Bringing together Dr. Vikas Saini (the Lown Institute), Dr. Katherine Peeler (Boston Children’s Hospital), Dr. Omar Lateef (RUSH University Medical Center), and Dr. Thea James (Boston Medical Center), the discussion focused on the role of hospitals in addressing problems like moral stress and burnout and how a commitment to equity fits into their resolution. Watch the video of the event and read some of the highlights from the discussion.

The dilemmas facing hospitals 

Panelists emphasized the conflicting incentives for health systems between prioritizing equity and keeping the lights on. “The more right you do in health care, the more wrong your operating margin will report at the end of the year,” said Dr. Lateef. 

He shared how RUSH University Medical Center’s strategy during COVID-19 of taking as many patients from safety net hospitals as possible was an energizing force for physicians who saw the difference they were making in their community, but it created financial issues for the hospital. “Because we had lost so much money, we were going to fall below our debt covenant. We couldn’t pay our loans …. We had unprecedented losses through the pandemic,” he said.

Another key challenge for hospitals is making sure that the C-suite and frontline hospital staff are on the same page. “Hospitals often say they have a plan, but physicians who are in the trenches often don’t see this plan,” Dr. Peeler explained. “If hospital’s systems that support equity… aren’t clearly communicated, physicians find themselves in the tough position of not knowing how to actually access the resources in their own hospital to deliver the care their patients deserve,” she said.

And for hospital workers who had been trying to call attention to structural racism for years, it seemed suspect that leaders were vowing to improve equity only after it became popular to do so. “I couldn’t understand that while people don’t recognize inequity when it’s clearly in plain sight all day long, how can all of the sudden people have this commitment to equity?” said Dr. James.

How equity metrics help hospitals “do the right thing”

In order to bolster the contents and actionability of hospitals’ health equity plans, hospitals have to measure what matters and do so in a transparent way. “If we’re going to reframe what it means to be a great hospital, we need new metrics,” said Lown Institute President Dr. Saini. This goal is what drove the creation of the Lown Institute Hospitals Index for Social Responsibility, which evaluates hospitals on equity and value as well as outcomes. 

“Let’s measure things that aren’t currently being measured. Let’s do it in a way that’s transparent, and let’s measure things that would be really hard to game.”

Dr. Vikas Saini

However, it’s not just enough to measure health disparities or community investment – institutions have to be willing to internalize and act upon these results, said Dr. Lateef. That can be tough when the results bring feelings of discomfort and frustration for hospital systems. “We all feel like we’re doing an incredible amount of work and no one wants to hear that they’re not doing enough,” he said.

Equity-related measures in particular can provide a critical opportunity to increase the efficiency and impact of hospitals’ plans in the long-term, but only if hospital leaders take them to heart. “Metrics that look at equity should be discussed in boardrooms and when you’re doing that … you’ll drive change, said Dr. Lateef.

For Dr. James at BMC, to make strides on equity it was important to “look inside our own house,” she said. Their “Health Equity Accelerator” program started with hospital leaders meeting monthly in working groups to identify the biggest health disparities in their own patient population. Using this model, BMC has been able to reframe their approach to medicine by putting the identification and resolution of the root causes of ill-health at the forefront of their operations.

It’s not easy to remove health inequities that are baked into the system, but having health systems, researchers, and policymakers working together is a start. “In the same way that multiple forces led us to this moment over many decades, multiple economic, social, and political forces are going to be necessary to get us out of it and that means multiple solutions, different initiatives, multiple domains – all working together if we’re going to pull ourselves out of this tailspin,” said Dr. Vikas Saini.

The post WATCH: Hospitals reveal key challenges to achieving equity, and how they’re overcoming them appeared first on Lown Institute.

The nation is facing a significant shortage of physicians, particularly in rural areas. In fact, the shortage is estimated by the American Medical Association to fall between 37,800 and 124,000 physicians within the next 12 years. From primary care to psychiatry, obstetrics, neurology, and oncology, numerous specialties are facing a physician shortage. And with more and more physicians retiring and quitting from burnout, the problem isn’t getting better.

