With the broadest reach to patients, the primary care setting is well-suited for identifying and assessing depression.
The primary care setting is the most appropriate venue for the screening and early treatment of depression, according to the lead author of an article published recently in the New England Journal of Medicine.
Depression is one of the most common behavioral health disorders in the country, with the estimated lifetime risk of a major depressive episode set at about 30%. Suicide, which is associated with depression more than 50% of the time, has become more prevalent in recent years and is now the 10th leading cause of death for Americans.
"Primary care settings offer the broadest reach in terms of patients seeking care, and therefore are the optimal place to conduct screening for depression and suicide," Lawrence Park, MD, medical director of the Clinical Research Unit at the National Institute of Mental Health's Experimental Therapeutics and Pathophysiology Branch in Bethesda, Maryland, told HealthLeaders last week.
Although the primary care setting is well-suited to detect depression and suicidal ideation, there are challenges for clinicians to overcome, he said.
"One must be aware of not only depression, but all possible medical and mental health conditions. So, the primary care provider needs to be expert at detection and diagnosis across a broad range of diseases. Because depression is so common, we recommend the use of a brief screening tool for depression—and suicidal thoughts and behaviors—for all primary care patients."
If a patient presents signs of depression, primary care clinicians must weigh several options, Park said.
"When depression is suspected, primary care providers should conduct follow up assessment to determine the severity of the condition, safety evaluation, and consider interventions. Therapeutic interventions may include close monitoring of the patient's condition, initiation of psychotherapy and/or medications, referral to a mental healthcare provider, or hospitalization."
Primary care's depression niche
For treatment of depression, the primary care setting is only appropriate for patients with mild and moderate conditions, Park said.
"In primary care, there is a scarcity of healthcare resources. Primary care providers lack the time and support to comprehensively care for all aspects of the depressed patient. From our perspective, primary care is ideally placed to perform the critical screening function for depression and suicidal thoughts and behaviors. If quick and efficient screening is done on all patients, primary care providers can devote additional time for assessment to those with positive screens."
In cases of severe depression, interventions include the assistance of mental health specialists, time-consuming treatments such as psychotherapy, and higher levels of care such as emergency department evaluation, he said.
Avoiding primary care pitfalls
To provide optimal care for depressed patients, primary care physicians should have easy access to mental health resources, Park said.
"Many primary care settings have incorporated an embedded mental healthcare professional into their practices. Without adequate mental healthcare support, primary care providers may be reluctant, or unable, to conduct accurate screening and assessment of depression and suicidal thoughts and behaviors, or they may not be able to appropriately manage these conditions when they are identified."
Primary care clinicians also face a significant clinical challenge when managing depressed patients, he said.
"Primary care physicians should rule out underlying medical conditions that may cause or exacerbate depression, and they should distinguish between bipolar depression or major depressive disorder—unipolar depression—as both situations would have important therapeutic implications."
Researchers find 'modest improvement' in physician burnout and call for continued efforts to address the problem.
The rate of physician burnout has eased over the past three years but remains at an alarming level, according to research published Friday.
Physician burnout, which includes emotional exhaustion and depersonalization, has been linked to decreases in patient safety, professionalism, and patient satisfaction. Electronic health records, which have increased administrative burdens on physicians and reduced the amount of time they spend with patients, have been cited as a primary cause of physician burnout.
The new research, which was published in Mayo Clinic Proceedings, found that the country's physician burnout rate dropped 10.5 percentage points, from 54.4% in 2014 to 43.9% in 2017. The rate had been 45.5% in 2011.
The improvement is a positive development, but physician burnout remains a vexing problem for the healthcare sector, the researchers wrote.
"The current prevalence of burnout among U.S. physicians appears to be lower than in 2014 and near 2011 levels. This trend is encouraging and suggests improvement is possible despite the numerous contributing factors and complexity of the problem," they wrote. "Although the improvement is good news, symptoms of burnout remain a pervasive problem, and its prevalence among physicians continues to be markedly higher than in the general U.S. working population."
