used for more problems."
A recently published study found that female primary care physicians spend more time with patients than their male counterparts.
Female primary care physicians conduct fewer patient visits than their male counterparts but spend more time with patients, which helps to account for the physician gender pay gap, a recent research article found.
Several studies have shown that female physicians earn 8% to 29% less than male physicians. A report published last week by the physician network Doximity found that the wage gap between male and female physicians is 28% this year, with male doctors earning over $116,000 more annually than their female counterparts.
The recent research article, which was published by the New England Journal of Medicine, is based on an analysis of 24.4 million primary care office visits in 2017. The analysis of the office visits compared female and male clinicians in the same physician practices.
The study includes three key data points:
Female primary care physicians generated 10.9% less revenue from office visits compared to male PCPs
Female PCPs conducted 10.8% fewer patient visits over 2.6% fewer clinical days per year
Female PCPs spent 16% more time with patients than male PCPs
The additional time that female PCPs spend with patients relative to their male counterparts is a likely driver of the physician gender pay gap, the research article's co-authors wrote.
"We found that female PCPs generated nearly 11% less annual visit revenue than otherwise similar male PCPs in the same practices, yet they spent more time with patients per visit, per day, and per year. The revenue gap was driven entirely by differences in visit volume, which were only in small part explained by the fewer days that female PCPs saw patients. Taken together, these results suggest that the differences in time spent with patients may be a contributor to the gender pay gap, with female physicians effectively generating 87% of what male physicians generate per hour of direct patient care," they wrote.
Interpreting the data
The study has important implications for female physician work hours and compensating physicians based on patient visit volume, the research article's co-authors wrote.
"We found that female PCPs worked slightly fewer days per year and scheduled substantially fewer visits while—and possibly in part to compensate for—spending more time with patients per visit. Our finding that this additional time spent per visit translated into more time in direct patient care per day and per year challenges conventional assumptions that female physicians work fewer hours (even if they may also choose to schedule fewer visits on the basis of this aspiration). This finding also substantiates the common critique that volume-based productivity is an imperfect measure of physician work," they wrote.
The study also found significant billing differences between female and male PCPs. "Although female PCPs documented more diagnoses and placed more orders, they were more likely to miss opportunities to bill higher-paying visit codes on the basis of the time they had spent with patients, a finding that was consistent with the results of a study showing that female radiation oncologists billed fewer lucrative procedures than their male counterparts," the co-authors wrote.
In addition to providing insight into the physician gender pay gap, the study also may indicate why female physicians are more prone to burnout than male physicians, the co-authors wrote.
"Taken together, we found a nearly 11% gender gap in annual visit revenue among otherwise-similar physicians in the same practices. The gap was due primarily to male PCPs providing more visits, although female PCPs spent more time with patients per visit and overall. The disconnect between time spent and revenue generated may help to explain why female physicians (especially PCPs) face a greater risk of burnout than their male counterparts."
According to San Francisco-based Doximity, average physician pay has increased 1.5%.
Physician compensation growth has stagnated in 2020, according to a new report from Doximity.
The healthcare sector is under several financial strains during the coronavirus pandemic. Hospitals are losing billions of dollars, and a new American Medical Association survey found physician practice revenue was down an average of 32% this summer.
The new Doximity report, which is based on surveys of 44,000 full-time physicians conducted in 2019 and 2020, found average pay for physicians increased 1.5%. Previous Doximity physician compensation reports found physician compensation growth ranging from 3% to 5%.
The coronavirus pandemic is a likely driver of the tepid growth rate for physician compensations, says Peter Alperin, MD, vice president at Doximity and a staff physician at California Pacific Medical Center in San Francisco.
"We did find that the overall physician compensation was pretty flat as compared to the typical 3% to 5% increases we have seen in previous years. We are not 100% sure of the cause, but COVID-19 is most certainly playing a role."