Rural areas face the brunt of this shortage as urban areas have higher densities of both primary care physicians and specialists. Patients in rural areas tend to be older, poorer, and sicker, especially with chronic conditions. With fewer doctors around, they have to travel further for both preventative and emergency care, putting them at greater risk for poor health outcomes and mortality.   

The mismatch between medical school enrollment, residency slots, and the need for physicians in the workforce has resulted in a lose-lose situation where perfectly competent physicians face barriers to working while simultaneously, entire regions of the country are without sufficient access to physicians.

What can we do about this mismatch and resulting dilemma?

Increase residency opportunities through both federal and state funding

Most residency slots are funded by the Centers for Medicare & Medicaid Services (CMS), meaning that they need action by the federal government for expansion. This also means that no significant action had been taken for over 20 years (Congress had actually capped the number of residents), until the COVID-19 relief bill was passed. The COVID-19 relief bill opened the door for 1,000 new residency slots, 10% of which must be in rural areas. Another similar bill has been introduced in Congress that would allocate funding for an additional 2,000 residency slots every year for 7 years starting in 2025.

Another option is to increase residency slot funding on the state level. The majority of doctors stay in the states where they completed their residency. Both California and Texas–where the shortage is predicted to be the worst–approved multimillion dollar expansions in funding, resulting in increase retention of physicians in underserved, local areas. 

The Assistant Physician model

Missouri took a different approach, passing a law that launched a new category of licensure called assistant physicians (not to be confused with physician assistants). This allows medical school graduates who didn’t match to a residency on their first try to practice primary care in rural and underserved areas under the supervision of a licensed physician. While the program is relatively new, there is evidence it’s working at alleviating the rural physician shortage. As of early 2023, there were nearly 300 assistant physicians licensed in the state, about 3% the number of primary care doctors. Six other states now have similar laws allowing for unmatched medical school graduates to practice while they continue trying to match with a residency. Washington specifically designed their program for international medical graduates. 

The physician shortage in rural areas is a complex problem with numerous potential solutions. We need to increase the number of licensed medical professionals–including nurse practitioners, physician assistants, and international medical graduates–as well as retaining them. We need to reduce burnout so clinicians don’t hate their jobs and retire early. We need to incentivize trainees to serve in medical deserts where they’re needed the most. 

The realignment of community needs and the physician workforce pipeline will be tricky, but not impossible. While telehealth may help in the coming years, we should still be considering the most efficient way to build up our healthcare practitioner workforce.

The post How can we fix physician shortages in rural America? appeared first on Lown Institute.

Empathy is key to healing…but is devalued in our healthcare system

No matter the technological advancements made, AI will never be able to fully imitate human connection. There is something unique about the trusting relationship between patient and provider, about person-to-person contact, that is innate to healing. A popular refrain states that the first evidence of civilization was a fractured femur that had healed, demonstrating that at some point, at least one human had taken care of another one until they had healed. Society is built around empathy and compassion for our fellow human beings.

“The art of medicine is a process for nurturing a special human relationship that champions a partnership for healing.”

– Dr. Bernard Lown

Most healthcare workers enter the field to care for those in need. But the system we have now makes it difficult to practice medicine in a way that fosters connection. As Jennifer Lycette, a rural community hematologist/oncologist from Oregon, notes in her STAT opinion piece, the pressure placed on physicians to get through as many patients as possible, as fast as possible, is not conducive to compassionate care. The pressure to be as “efficient” as possible has resulted in less time with patients and more time documenting. The burnout in some hospitals has gotten bad enough to push medical residents to unionize.

Time pressure pushes physicians to go-go-go. The lack of quality time with patients has documented negative impacts on physician well-being, empathy, and patient outcomes; could it be that AI performed better than doctors because of a systemic flaw and not an individual one? 