The Mayo Clinic Proceedings research, which is based on data collected from more than 5,000 physicians, has several other key findings:
Satisfaction with work-life balance was higher in 2017 (42.7%) than in 2014 (40.9%) but lower than it was in 2011 (48.5%).
The depression rate has increased steadily among physicians: 38.2% in 2011, 39.8% in 2014, and 41.87% in 2017.
Compared to the general workforce, physicians have a significantly higher rate of burnout: 36.4% of physicians reported emotional exhaustion compared to 24.8% for the general workforce, and 18.0% of physicians reported depersonalization compared to 13.5% of the general workforce.
The data shows that efforts to address physician burnout should remain a high priority for health systems, hospitals, and physician practices, the researchers wrote.
"Despite the modest improvement, our results indicate that burnout among U.S. physicians remains a major problem for the healthcare delivery system. In our view, the effort to improve healthcare professional well-being is an ongoing journey, analogous to efforts to improve quality and safety," they wrote. "A coordinated, systems-based approach at both the national and organizational levels that addresses the underlying drivers is the key to making progress."
Possible explanations
The researchers identify five potential factors for the reduced physician burnout rate in 2017:
2014 may have been an outlier year, with high levels of hospital and medical group consolidation, several new regulations, and heightened administrative burdens.
Physicians and their organizations may be adapting to the new practice environment.
Physicians who have burned out may be leaving the profession.
Large-scale initiatives to reduce physician burnout such as efforts at the American Medical Association and Association of American Medical Colleges may be taking hold.
Initiatives designed to improve the efficiency of the practice environment such as team-based care could be easing pressure on physicians.
"Efforts to improve physician well-being have proven to be efficacious and should be recognized as potential contributors to the favorable trend," the researchers wrote.
For clinicians, effective communication with patients, families, and colleagues is crucial to achieve optimal care in the final months of life.
For a significant number of Medicare beneficiaries, the final months of life degenerate into alternating back and forth between acute care hospitals and postacute care facilities, a recent journal article shows.
In 2013, about 23% of hospitalized Medicare beneficiaries were discharged to a postacute setting, with 87% of those patients sent to a skilled nursing facility (SNF). From 2006 to 2011, one in eight of Medicare beneficiaries who died were transferred back and forth from hospitals to SNFs in the last year of life.
"In treating discharge to a postacute care facility as a routine event, we are missing an opportunity to improve care for seriously ill older adults," the authors of the New England Journal of Medicine article wrote.
Improving communication between clinicians and patients
To help break the hospital-to-SNF care cycle, clinicians should hold discharge discussions for patients that mirror typical goals of care conversations, the lead author of the journal article told HealthLeaders last week.
"When discussing discharge, clinicians should get a sense of the patient's and family's understanding of the patient's condition, fill in the gaps where needed including discussion of prognosis for functional recovery, however uncertain it may be, then identify the patient's and family's goals given the new clinical situation," said Lynn Flint, MD, an associate professor in the Division of Geriatrics, School of Medicine, University of California, San Francisco.
Reconciling the prognosis with the patient's and family's goals is essential, she said.
"If the goal is to get as close to prior functioning as possible, a short stay in a nursing home for rehab could make sense. However, if the prognosis is uncertain and time might be limited, certain patients and families might value time at home over maximal functional recovery, and a home discharge with added supports could be explored."
Resources are available to help clinicians hold these conversations, Flint said.
"All inpatient clinicians and postacute clinical staff could benefit from additional training in serious illness communication. A great option is the VitalTalk 'Mastering Tough Conversations' course. The VitalTalk website has some frameworks for breaking bad news and eliciting goals of care that can be a useful introduction or refresher for those who are unable to take a formal course."
There are several essential elements to training clinicians about serious-illness communication, Flint said.
"The key pieces to learn and practice are the basics: active listening, responding to emotion, breaking bad news, and inquiring about what matters most. This sounds straightforward, but these things are really difficult in the moment and every situation is unique."