Even if hospital and physician practice finances stabilize before the end of the year, any increase in 2020 physician compensation is likely to be modest, he says. "We know that hospitals and private practices have seen significant declines in revenue because of patient visits being cancelled and there being a switch over to telehealth. That said, a lot of that is coming back, so where things will end up at the end of the year is a bit of a guess. But the increase in compensation is unlikely to reach the 4% level that we have seen in previous years."
By the numbers
The new Doximity report has several key data points.
Metro areas with the highest compensation for physicians in 2020:
1. Milwaukee, WI — $430,274
2. Atlanta, GA — $428,244
3. Jacksonville, FL — $427,090
4. Buffalo, NY — $407,070
5. Orlando, FL — $406,587
Metro areas with the lowest compensation for physicians 2020:
1. San Antonio, TX — $329,475
2. Virginia Beach, VA — $331,952
3. Boston, MA — $347,894
4. Baltimore, MD — $348,389
5. Washington D.C. — $351,572
The five specialties with the highest average annual compensation rate:
1. Neurosurgery $746,544
2. Thoracic Surgery $668,350
3. Orthopedic Surgery $605,330
4. Plastic Surgery $539,208
5. Oral & Maxillofacial $538,590
The five specialties with the lowest average annual compensation rate:
1. Preventive Medicine $234,587
2. Pediatrics $243,253
3. Medical Genetics $252,930
4. Endocrinology $259,748
5. Family Medicine $261,536
Top five specialties with the largest increase in average annual compensation:
1. Vascular Surgery 4.9%
2. Physical Medicine/Rehab 4.7%
3. Geriatrics 4.6%
4. Genetics 4.4%
5. Emergency Medicine 4.3%
Gender wage gap: The new Doximity report found that the wage gap between male and female physicians was 28%, with male doctors earning over $116,000 more annually than their female counterparts. In last year's Doximity physician compensation report, the gender pay gap was to 25%.
Interpreting the data
The impact of the coronavirus pandemic is reflected in the new physician compensation data, Alperin says.
The increase in the gender pay gap is likely related to the pandemic, he says. "It could be that female physicians are decreasing their work hours more than male physicians to help take care of family members. It is certainly something to watch. If we see this as a trend over the next couple of years, it would be alarming."
The pandemic has affected compensation growth for specialties in high demand during the crisis, Alperin says.
"We have seen relatively high compensation increases in specific specialties—including geriatrics and emergency medicine. The increases in compensation for geriatrics and emergency medicine are almost certainly because of demand driven by COVID-19. With elderly patients, geriatrics is a field that is always in demand; but with COVID-19 there is a lot more going on with elderly patients. For emergency medicine, emergency rooms have been hard hit by COVID-19."
Despite the disruptive effects of the pandemic on physician compensation, robust growth in doctor pay should be expected in the long run, he says.
"Over the long term, it is unlikely that we are going to see any fundamental change in physician compensation because the fundamentals of demand for physicians have not changed. Some patients are foregoing their required screenings and other sorts of medical care, but patients who need services such as knee replacements are still going to need those services. So, the underlying fundamentals have not changed, nor have the fundamentals related to the number of physicians. For example, it takes a lot of time to start a new medical school."
Rather than having an enduring impact on physician compensation, the pandemic appears to be a catalyst for change in where doctors practice, Alperin says.
"There is unlikely to be a long-term change in physician compensation. However, there could be a long-term change in how physicians are employed. The pandemic could accelerate the change from private practice toward more physicians being employed by large physician groups and hospitals, because the impact of the shutdown in the early phase of the pandemic was intense for many private practices. There were many private practices that were not well capitalized to withstand the storm."
Coronavirus pandemic-related decreases in patient volume and increases in costs for infection control are hitting physician practices hard.
Physician practices remain "under threat" from severe financial strain from the coronavirus pandemic, an American Medical Association survey published this week shows.
Drops in patient volume and increases in costs for infection control such personal protective equipment (PPE) have hit physician practice bottom lines hard during the pandemic. In the spring, a poll conducted by the Primary Care Collaborative and The Larry A. Green Center found only 33% of primary care clinicians had enough cash on hand to function for four weeks.