AI could support, not replace, human healthcare

It’s worth noting that the JAMA IM study is not completely comparable to real-life circumstances. Researchers could not ethically feed real electronic medical records into AI without violating HIPAA, so patient questions were chosen from a Reddit forum. This does not diminish the validity of the questions but could influence how human physicians answered them. Online culture, particularly Reddit, does not prioritize empathy and the humans responding may have followed online communication norms rather than professional communication norms. Human respondents were also not familiar with the entire medical history of the patients and may have had better results if they were seeing them in real life. 

This study suggests that AI at least has the potential to support quality, empathetic care. Already, AI is being used to streamline administrative tasks, answer patient questions, and for machine learning; its likely that in the near future there will be more AI scribes and virtual nursing assistants. As the technology continues developing, AI will be used to supplement care but it can’t replace doctors. The art of healing is a human one.

The post Could AI really replace human doctors? appeared first on Lown Institute.

After enduring years of stressful and heartbreaking work through the Covid-19 pandemic, healthcare workers had hoped that this crisis would motivate the changes we desperately need to fix our health system, only to find out that nothing meaningful has changed.

Now, they’re quitting in droves. In 2021, healthcare and social services workers quit at a the highest rate in twenty years, according to data from the Bureau of Labor Statistics. At the peak in November 2021, 3% of these workers quit their jobs. While the quit rate has slowed somewhat, in October 2022 the quit rate was 2.5%, still higher than any month before 2021.

What’s driving this trend?

It’s not a secret what factors are behind this healthcare worker exodus. In surveys of nurses and reports from healthcare worker unions, many of the similar problems come up.

Staffing shortages are a huge concern. When nurses are short-staffed, the number of patients they are caring for at a time grows, which makes it increasingly harder for workers to give patients the care they need. In a 2022 survey of nurses in Massachusetts commissioned by the Massachusetts Nurses Association, more than half said that understaffing was their biggest obstacle to delivering quality care. Staffing problems create more burden for remaining nurses, leading to more of them quitting, which exacerbates the problem. It quickly becomes a downward spiral.

Workplace violence is also a key issue. High tensions and reduced staffing during the pandemic were conducive to unchecked violence against healthcare workers. In an online survey of 373 nurses working in hospitals, 44% reported experiencing physical violence and 68% experienced verbal abuse from patients in the first few months of Covid-19. From 2019 to 2020, the rate of violence in hospitals increased by 25 percent in one year alone, according to data from the Bureau of Labor Statistics, as reported by the AFT Nurses and Health Professionals union.

“There’s no point in staying in nursing if we’re expendable.”

Reese Brown, former travel nurse, NBC

The issues caused by understaffing and workplace violence are exacerbated by a widespread feeling from healthcare workers that they aren’t being heard or appreciated. In many cases, the experience of working through the pandemic and watching patients and coworkers die has left nurses traumatized, but hospitals have not done enough to address this moral injury. Hospitals’ efforts to make healthcare workers feel appreciated, like pizza parties or rock-painting activities, can feel tone-deaf when not accompanied by real policy changes that improve their work situation.

Proposed reforms

To address these issues, healthcare workers and unions have proposed a variety of solutions including:

• Support legislation to protect healthcare workers from violence, such as the “Safety From Violence for Healthcare Employees Act“;
• Ensure that healthcare workers are protected from infectious disease and given the PPE they need to do their job safely;
• Create safe staffing requirements to ensure appropriate patient limits for nurses and protect patient safety;
• Conduct targeted outreach and coordinate educational efforts nationwide to fill shortages in the regions most in need;
• Provide affordable access to training and expand student loan forgiveness programs to remove barriers to training, and;
• Create apprenticeships, bridge programs, and training programs within hospitals to fill shortages quickly, where possible.

Fulfilling our promise to healthcare workers

If nothing is done, the shortage of healthcare professionals in the U.S. will only get worse. A recent report from McKinsey estimates that by 2025 we could have a shortage of between 200,000 and 450,000 nurses nationwide.