Improving communication between clinicians
Discharge discussions between acute care clinicians and patients should be shared with clinicians at postacute facilities, Flint and her coauthors wrote. "The details of these discussions could be documented in the medical record and communicated explicitly to clinicians at the postacute care facility, enabling them to continue the conversation more effectively."
Boosting communication between clinicians in the acute and postacute settings requires additional time and effort, they wrote.
"We recognize that these types of conversations are more complicated and time consuming than typical discharge communications. But hospitalists, discharge-planning nurses, and social workers can be trained in communication about serious illness. Advance care planning codes, introduced in 2016, can be used to bill for the extra time spent."
Techniques to retain millennials include dress code changes and providing opportunities for career advancement.
Having trouble with turnover in your millennial healthcare workforce?
Since more than a third of the U.S. labor force are millennials, according to the Pew Research Center, you want to ensure you have strategies in place to understand the needs of the millennial workforce and how to retain them.
It matters to keep millennials happy in the workplace. That's why one Indianapolis-based health system has made millennials the focus of its workforce strategy.
AtIU Health, about 59% of its new hires are millennials, says Amanda Bates, vice president of human resources. "We employ a lot of millennials, and strategically as we look at growth and future hires, they will become more and more of our new hires."
"Forty-one percent of our workforce is millennials. Fifty-one percent of our nurses are millennials, and 31% of our physicians are millennials. So, a lot of our key jobs that touch our patients are millennials, and they will continue to grow in terms of the numbers employed. Strategically, we need to accommodate these folks."
IU Health has implemented four strategies to accommodate and retain millennial healthcare workers at their organization.
1. Adopt a new dress code
IU Health, with 16 hospitals across Indiana, has relaxed its dress code to allow all staff members to have tattoos and piercings, which are defining characteristics of many members of this generation. The change took some courage and it came with a measure of controversy, Bates says.
"The one thing we did that was the big difference maker was go to our patient advisory councils. We went to our patients and asked, 'What's important to you?' We found that what patients really cared about was the quality of their care and the compassion of their caregivers. They cared less about what their caregivers looked like."
Bates and other health system leaders addressed opposition to the new dress code by demonstrating the necessity for change.
"When we rolled it out, there was overwhelming acceptance, but there was a small group of people who were sending me letters about selling out to tattoos and piercings. My response was that we had not sold out at all—this is reality. Millennials present differently than the baby boomers presented, and we needed opportunity for that expression," she says.
2. Provide opportunities for career advancement
IU Health has adapted to the desire of millennials for career mobility and advancement, particularly for nurses and medical assistants, Bates says.
"In nursing, we started developing career pathways, which are ways for people to develop knowledge and incremental skills in areas of their preference like research, leadership, clinical care, safety, or informatics. We give people in clinical areas many options in terms of their development and pathways to gain knowledge or certifications."
Prior to establishing career pathways and ladders for medical assistants, they had the highest job turnover of any other clinical role at IU Health, she says.
"We did focus groups with our medical assistants, and we found out that they wanted career development and career progression. It was a very flat job that did not pay a lot. So, we talked with them about the skills that would be of most benefit, then we developed opportunities for people to become trained and certified in those skills. Now, we have 65% of our medical assistants who have received promotions on our career ladder, which comes with pay increases and increased responsibility. Our turnover is down to the 10th percentile."
IU Health also has established career pathways and ladders in other areas of the organization, including human resources, finance, and information technology.
3. Reform hiring and training practices
The health system has made the hiring process more appealing to millennials, Bates says.
"Until 18 months ago, you had to apply the old-fashioned way—getting on a computer and filling out an application that took 30 minutes, then taking a test to measure job aptitude. You can still apply that way, but 65% of our applications now are made on a mobile app—it takes just a few minutes. We significantly reduced the number of questions that we asked, and we have doubled the number of applications that we get."
Texting is the next frontier of IU Health's hiring efforts, she says. The health system is adopting a texting application that helps communicate with applicants with a text rather than a phone call.