The AMA survey published this week, which was conducted from mid-July through the end of August, found a 32% average drop in revenue at physician practices.
AMA President Susan Bailey says physician practices are struggling financially and need federal assistance.
"Physician practices continue to be under significant financial stress due to reductions in patient volume and revenue, in addition to higher expenses for supplies that are scarce for some physicians. More economic relief is needed now from Congress as some medical practices contemplate the brink of viability, particularly smaller practices that are facing a difficult road to recovery," Bailey said in a prepared statement.
The AMA survey features data collected from 3,500 physicians. The survey includes several key data points:
81% of survey respondents said revenue remained below pre-pandemic levels
81% of survey respondents said in-person patient visits remained below pre-pandemic levels
Despite a significant increase in telemedicine visits, the survey found 70% of physicians were conducting fewer total patient visits than before the pandemic.
Two-thirds of physician practice owners reported increased spending on PPE, with the average hike in PPE spending pegged at 57%.
One-third of survey respondents said acquiring PPE was very or extremely difficult.
Federal assistance was popular in the survey: 80% of survey respondents said the Cares Act was very or extremely helpful, 71% of survey respondents said the Medicare Accelerated and Advance Payment Program was very or extremely helpful, and 88% of survey respondents said the Small Business Administration Paycheck Protection Program was very or extremely helpful.
Liselotte "Lotte" Dyrbye, MD, MHPE, delivered a keynote address at a national summit on promoting well-being and resilience in healthcare workers.
A Mayo Clinic expert says there are more than a dozen ways to promote well-being and limit burnout at healthcare organizations.
Healthcare worker burnout was at epidemic proportions before the coronavirus pandemic, and a Stanford Medicine burnout researcher expects a new national survey will show the pandemic has exacerbated the problem. A study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
Last week, Liselotte "Lotte" Dyrbye, MD, MHPE, a professor of medicine and medical education at Rochester, Minnesota–based Mayo Clinic, was one of the keynote speakers at the second national Summit on Promoting Well-Being and Resilience in Healthcare Professionals. In her presentation, Dyrbye said there are at least 14 methods to address healthcare worker burnout:
Appointing a chief wellness officer
Securing commitment to tackle burnout from top leadership
Having governing boards hold healthcare organizations responsible for creating a positive work environment
Holding leaders at every level of healthcare organizations accountable for improving the work environment
Creating a workplace culture that supports change management, psychological safety, and peer support
Establishing clear alignment between organizational values and workforce values
Including well-being in decisions, policies, mandates, and resource allocation
Redesigning clinical systems so that they meet the needs of healthcare professionals
Targeting known systems factors that affect the balance between job demands and job resources
Building infrastructure and culture that supports accountability
Improving electronic medical record usability
Having strong relationships between healthcare professionals to increase social support
Providing professional coaching for clinicians
Promoting the ability of healthcare workers to seek help if they are experiencing burnout
After Dyrbye delivered her keynote presentation, she spoke with HealthLeaders in greater detail about some burnout prevention efforts. The following is a lightly edited transcript of that conversation.
HealthLeaders: How do healthcare organization leaders play a role in curbing burnout?
Liselotte "Lotte" Dyrbye: It is really systems factors that are contributing to workplace stress, which leads to burnout. So, healthcare organization leaders need to look at the work demands and the work resources, then get them into a better balance.
Practically, this means that healthcare organization leaders need to do some measurement using validated instruments, so they know what is going on. They need to find out about the levels of burnout and satisfaction. They need to understand the contributing factors for burnout in the workplace. Then leaders need to get that data down to the work units to help identify hotspots for burnout. They need to engage in a dialogue with the "boots on the ground" to identify the drivers of burnout and identify the solutions.
Other important factors that healthcare organization leaders can influence are culture, values, meaning in work, and leadership skills. We need to be thoughtful that the people we put in leadership roles have good leadership skills and seek opportunities to refine their leadership skills. Local leadership makes a difference.