In 2020, we anticipated the widespread loss of healthcare workers and recommended that we offer a “GI Bill” of sorts for health professionals, to address their long-held concerns about mental health, safety, and administrative burden.

“In order to retain health professionals after this epidemic, we must do more than recognize their sacrifices, or address their current anger. We must answer their long-held concerns—and involve them in charting new policies and ways of keeping them healthy enough to tend the sick.”

Judith Garber, Shannon Brownlee, & Vikas Saini, Zocalo Public Square

Such a “GI Bill” is needed now more than ever. If we want to have a working healthcare system three years from now, we have to listen to what healthcare workers want and give them a voice in creating the policies that shape their work.

The post Where have all the nurses gone? appeared first on Lown Institute.

By Judith Garber, Shannon Brownlee, and Vikas Saini

In late March, a mutual friend of ours called with a grim picture of the situation on the ground at the Queens hospital where he works. New York City had not yet experienced the peak of the outbreak, but the hospital already had 140 COVID-positive patients, 35 of them on ventilators. And there were only five ventilators left.

Our friend, a physician, had just witnessed the death of a 27-year-old man with no chronic conditions. In his hospital, doctors were already making decisions about who to put on ventilators. “It’s a mess and there’s no help,” he told us. The young residents—doctors in training—were completely disillusioned; one of them told him, “When this is over, I don’t want to do this anymore, if this is what our health care system has come to.”

If this pandemic can be compared to a war, we have sent our soldiers—our medical professionals—to the front lines without the protection they need to survive.

We should all be afraid about that reaction to COVID-19. If this pandemic can be compared to a war, we have sent our soldiers—our medical professionals—to the front lines without the protection and protocols they need to survive. Physicians, nurses, and other hospital workers are overwhelmed by endless streams of patients, the extra-long hours, and the deaths they see all around them. Scared and confused, they fight on. We should expect that when their duty is done, some of our best and brightest will decide never to return to the battlefield again.

In this respect, this pandemic is an extension of the ordinary. The United States routinely neglects the needs of one of its most vital workforces. If COVID-19 has any silver linings, the most important one will be its exposure of the fault lines in American healthcare, including the fact that even before the epidemic hit, healthcare professionals were suffering from toxic levels of burnout that hampers their ability to care about their patients.

More broadly, this epidemic shows that many aspects of the way we speak and think about healthcare, and the way we provide it, need to be reconceived and redesigned. To do that, we need to listen to doctors, nurses, and other healthcare professionals.

Despite the health risks of treating COVID-19 patients and the lack of masks and basic protection in many hospitals, healthcare professionals are not running from the challenge. Instead, they are building their own masks out of office supplies, coming out of retirement to offer aid, and isolating themselves in garages and trailers to protect their families.

Such commitment is particularly impressive when you consider that even before COVID-19, a significant proportion of them were unhappy in their jobs. According to research from the National Academy of Medicine, between 35 percent and 54 percent of U.S. nurses and physicians feel substantial symptoms of burnout, including exhaustion, depression, and emotional numbness. For medical students and residents, the prevalence of burnout ranges from 45 to 60 percent.

Even before COVID-19 hit, healthcare professionals were suffering from toxic levels of burnout that hampers their ability to care for their patients.

Our caregivers are not just tired or stressed—they are experiencing “moral injury.” The term moral injury was coined in 2009 to describe how soldiers’ mental health suffered from having to act against their own moral compass in times of war. Dr. Simon G. Talbot and Dr. Wendy Dean applied this term to the healthcare setting to describe the “suffering, anguish, and loss” clinicians feel when they cannot deliver the care patients need in our profit-based healthcare system.

In our profit-based healthcare industry, billing is king, and clinicians bear the brunt of the busy work that’s required. According to an annual survey conducted by Medscape, an online medical news outlet, the most common contributor to moral injury is the absurd number of bureaucratic tasks healthcare workers now do. For example, a 2016 study found that physicians in four specialties spend about half of their work day filling out electronic medical records and paperwork. Family physicians spend another 1 to 2 hours at home after work doing coding and billing in the electronic medical record.