IU Health is starting to conduct screening interviews via text. The health system has built a library of standard questions that recruiters ask of each candidate, which they can auto-populate into the chat trail for quick conversations to learn about factors such as candidate qualifications and shift availability. A transcript of the conversation can be shared internally to help avoid duplicate questions being asked when the hiring leader conducts interviews.
Millennials tend to be more job ready than earlier generations of healthcare workers, so the health system has streamlined orientation processes, she says.
"A couple of years ago, we reduced the amount of time new hires spend in orientation before they join their units. For our nurses, we used to have service requirements before we would move them into operating rooms or ICUs, but we discontinued that. We can move millennials into jobs that require fast-pace and critical thinking."
With the proclivities of millennials in mind, IU Health also has been innovating in how the organization trains employees in ways that are novel, fun, and social, Bates says.
"We recently rolled out an escape room program for new nursing hires. They are broken into groups and have an hour to solve safety and quality puzzles. You need to try to beat the time of the other cohort teams in your training group."
4. Enhance tuition reimbursement for continuing education
IU Health also is using tuition reimbursement to cater to millennials as an opportunity for career advancement, she says.
"We have improved tuition reimbursement. We stopped making it a requirement for nurses to have a bachelor's degree and offered a generous tuition reimbursement. We doubled the number of academic programs that we would pay for. In one year, we tripled the number of people in our tuition reimbursement program."
Researchers find that market concentration has a negative impact on all 10 of the patient satisfaction measures in Hospital Compare.
Market concentration including vertical integration between hospitals and physicians has a negative impact on patient satisfaction, recent research indicates.
With the changing economics of the healthcare sector, vertical integration between hospitals and physicians as well as hospital mergers have become increasingly common. For example, the number of hospital-employed physicians increased about 63% from 2012 to 2016.
Market concentration is reducing competition with predictable results, the lead author of the recent research published in Medical Care Research and Review told HealthLeaders last week.
"From a data standpoint, market concentration is a proxy for competition within the market, where higher market concentration corresponds with
lower competition. With lower competition, we suspect that there is simply less incentive for providers to keep patients content," said Marah Short, associate director of the Center for Health and Biosciences at the Baker Institute for Public Policy, Rice University, Houston.
The researchers examined 29 quality measures in the Hospital Compare database at the Centers for Medicare & Medicaid Services from 2008 to 2015. While vertical integration was linked to a minor impact on some quality measures, market concentration in general was "strongly associated" with reductions in all 10 patient satisfaction metrics such as measures for doctors communicating well and patients receiving help as soon as they want it.
"Given the nature of some satisfaction measures, such as explaining medications and communicating well with patients, overall clinical quality could suffer if patients do not properly understand care recommendations during their hospital stay or post-discharge," Short and her coauthor wrote.
The researchers acknowledge that patient satisfaction may not always be associated with clinical quality; however, they contend that patient perception is an important metric because more and more patients are using online physician reviews to pick healthcare providers.
"In one U.S. study, 59% of survey respondents stated that physician ratings are 'somewhat' or 'very important' in their choice of physician, and consumers aged 18 to 24 years are more likely to use online health information and physician ratings for provider selection than the general population. As this young cohort becomes a larger consumer of healthcare, we expect this increase to continue," they wrote.
Regulatory review is needed to maintain patient satisfaction levels after healthcare deals that impact market concentration, the researchers wrote. "Regulators should continue to focus scrutiny on proposed hospital mergers, take steps to maintain competition, and reduce counterproductive barriers to entry."
The difficulties of achieving appropriate administration of antibiotics in intensive care units include early treatment of patients due to severity and acuity of illness.
Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.
Research co-author Richard Wunderink, MD, FCCP, of Northwestern University Feinberg School of Medicine in Chicago, told HealthLeaders that there are three primary unique aspects of antibiotics stewardship in the ICU.