HL: Give an example of how clinical systems can be redesigned to promote clinician well-being.
Dyrbye: One example is having a medical assistant in the exam room with the clinician in the primary care setting. Under this model, the medical assistant goes into the room first, collects the medical history, makes sure the patient's medications are in the medical record, and gets the patient prepared for the visit.
When the clinician comes into the room, the medical assistant summarizes the medical history, the clinician can ask targeted questions, and the medical assistant can enter notes into the medical record as well as prepare any equipment that will be used during the visit such as throat swabs. The clinician and the medical assistant work together collaboratively to meet the needs of the patient. The clinician can focus on the patient, and the medical assistant can focus on clerical tasks.
At the end of the visit, the clinician can sign the medical orders that the medical assistant has put into the medical record, and the clinician can provide some counseling then leave the room. The medical assistant can finish up with patient education, make sure the patient understands the plan of care, then finish up the notes for the clinician to review and sign.
Under this model, the clinician is working at the top of his or her licensure, and the medical assistant is working at the top of his or her licensure. Patients are satisfied. Quality metrics go up. The medical assistant is satisfied. And the physician is more satisfied.
HL: Give examples of where electronic medical record usability needs improvement.
Dyrbye: These systems are incredibly complex. The interface has multiple different colors, font sizes, and there is so much busyness going on. It is hard to figure out where information is, where you need to enter information, and how to get tests done. The whole work process is very difficult.
I am fortunate. I work in one health system that has one electronic medical record. But there are many other healthcare professionals who work in multiple hospitals, and each hospital has its own electronic medical record that is set up differently. There is no standardization.
One concern is when nurses must enter data into different boxes, and they cannot advance to the next field if they leave a box blank. There are some situations where information is not available or not applicable. So, the nurses get stuck, which is incredibly frustrating.
There are innumerable opportunities to improve the usability of electronic medical records.
HL: How does professional coaching boost clinician well-being?
Dyrbye: We did a randomized controlled study where physicians received three-and-a-half hours of professional coaching over a six-month period. That coaching led to improvements in burnout, increased quality of life, and more resiliency.
This is a low-cost, feasible intervention that can be done during the pandemic. Physicians mostly get coached on factors that fall into the professional sphere. Although some physicians got coached on overcoming barriers to physical fitness and those types of issues, most were coached on how to have crucial conversations, how to lean into change at work, and how to make meaningful differences at work.
Coaching is different than mentoring. It is focused on listening, being curious, and not giving advice. The coach asks a series of open-ended questions that get clinicians to clearly identify their goals, help them to understand their options, and determine where there is the will to change.
HL: How can healthcare organizations encourage staff to seek help for burnout?
Dyrbye: Psychological safety is a big issue. Organizations must make seeking help safe. You must change the culture to make seeking help a sign of strength rather than weakness.
Many organizations have various versions of employee assistance programs that keep confidential records—these records are not part of an employee's work file to try to reduce barriers to seeking help.
At Mayo Clinic, we have an Office of Staff Services, which is a place where clinicians can go and talk with a physician who can refer them to an internal psychologist if necessary, to help with burnout or other work-related issues.
What is great about the Office of Staff Services is I can go there for help with my 401(k) or I can go there because I am burned out. There are a variety of reasons why I would go to that office. So, it feels safe to go there.
A new COVID-19 recovery program focuses on long-term symptoms after acute illness with individualized and expedited treatment.
A New York-based medical center has established a clinical program for coronavirus "long haulers"—patients who experience symptoms for weeks or months after the acute phase of their illness.
Since the first case of COVID-19 was diagnosed in the United States, the disease has perplexed clinicians at several turns. For example, during the spring coronavirus patient surge, clinicians placed seriously ill patients on ventilators relatively quickly as they are inclined to do with other patients suffering with acute respiratory distress syndrome (ARDS). However, proning and nasal high flow therapy have emerged as better courses of treatment for many coronavirus patients who develop ARDS.