Another casualty of profit-driven healthcare is the time doctors get to spend with patients. More patients per day means more billing opportunities, and many clinicians are pressured to fit as many patients in their schedule as possible. The “15-minute visit” in primary care has become routine. Many physicians barely have time to listen to patients’ concerns before sending them for one test or another. This diminished time with patients gives doctors and nurses the feeling that they are mere cogs in a computerized system that cares little about people and their health problems.

This is not what most practitioners signed up for, and the mismatch between the ideals of medicine and the reality takes a high toll. Physicians in the U.S. have the highest suicide rate of any profession. That statistic may reflect the fact that physicians are stigmatized and sometimes punished for seeking mental healthcare.

Of course, the COVID-19 pandemic has reinforced the sense of purpose driving many medical professionals. But as they’re putting themselves in danger, and their mental health is suffering as they watch patients and even colleagues die. For many, including our friend in Queens and his colleagues, the crisis has already inflicted a devastating emotional impact.

In order to retain health professionals after this epidemic, we must answer their long-held concerns–and involve them in charting the path to a new health system.

In order to retain health professionals after this epidemic, we must do more than recognize their sacrifices, or address their current anger. We must answer their long-held concerns—and involve them in charting new policies and ways of keeping them healthy enough to tend the sick. Call it the GI Bill for Healthcare Professionals, if you will.

Some of these new policies should be financial. Nursing and medical students often leave school with thousands of dollars in debt, and the mental stress that accompanies it. Educational debt also adds pressure for doctors to choose a high-paying specialty rather than primary care and geriatrics, where the need for a larger workforce is most urgent. Steps can be taken to address that: Erase all health professionals’ school debt to help those already in the field. In addition, medical, nursing, and physician’s assistant training should be free for all low-income students, to encourage more people from disadvantaged neighborhoods and regions to pursue these necessary careers.

We also need to ease some of the burdens of daily work life. Electronic health records, as currently configured, are primarily tools for maximizing billing. Beyond the time required to fill them out, they create all kinds of headaches for doctors and nurses, who find them incredibly frustrating to use. These record systems need to be redesigned into one single, easy-to-use platform, with the primary purpose of improving care. A committee of healthcare workers should be the principal advisors in this endeavor.

We also need to adjust regulations to make it easier to deliver care to patients. In this state of emergency, the federal government has eased regulatory requirements to allow increased flexibility in where and how patients are treated. For example, Medicare is now paying clinicians for a wide range of telehealth services. We have heard from frontline clinicians that the reprieve from many regulatory and administrative burdens has reminded them of how much better it feels to devote time to caring for patients, rather than navigating paperwork and rules.

One primary care doctor told us that before COVID, she would have to see patients in person to determine that they did not need to see her for in-person visits. Now, she is encouraged to care for patients virtually whenever possible, without an unnecessary in-person visit beforehand. Common-sense policy changes like these should be made permanent if possible, with recommendations from healthcare workers helping to drive decisions.

Unfortunately, it isn’t enough to make health jobs easier and more patient-focused. After this pandemic, doctors, nurses, and other healthcare workers will need to recover from what they’ve recently experienced. Hospitals should expand access to counselors and other mental health services we need, and teaching hospitals must do the same for trainees. Health professional schools should follow the example of Weill Cornell Medicine in offering free mental health counseling for all students. Mental health services should be accompanied by safe and confidential screening services for depression, PTSD, and other mental health issues, to reduce barriers to access.

World War II veterans got the GI Bill. Clinicians today deserve the same assurances.

Finally, in the wake of COVID-19, the U.S. public health response to pandemics will have to be re-evaluated and overhauled. One priority must be to make sure healthcare workers are never forced to beg for masks and other basic protections again. To that end, we should establish a Clinician’s Affairs agency within the Department of Health and Human Services with representation from nurses and doctors. By putting clinician representation at HHS, and also at the Department of Homeland Security, it would position healthcare professionals to give direct input on national health and security policies.