Severity and acuity of illness requires early administration of antibiotics
Diagnostic uncertainty in a patient who presents with multiple potential sites of infection prompts multiple potential antibiotic treatment regimens
There is a tendency for patients with risk factors for multidrug-resistant, extensively drug-resistant, and pan-drug-resistant infections to require transfer to the ICU
As a result of these challenges, ICU clinicians often deal with the negative impact of excess antibiotic therapy, Wunderink and his co-authors wrote in the journal CHEST.
"Many ICUs become sinks for multi-drug resistant pathogens, accumulating patients with treatment failure due to antibiotic resistance. Prolonged duration of mechanical ventilation also predisposes to recurrent ventilator-associated pneumonias (VAPs), with each pathogen more resistant than the previous."
The research team found there are three main barriers to good antibiotics stewardship in the ICU: diagnostic uncertainty, fear of not adequately covering the causative pathogen, and underestimation of antibiotics toxicity. Wunderink said there are approaches to overcome these barriers.
Developing new rapid diagnostic tests as opposed to culture-based techniques—the greatest needs are for direct-from-blood samples and accurate samples from respiratory secretions
Promoting better clinical research with more accurate tests to determine the true incidence of "missed" pathogens
Raising awareness about antibiotic toxicity and the difficulty of separating drug toxicity from the underlying infection; for example, both often can cause fever
Antibiotic stewardship program
Implementing a formal antibiotic stewardship program is essential in the ICU setting, the researchers wrote.
"Judicious use of antibiotics in the ICU is essential to control development of resistant organisms and the benefits of implementing an ASP in the intensive care unit are well-documented. Studies have shown that ASPs reduce rates of antibiotic resistance, duration of ventilation, days of antibiotic use, and healthcare costs in critically ill patients."
An ASP in the ICU setting should have seven elements, according to the researchers.
Leadership: An infectious disease pharmacist and infectious physician should responsible for administering the ASP along with the ICU leadership.
Audit and feedback: Antibiotics administration should be reviewed and revised in response to changing circumstances such as new diagnostic results. Revised courses of treatment include de-escalation of medication.
Antibiotic time out: This physician-trainee approach reviews antibiotic indications on a bi-weekly basis and includes monthly trainee instruction.
Rapid diagnostics: The ICU should be equipped with a viral multiplex polymerase chain reaction platform, rapid PCR for methicillin-resistant Staphylococcus aureus, and serial procalcitonin.
Clinical pathways: These guidelines require physicians to document signs and symptoms, then provide antibiotics recommendations. Some pathways stratify patients based on risk factors for multi-drug resistance, which can determine the length of antibiotics treatment.
Computerized decision support: Electronic analysis of antibiograms and patient data generate antibiotics recommendations. Computerized decision support can provide an individualized approach to antibiotic decision-making for each patient.
Infection control: ICU staff should take preventative measures such as hand washing.
New research contradicts the perception that better sepsis care alone can reduce mortality.
Most sepsis-associated deaths are linked to other underlying causes and are not preventable with better sepsis care alone, research published today indicates.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths.
The research published today in the Journal of the American Medical Association focused on sepsis-associated deaths at six academic medical centers and community hospitals, where sepsis was the most common immediate cause of death.
"However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved," the researchers wrote.
The researchers reviewed the case histories of more than 500 randomly selected patients who either died in the hospital or were discharged to hospice care. The case history reviews generated several key findings.
300 of the patients were afflicted with sepsis and the infection was the immediate cause of death in 198 of those patients, or 34.9% of the total study cohort
The second most common immediate cause of death was cancer, which claimed 92 patients, or 16.2% of the total study cohort
The third most common immediate cause of death was heart failure, which claimed 39 patients, or 6.9%
For the 300 patients with sepsis, the top underlying causes of death were solid cancer (63 patients), chronic heart disease (46 patients), hematologic cancer (31 patients), dementia (29 patients), and chronic lung disease (27 patients)
Suboptimal care such as delayed administration of antibiotics was found in 22.7% of the 300 sepsis cases, but only 12% of sepsis-associated deaths were deemed potentially preventable
Gauging the preventability of sepsis-associated deaths
These findings call into question prior views of sepsis care, the researchers wrote.