Gary Rogg, MD, an attending physician in internal medicine and co-director of the Post-COVID-19 Recovery Program at Westchester Medical Center in Valhalla, New York, says coronavirus long haulers can have a range of long-term symptoms.
Cough
Shortness of breath
Constitutional symptoms such as numbness and tingling
Cardiac issues
Deconditioning
Hair loss
Anxiety and depression
Brain fog: "They will understand what you are asking them and they know the answer, but it takes them a while to formulate the answer, which is very different from these people's baseline," he says.
"What became apparent through the pandemic is that COVID-19 is very different from the flu. With influenza, pretty much everyone has fever and body aches for a week or two, then it just resolves. With COVID-19, patients are having ongoing symptoms for week after week," Rogg says.
He says about 10% of Westchester Medical Center's coronavirus patients are long haulers, but the percentage could be higher. "As time goes on, that number could increase, particularly in the younger and healthier group. Those patients recover and have symptoms, but they go to work, go about their lives, and maybe have some denial hoping the symptoms will go away. So as time goes on, we will probably see more long haulers. It could go up to 15% of all coronavirus patients."
Caring for long haulers
Westchester Medical Center launched the Post-COVID-19 Recovery Program after Labor Day.
"During the first COVID-19 patient surge, I was asked to organize the coronavirus response for the medical center. One of the things we developed was a rapid response team, where we had dedicated physicians from each of several specialties. When we had hospitalized patients, they would not go through the standard mechanism for consultation—the physicians would be called directly, which provided expedited specialty care. We modeled the Post-COVID-19 Recovery Program along those lines," Rogg says.
Primary care physicians play a key role in the recovery program, he says. "What we try to do with the program is to personalize and individualize the care of these patients. We have set up a dedicated group of primary care providers who serve as a gateway."
Physicians in several specialties also are participating in the recovery program, including neurology, pulmonology, cardiology, rehabilitative medicine, and infectious disease.
Patient navigators are a unique aspect of the recovery program, Rogg says. "This program is not one-size-fits-all. It is individualized. The patient navigators are a resource and extension of the physician to expedite any issues that arise. The patient navigators schedule patients for appointments in the recovery program and they expedite specialist appointments. They are basically an appointment contact person."
The patient navigators help ensure that care is provided on a timely basis, he says. "We see patients in an expedited manner. For specialty care, we can get patients in to see a clinician within a week or two. If necessary, we can set those appointments faster."
Once a coronavirus patient is enrolled in the recovery program, the first step is an initial evaluation, Rogg says. "We look for other contributing or secondary causes of symptoms, we see what was done on the patients during the acute phase of their illness, then we refer patients for testing and for specialty evaluation. … We do a blood panel, check inflammatory markers, and conduct tests looking for secondary issues."
Some long haulers are evaluated for blood clotting, he says. "Many patients who have an issue with shortness of breath either have emboli and are given CT scans, or they have diffusion abnormalities such as scarring or inflammation in the interstitial space—the air spaces in the lungs. In the latter cases, air cannot get into the lungs adequately. For patients with diffusion abnormalities, we conduct pulmonary function testing."
For long haulers with suspected cardiac issues, echocardiograms are conducted, Rogg says.
In search of a cause
The cause of long hauler symptoms remains a mystery, but Rogg has a theory. "The thought is that COVID-19 is causing persistent changes in a person's immune system—there is an immune system-mediated process driving the long-hauler symptoms."
The course of symptoms also points to the immune system, he says. "A pattern we see with long haulers is waves of symptoms. A patient will wake up and say, 'This is the first day that I'm starting to feel better.' Then a couple of days later or a week later, their symptoms recur. We have seen that in the acute illness, too. The symptoms seem to fluctuate. The only thing that can cause that kind of fluctuation is some kind of dysregulation of the immune system."
The biennial conference, which met virtually this year, is designed to share best practices and evidence-based approaches to curb burnout.
Last week, nearly 400 healthcare professionals participated in a national summit on healthcare worker well-being and resilience.