For years, Americans have stood by as the healthcare system pushes our doctors and nurses to the breaking point. Now, our need for them is as great as it’s ever been, and we are pushing them further. World War II veterans got the GI Bill. Clinicians today deserve the same assurances. We need a Healthcare Professionals Bill that eases their educational debt and also includes them in redesigning multiple aspects of our broken system.

The post Why we need a new “GI Bill” for clinicians appeared first on Lown Institute.

For non-clinicians, we too can rise to the challenge by honoring social distancing directives. By reducing the spread of COVID-19, not only are we protecting older and chronically ill populations—we are also helping save the lives of clinicians who are at great risk of being exposed to this disease. (For more information on practicing social distancing, see this piece by Dr. Asaf Bitton, primary care physician at Brigham and Women’s Hospital.)

In the long term, we can advocate for the systemic health care changes we need to prevent such a pandemic from happening in the future. For those itching to take more action, the Right Care Alliance will be holding virtual meetings to discuss what we can do about clinician health, drug prices, and more, in the face of COVID-19.

Whatever your role in the health care system, thank you for all you are doing to help keep all of us as safe and healthy as possible.

The post How we can help health care workers on the front lines of the pandemic appeared first on Lown Institute.

Dr. Simon Talbot and Dr. Wendy Dean’s use the term “moral injury” to describe what happens when health care workers who are following a calling to help others confront a system that cares only about profit. Clinicians usually choose medicine as a career because they care about helping people, but they enter a health system that prioritizes volume over value, and forces them to churn through patients with no time to make a real connection. This disconnect between what clinicians want to do and what they spend their time doing creates stress, depression, and, eventually, burnout.

The movement to bring attention to moral injury highlights the ways in which overuse and burnout are linked. The systemic factors that lead to overuse and waste are also hurting clinicians.

In a recent piece in Kaiser Health News, journalist Melissa Bailey interviews doctors who are experiencing moral injury and speaking out about it. Dr. Keith Corl, assistant professor of medicine at Brown University, said that the “fast and loose” model of care in many emergency rooms pushes clinicians in the emergency department to conduct excessive testing instead of conducting a thorough physical and history.

This type of practice, known as “provider-in-triage,” allows EDs to churn through many more patients, but often results in unnecessary testing and additional costs for patients (and more revenue for hospitals). Although one might think that conducting a battery of diagnostic tests right away would solve the patient’s problem more quickly, skipping the physical and rushing to test can miss obvious clues. Korl tells the story of one man who went to the emergency room for chest pain and received a chest x-ray, an electrocardiogram, and blood work. However, when Korl conducted a physical exam, it was apparent from a distinctive rash that the patient had shingles.

“I didn’t need a chest x-ray, electrocardiogram, or blood work to make that diagnosis. Nevertheless, he left the hospital that day with a bill for thousands of dollars,” wrote Korl.

We need to move toward a system of right care in emergency medicine (and in all other specialties), in which clinicians and hospitals are paid for value rather than volume, and clinicians are allowed to spend the time they need interacting and connecting with patients.

Without these system changes, we will not only increase waste in the health system— we will “grind good docs and providers out of existence,” said Korl.

The post The link between overuse and burnout appeared first on Lown Institute.

This study followed 80 internal medicine interns in six US medical resident programs, for a cumulative 2173 hours, making this analysis the largest time-motion study in the US to date. The authors found that interns spent 3 hours (13%) of their day working directly with patients and 2 hours (7%) on educational activities. This is a stark change compared to the 1990s, in which interns spent 81% of their workdays engaged in direct patient care activities. Additionally, the time-motion study highlights how much interns today are multitasking; even when they are face-to-face with patients or at a lecture, they are also working in the EMR 25% of the time.