"The high burden of sepsis and the perception that most sepsis-associated deaths are preventable with better care has catalyzed numerous sepsis performance improvement initiatives in hospitals around the world. The extent to which sepsis-associated deaths in adults might be preventable, however, is unknown."
Sepsis-associated mortality may not be as preventable as previously considered, they wrote.
"Sepsis disproportionately affects patients who are elderly, have severe comorbidities, and have impaired functional status. Some of these patients may receive optimal, guideline-compliant care yet still die due to overwhelming sepsis or from their underlying disease."
The researchers acknowledge that their conclusions are at odds with earlier studies that have shown positive outcomes from efforts to improve sepsis care.
"Our findings are notable in light of many sepsis quality improvement initiatives that reported substantial decreases in mortality rates after implementation of sepsis care improvement initiatives. These studies imply that many sepsis-associated deaths are preventable," the researchers wrote.
They say there are two possible explanations for the discrepancy.
The hospitals in the JAMA study had already improved sepsis care, impacting the preventability of sepsis-associated deaths.
Sepsis-care improvement initiatives have over-estimated their impact on mortality. A common element of these improvement initiatives is better recognition of sepsis, which leads to identification of more subtle cases of the infection and the impression of lower mortality rates.
To decrease sepsis-associated deaths, hospitals may have to expand the scope of care for patients afflicted with the infection, the researchers wrote.
"Our findings do not diminish the importance of trying to prevent as many sepsis-associated deaths as possible, but rather underscore that most fatalities occur in medically complex patients with severe comorbid conditions."
ProMedica's initiative is designed to help the country rise to the challenge of the exploding senior population.
Toledo-based ProMedica launched an aging institute earlier this month.
The Centers for Disease Control and Prevention (CDC) has forecast meteoric growth in the country's senior population, which is expected to also drastically increase the number of Americans afflicted with chronic diseases. In 2015, 45 million adults were 65 or older, and that figure is anticipated to reach about 80 million by 2050, according to the CDC.
"We are going to have an explosion of people who are going to be in their 70s and 80s, and our national workforce is going to have a lot fewer young people compared to seniors," says Steve Cavanaugh, MBA, president of the HCR ManorCare division of ProMedica and a member of the leadership team at the new ProMedica Healthy Aging Institute.
The aging institute will be working in three core areas.
Innovation and research: Identifying and developing new health and wellness models for the senior population
Education and training: Preparing the next generation of administrators and clinicians to support all aspects of senior health and well-being such as continuing education for professionals in the senior care field
Advocacy: Driving industry reform and supporting efforts to redesign healthcare for seniors
The long-term goal of the aging institute is to serve as a catalyst for change at a national level, Cavanaugh says.
"If you think about the current state of healthy aging and healthcare in general, despite all the work we have done the country's health system remains siloed. We still have a system that is anchored in fee-for-service, and we still have a model that is focused on the clinical aspects of care that ignores things like social determinants of health."
Innovation and research
The aging institute is being designed to generate evidence-based approaches addressing the challenges associated with the country's increasing senior population, Cavanaugh says.
"On the innovation and research side of the institute, we see opportunities to try some things with our own health system and provide some academic rigor on whether initiatives work and whether they can be applied across the country."
Education and training
The aging institute is not expected to provide training. Instead, the institute is expected to partner with other institutions to develop curricula to train the next generation of clinicians and healthcare professionals who work with elderly patients, he says.
"We are going to need a healthcare workforce that is more and more well versed in caring for seniors."
Administrative leaders will be another focal point of the aging institute's education and training efforts, Cavanaugh says.
"We are going to need leaders who know how to manage in the senior care space. Now, the leadership in healthcare is heavily weighted toward the hospital setting. As we shift away from hospitals to postacute care, we are going to need leadership that is more familiar with that setting of care."