Research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published in October 2018 found that burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
Formed in 2017, the collaborative has launched several initiatives and resources, including resources to support clinician health and resilience during the COVID-19 pandemic, a clinician well-being knowledge hub, publications, and events and webinars.
Dzau reflected on the accomplishments of the action collaborative over the past four years.
"We have convened key players and entities to address burnout. That includes many stakeholder organizations, many commitment statements, and many activities. We have created webinars and convened a summit of CEOs to affirm the importance of clinician well-being and to look for solutions. We have created an art form of expression that is a gallery that has been presented across the country. We have collected data and conducted analysis. We have been active, with 65 member organizations. This is collective action, where we cannot make progress alone."
Pandemic as catalyst
Perry Gee, PhD, RN, nurse scientist at Salt Lake City, Utah-based Intermountain Healthcare, discussed how the health system seized on the coronavirus pandemic as an opportunity to launch a bevy of well-being and resilience programs for healthcare professionals. "We had to react. We had to implement programs that were in development or in pilot phases," he said.
Intermountain launched several programs:
A major campaign for marketing and communications to provide transparent information for caregivers
A compassionate connections program to help healthcare professionals learn to speak and listen about difficult challenges such as changes in patient visitation during the pandemic
A 24/7 call-a-chaplain program for family members, patients, and caregivers
Wellness rounds by health system leaders that include bringing a cart or basket with treats to medical units that provide an opportunity talk with caregivers
Facilitated peer support groups
Checklists such as a going-home checklist and family safety checklist
Respite rooms close to COVID-19 treatment centers that are manned by employee assistance program staff
A crisis response program developed by the EAP to provide a range of services including psychological first aid
Daily virtual mindfulness sessions that are led by experts in behavioral health and the EAP
"The pandemic gave us an opportunity to implement programs that we had been considering, and we are going to continue to circle back and make improvements on those programs. We quickly learned what our caregivers needed, and we reacted to adapt our programs to those needs," Gee said.
Strengthening relationships
Diana McMahon, MSN, RN, director for professional practice at The Ohio State University Wexner Medical Center—James Cancer Hospital in Columbus, Ohio, discussed her organization's approach to relationship-based care.
"Relationship-based care is the conceptual framework and roadmap that we use to stay focused on our mission. Relationship-based care focuses on four caring relationships: care of the patient and the family, care of self, care of colleagues, and care of the community. It provides consistent coherence in a world that is ever changing. What COVID-19 has taught us is that when everything is changing, relationships bring stability. The pandemic has also taught us that being part of a team builds security and decreases stress," she said.
Examples of programs developed to foster relationships include relationship-based resilience. The one-day retreat is designed to introduce staff to the four key relationships of relationship-based care and to learn how to leverage relationships to increase personal and organizational resilience.
With a positive approach to change, healthcare workers and their organizations can emerge from the pandemic stronger and more resilient.
At the individual and organizational levels, posttraumatic growth can be a positive response to the coronavirus pandemic at healthcare organizations, a recent journal article says.
COVID-19 has wreaked havoc on the healthcare sector. At the individual level, healthcare workers have faced a range of adversity from shortages of personal protective equipment to the strain of losing patient lives to the virus. At the organizational level, health systems, hospitals, and physician practices have endured many disruptions, including financial distress and the suspension of elective surgeries during coronavirus patient surges.
Posttraumatic growth features positive psychological change achieved after severe adversity and the establishment of a "new normal." The recent journal article, which was published by the Journal of the American Medical Association, says posttraumatic growth has five spheres.
Development of stronger relationships
Willingness to embrace new possibilities
Improved perception of personal strength
Heightened sense of spirituality
Increased appreciation of life
Although posttraumatic growth is challenging for individuals, who must engage in deliberate reflection and dedication to improvement, the process can be significantly beneficial, the co-authors of the recent journal article wrote.