In an accompanying commentary in JAMA Internal Medicine, Dr. Christopher Moriates, MD and Dr. F. Parker Hudson from the Dell Medical School at The University of Texas at Austin relate this study to larger concerns about internal medicine. This study confirms that over time, technology seems to have increased interns’ administrative burden, not relieved it. The study also finds that the same pattern of more time spent on indirect than direct patient care is consistent across types of care settings, from major academic programs to community-based programs. No EMR system appears to be providing relief from the mounting burden of patient documentation. 

Moriates and Hudson address the question of whether spending time on electronic medical records (EMR’s) is directly related to the ever-worsening problem of physician burnout. They draw from their own teaching experiences, recalling interns who went into medicine to care for patients, not document their care, being discouraged by the lack of time they had with patients. They fear that the pattern of growing EMR burden for interns could be “leading to a deficit in the humanistic bonds that create exceptional care and replenish our psyche.” How will internal medicine retain doctors when their first taste of medicine is so cold and metallic? 

If we indeed value the human side of medicine, this study should serve as a “clarion call to reinvest in the humanistic aspects of medical training,” write Moriates and Hudson. This could mean hiring scribes to do more patient documentation, restructuring EMRs to make them more intuitive and clinician-friendly, or streamlining EMR messages to reduce alert and message fatigue. If we do nothing to solve this problem, we will likely see an even more detrimental impact on clinician burnout and doctor-patient relationships.

The post Does it matter how much time interns spend with patients? appeared first on Lown Institute.

In recent surveys of of physicians, 44% report feeling “burned out” regularly, although 78% of physicians report symptoms of burnout at least sometimes. And it’s not just physicians; nurses, nurse practitioners, and other health care professionals report high rates of burnout and depression as well.

Clinicians have previously pointed out the systemic nature of exhaustion and depression among health care workers. In a Youtube video this week, Dr. Zubin Damania (aka ZDoggMD) argues that the term “burnout” mischaracterizes the issue, and furthers the status quo (Warning: This video contains strong language).

“Burnout is a kind of victim shaming,” explains Damania. “It’s saying, you’re not resourceful enough, you’re not strong enough, to adapt to a system.”

Damania cites Dr. Simon Talbot and Dr. Wendy Dean’s usage of the term “moral injury” to describe moral injury as what happens when health care workers who are following a calling to help others confront a system that cares only about profit. Our health care system “is the opposite of what [clinicians’] morality tells them they need to do for patients,” says Damania.

It’s also extremely difficult for clinicians to care for patients when they don’t feel like their institution cares for their workers. On the In-House Blog, Jennifer R. Bernstein writes a visceral, heartbreaking account about watching her partner, a resident at a community hospital, gradually get “destroyed by the thing he once loved.” Trainees are often subjected to absurdly long shifts of 30 hours or more in a row, deprived of sleep, and dehumanized or abused by others for showing any vulnerability. 

A recent report shows that hospitals are not even able to keep clinicians safe from violent attacks from patients or intruders; incidents of workplace violence in medicine are four times more common than in private industry on average. Piecemeal “wellness” efforts from institutions to address clinician exhaustion and depression are not even close to sufficient. “‘Wellness’ is admin-speak for, ‘Stay just sane enough to continue providing indentured labor for the hospital,’ writes Bernstein.

What can we do? The only way to treat moral injury is to change the system — to make it possible for doctors to treat all patients, regardless of ability to pay, without financial pressure from insurers or hospital systems. We need to provide health care professionals with tools that facilitate personal and caring clinician-patient relationships, instead of treating health care visits as only financial transactions. And we need to remove barriers to exposing and regulating institutions that overwork and abuse their workers; this starts with removing the stigma of discussing moral injury in the medical community. 

The post Moral injury: A systemic issue in medicine appeared first on Lown Institute.

A growing epidemic

According to Medscape‘s recently released National Physician Burnout, Depression & Suicide Report, burnout is becoming more widespread. Last year, 42% of the 15,000+ physicians surveyed reported feeling burnt out, while this year, the proportion rose to 44%. This is causing many physicians distress; 14% of physicians surveyed had thought about committing suicide and 10% of physicians surveyed were thinking of leaving medicine. Ironically, burnout can cause significant medical problems; for example, one physician said she suffered recurrent miscarriages due to stress at work.