Healthy aging advocacy
Entering the political arena is a necessary step toward improving care for seniors, he says.
"You can come up with the best public policy options available, but if you don't implement them through the regulatory and reimbursement systems in the political process you are not going to get the change that the country needs. We have a role to provide information and work with other parties to arm them with arguments for particular policy options that we view as beneficial for the country."
Seeking to end the practice of denying Medicare coverage for skilled nursing facility costs after an observation-status stay at a hospital is an example of the aging institute's advocacy role, Cavanaugh says.
"That might be a narrow issue where we can raise our hand with others in the near-term and say, 'It's not right. It's not good policy.'"
Jerry Penso shares insights from visiting more than 65 AMGA member organizations since October 2017.
You could say that Jerry Penso, MD, MBA, likes to travel. With purpose.
The former family physician at Sharp Healthcare in San Diego became president and CEO of AMGA in 2017, and he made a commitment to the organization that racked up thousands of frequent flyer miles.
"When I took the role, I promised the board of directors that I would visit 40 medical groups in 40 weeks. It started in October 2017 and ended in June 2018," Penso says.
After making that promise as part of his hiring process, Penso visited more than 65 AMGA members.
He joined Alexandria, Virginia–based AMGA seven years ago as the organization's first chief medical and quality officer. Prior to working for AMGA, Penso was continuum of care medical director for Sharp Rees-Stealy Medical Group in San Diego.
AMGA—formerly the American Medical Group Association—has more than 400 medical group and health system members. More than 175,000 physicians practice at AMGA members.
HealthLeaders recently spoke with Penso to discuss his 9-month cross-country journey to visit physician practices and medical groups, and he reveals the three primary issues on physicians' minds. Following is a lightly edited transcript of that conversation.
HealthLeaders: Were there commonalities between healthcare organizations?
Penso: There were three issues that came up repeatedly at every medical group or health system that I visited.
1. Pressure on margin: Most of them are seeing or projecting flattening revenues, but expenses continue to rise based on a bunch of reasons from labor, to pharmaceuticals, to information technology. They are focused on the margin issue and are trying to figure out how to manage expenses.
2. Challenges in the move to value: Many see value as the future, and they understand that is the direction they need to go. However, there are challenges—struggles with the payers, care redesign, and grappling with some of the payment models.
3. Physician leadership and physician burnout: Senior leaders are finding they need a new kind of physician leader to help with the challenges they face—integration with other practices, the move to value, engagement of physicians in working with patients in new ways, and practice redesign. These responsibilities are contributing to burnout—more and more burdens are being place on physicians.
HL: Gauge the level of optimism you encountered during these visits.
Penso: It was one of the surprising things that I found—the medical group and health system leaders I met were surprisingly optimistic. They realize there are challenges with the payment models, redesigning care, and physician engagement, but these leaders are committed to their communities.
Our medical groups and health systems are often the largest employers in their areas. So, they are embedded in their communities. That commitment gives them a mission to improve the healthcare they provide for their friends, families, and others who live among them.
HL: What were the qualities of the top performers?
Penso: There were two keys to top performers.
1. They had an organized system of care. They had infrastructure to deliver care in a systematic, coordinated, consistent, and reliable way, and a common electronic health record across their system. They also had good analytics to understand their population, and a care coordination strategy. They also had strong physician leadership to manage the group.
2. Top-performing medical groups had a culture of learning and collaboration. They are always working to improve care and outcomes, and they measure it. All of the components collaborate—the hospital, nurses, physician staff, and IT professionals all work together.
HL: How is the physician shortage impacting AMGA members?
Penso: I heard about physician shortage at many of the places I visited, but particularly in the rural areas of the country. Their challenge is to attract and retain physicians—especially primary care physicians.
Most practices are facing a demographic issue. Many physicians are older and nearing retirement. Figuring out a strategy to replace those physicians is on the minds of many of my health system and physician practice leaders across the country.