"Typically, posttraumatic growth develops following a physical or psychological trauma that is disruptive enough to the affected individual's perspectives and values that it stimulates reassessment and rebuilding of psychological and philosophical beliefs and approach to living. Such traumas often force affected individuals to recognize they are not invincible, consider what they do and do not control, and reassess their personal and professional priorities."
Posttraumatic growth can be equally beneficial for organizations, the journal article's co-authors wrote. "When organizations are affected by adversity, they often use crisis management with the goal of restoring the system back to its normal level of functioning. In contrast, organizational posttraumatic growth refers to a process by which organizations are not only restored, but achieve a higher level of functioning as a result of addressing and learning from a traumatic event."
Promoting posttraumatic growth
Healthcare workers and organizations can take five steps to promote posttraumatic growth as a response to the coronavirus pandemic, the journal article and its lead author say.
1. Assessment and learning
Individuals and organizations should assess the impact of the pandemic and determine what can be learned from the experience. At the organizational level, the assessment and learning process should include creation of a team of leaders and frontline healthcare workers to reimagine a new normal.
Posttraumatic growth is a method for individuals and organizations to get through the pandemic and not only bounce back to where they were but also be better and stronger than where they started, the lead author of the journal article told HealthLeaders.
"The process of reimagining a new normal starts with recognizing the loss of the old normal and acknowledging the loss of the old normal. Then you need to set upon finding new ground and the new normal. A major part of the concept of posttraumatic growth is you have lost the ground under your feet—there has been a seismic shift—and you want to move into the new normal," said Kristine Olson, MD, MS, chief wellness officer at Yale New Haven Hospital in New Haven, Connecticut.
2. Role models
Individuals and organizations should seek out role models that have improved because of the pandemic. Role models show that posttraumatic growth is possible, how posttraumatic growth can be achieved, and how individuals and organizations can respond to the pandemic in a way that makes them stronger and more resilient.
For individuals, a good role model is someone who has risen to the challenge, Olson said. "For example, if you were afflicted by COVID-19, you may see somebody who has gone through ECMO and three months of intubation and survived. You can see that this other patient is now joyful and productive. That can help you in your recovery."
For organizations, leaders should look for other organizations that are exemplary of best practices, she said. "You need to look for role models who have tackled the pandemic well. When you are looking for a role model, you are looking for organizations that have been impacted and tackled the pandemic and can be exemplary of how your organization can tackle the pandemic."
3. Creativity
Individuals and organizations should view the pandemic as both a traumatic experience and an opportunity for improvement. A key question to ask is how the pandemic can serve as a driver of change. Creativity is crucial because it can spur new ideas, attitudes, procedures, and structures that can fuel growth.
Healthcare organization leaders should create a workplace climate that supports creativity among groups of individuals, Olson said. "If you can make people feel in control, make sure that their needs are being met, provide a safe environment for cultivating optimism, and reimagine the new normal, then you can do it faster as a group than you can as individuals."
4. Altruism
Individuals and organizations should assess how the pandemic has fostered connections to humanity and the broader society as well as promotion of altruistic solutions. At the organizational level, leaders should reconsider how to show genuine commitment to healthcare workers and reaffirm altruistic values.
To emerge stronger from the pandemic, healthcare organization leaders should be grounded in the mission to provide high-value care to their communities, Olson said. "When we decide to come together to solve problems, we find that we are more creative, and we find new ways to reframe and create the new normal. We find out that we are not alone and are in this together. All of that is easier when we are oriented to our altruistic mission."
5. Loss and grief
In the process of coping with loss and grief, organizations should reassess priorities and seek out reasons for gratitude. Leaders should reflect on whether they are supporting healthcare workers appropriately and look for reasons to be optimistic.
Healthcare organization leaders can play a pivotal role in helping their workers deal with loss and grief, Olson said.
"When I ask our bereavement counselors about this topic when we have a community shaken by loss, they say that leaders need to acknowledge the trauma, the loss, the goals that have been disrupted, and the passing of the old normal. Leaders need to promote self-compassion and compassion for others as well as gratitude for one another. Leaders need to foster optimism."