Physician burnout doesn’t just affect doctors. More than half of doctors surveyed reporting that burnout affect their patient care, with 14% reported making medical errors because of burnout. And 70% reported a negative impact on their relationships with staff and other clinicians because of burnout. 

Sources of burnout

The most frequently reported reason for burnout among survey respondents was having too many bureaucratic tasks, such as charting and paperwork, with 59% of respondents citing it as a reason for burnout. This makes sense, as doctors spend more time using the electronic medical record (EMR) than they do face-to-face with patients during patient visits. Doctors even spend their time at home after work and on weekends catching up, when they should be free to spend time with family, friends, or doing other hobbies. 

“Electronic medical records have become the bane of doctors and nurses everywhere,” said Vikas Saini, president of the Lown Institute. “They are the medical equivalent of texting while driving.”

Long hours is another major contributor to burnout. More than a third of respondents in the Medscape survey said that spending too many hours at work made them burnt out. The more doctors work, the higher their level of burnout, the survey shows. In a recent blog post on NEJM Journal Watch, chief resident Dr. Ellen Poulose-Redger “calls BS” on the promise of “work-life balance” in medicine. The long hours required in medicine “doesn’t really leave a lot of time for any sort of a life, hobbies, research, or anything else that would help me to be a thriving and well-rounded person,” she writes. 

A call to action

In response to growing burnout crisis, leaders of the Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute issued a joint Call to Action on Physician Burnout. 

The authors offer three crucial policies to reduce burnout that focus on the root causes of burnout. The first is to provide proactive mental health treatment to doctors, to reduce the stigma of asking for help when doctors are overwhelmed. This is important because, according to the Medscape survey, many doctors (almost 20% of respondents) have gotten or considered getting mental health treatment in secret, because they were worried about being found out. 

The second policy is to improve EMR standards with a focus on usability and “open APIs.” EMRs with open APIs (Application Programming Interfaces) would allow third parties to develop apps that could work with any EMR, making it easy for physicians to “customize their workflow and interfaces according to their needs and preferences.” In short, this would giving physicians a better EMR experience and hopefully reduce the time they spend on EMRs. While open APIs are supposed to be mandatory, progress on this front has been slow.

The last policy the authors suggest is to appoint executive-level Chief Wellness Officers. This would change the game in a good way, by making clinician wellness an ongoing issue, just like quality. With someone responsible for clinician health, there would likely be better tracking of burnout levels, more initiatives to solve the problem, and faster accumulation of best practices knowledge. Hiring a Chief Wellness Officer also signals to clinicians that their institution cares enough about this issue to investigate significant resources in a permanent position. 

What’s missing?

Several crucial elements were missing from the Medscape Survey and Call to Action that deserve mention. The Medscape survey asked doctors how they dealt with burnout, with suggestions like exercise, talking to friends, and sleep. However, they did not ask doctors whether they tried to address upstream factors of burnout with collective action or activism. Taking action, whether it is protesting, volunteering, or just discussing how larger social problems affect their patients, can be empowering to doctors who feel like a cog in the health care system. 

Another missing discussion point was how to stop the roots of burnout in medical schools and training. As Dr. Timothy Hoff wrote in STAT, doctors in training are already burning out in high numbers. Medical schools need to take responsibility for teaching future doctors “street smarts, business training, resilience, adaptive mindsets, and emotional intelligence they need to navigate difficult and uncertain work circumstances,” writes Hoff.

The culture of medical school and training is also a problem, because it puts unreasonable expectations on physicians. Medical training and residency is extremely demanding, but as Dr. Ellen Poulose-Redger points out, there’s an expectation that doctors will be able to “have it all.” We should telling doctors the truth — that they will likely have to sacrifice other parts of their life for work — so that doctors don’t blame themselves when they find there isn’t a real work-life balance.

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