In response, they are figuring out how to deliver care differently, which will probably require more of a team-based approach. They want to make their practices more efficient and use their physicians exactly as they are needed, then use other providers such as advanced practice practitioners to provide care for patients. They are also utilizing technology such as telemedicine, so you may not need as many face-to-face visits with a physician.
HL: How do your members view the healthcare policies of the Trump administration?
Penso: In late 2017 and early 2018, there was a lot of uncertainty about the Trump administration—the direction they were going with healthcare. The unsuccessful effort to repeal the Affordable Care Act was on everybody's mind. AMGA members wanted some help understanding the direction of the administration. The previous administration had been very assertive in moving toward value, and they wanted to know whether the current administration was going to follow those policies.
We have seen a lot of movement in this administration toward value, so we are very encouraged. There is also a strong push toward regulatory relief. So, we think the direction under Alex Azar and Seema Verma appears to be favorable to moving toward value-based models.
Physician says hospitals are too tolerant of assaultive behavior by patients and their loved ones.
Amy Costigan, MD, wants to be able to practice emergency medicine without being punched in the face.
Healthcare staff carry a heavy workplace violence burden, with about 74% of workplace assaults occurring in the healthcare setting. Workplace violence is prevalent in the emergency department—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
Costigan wrote about her workplace violence experience in Annals of Emergency Medicine. She had lost a young woman in cardiac arrest, then went to a family room to inform the woman's mother.
When she entered the room, the ER physician had a choice—sit in a chair near the door or sit on the couch next to the young woman's mother. Costigan picked the couch.
After she shared the bad news, the enraged mom punched her in the face.
"I do things a little differently now when giving bad news. I never go alone," Costigan wrote in the journal. "Sometimes I have security stand around the corner. The door always stays open. I know my exits. I always choose the seat by the door."
Extended impact of workplace violence
Costigan, a member of the Department of Emergency Medicine at the University of Massachusetts Medical School in Worcester, shared her views about workplace violence with HealthLeaders last week.
In the healthcare setting, workplace violence erects barriers between physicians and patients in two ways, she said.
"First, we can never provide good patient care when workers are scared for their safety. It creates distraction, mistrust, apathy, poor care, and disengagement with patients. You don't want your doctor or your nurse to be afraid to sit with you, hold your hand, or sit there and cry with you. Unfortunately, workplace violence is slowly stripping our ability to be physically and emotionally present with patients.
"Second, an unsafe environment for staff is an unsafe environment for patients. In the emergency department, patients are witnessing violence. It is traumatizing and scary for those patients. They are also at risk."
Costigan said being the target of workplace violence has compromised her ability to be compassionate with her patients and their loved ones.
"We are taught in medical school to sit with the patient when giving bad news. You are supposed to put a hand on their shoulder. You are supposed to be close emotionally and physically. Most of the time now, I try to figure out the best place to sit for my safety. I still try to be close and emotional, but I never go alone and sometimes I have security outside the room. That's not the way I want it to be."
'We are tolerating it'
In healthcare, the widespread practice of abstaining from pressing charges in cases of workplace violence is making the problem worse, Costigan said.
"Workplace violence is persisting and increasing because we are tolerating it. It's never OK to assault another person, not when you're drunk, not when you're sick, not when you're having a bad day—it's just never OK. To my knowledge, violence is not tolerated in any other profession."
The emotionally challenging environment in healthcare settings does not excuse assaultive behavior or justify exposing healthcare workers to violence, she said.
"We work in emotionally charged and high-stress situations, but our protection in the hospital shouldn't be any different than what is afforded to everybody else. We don't tolerate assault in a courtroom, or a library, or a restaurant. The same rules should be applied and enforced everywhere because everybody has a right to feel safe, supported, and protected in their workplace."
There must be some accountability when workplace violence incidents occur, Costigan said. "Healthcare workers need support from the administration, the police, the district attorney, and judges. The only way to stop this violence is to send a clear message that it is not acceptable."