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Under Pressure

A changing healthcare landscape has doctors feeling stressed, unsatisfied, and burned out like never before — and that could have dire effects on patient care. That’s why the industry is focused on diagnosing the problem and prescribing remedies.

Every day, patients rely on doctors to tackle their chronic health and wellness issues and make them feel better.

But what if it’s the doctors feeling miserable? Or stressed-out, anxious, and overwhelmed? Unfortunately, that’s happening constantly.

Burnout among physicians has become so pervasive that a new paper recently published by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Mass. Medical Society, and the Mass. Health and Hospital Assoc. deems the situation no less than a public health crisis.

“A Crisis in Health Care: A Call to Action on Physician Burnout,” as the document is titled, includes a number of strategies aimed at curbing the prevalence of burnout among physicians and other care providers, including improvements to the efficiency of electronic health records (EHRs), proactive mental-health treatment and support for caregivers experiencing burnout, and the appointment of an executive-level chief wellness officer at every major healthcare organization (much more on all of these later).

But the report also details just how extensive the problem is, and why it should be a concern for patients. In a 2018 survey conducted by Merritt-Hawkins, 78% of physicians said they experience some symptoms of professional burnout — loosely described in the survey as feelings of emotional exhaustion, depersonalization, and/or diminished sense of personal accomplishment.

Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession. And that’s concerning in itself; the U.S. Department of Health and Human Services predicts a coming nationwide shortage of nearly 90,000 physicians, many driven out of practice due to burnout.

“The issue of burnout is something we take incredibly seriously because physician well-being is linked to providing quality care and favorable outcomes for our patients,” said Dr. Alain Chaoui, a practicing family physician and president of the Massachusetts Medical Society. “We need our healthcare institutions to recognize burnout at the highest level, and to take active steps to survey physicians for burnout and then identify and implement solutions. We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.”

Dr. Alain Chaoui

Dr. Alain Chaoui

 “We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.”

While some have pointed to the passage of the Affordable Care Act (ACA) in 2010 — the most significant recent change in the American healthcare landscape — as a stressor, the roots of the crisis date further back, the report notes. For example, EHRs, mandated as part of the 2009 Reinvestment and Recovery Act, have dramatically changed the way doctors allot time to their jobs. And the 1999 publication of the Institute of Medicine’s “To Err is Human” report, highlighting the prevalence of medical errors, directed new attention to the need for quality improvement, physician reporting, and accountability — and brought heightened pressure.

In the past, the report notes, some have proposed ‘self-care strategies’ — such as mindfulness or yoga — as a response to burnout and presented some evidence of limited success with such approaches. However, physicians typically don’t have time to fit such coping strategies into their routine. They also don’t really address root problems.

“Such an approach inaccurately suggests that the experience and consequences of burnout are the responsibility of individual physicians,” it continues. “This is akin to asking drivers to avoid car accidents without investing in repairing and improving hazardous roads. Simply asking physicians to work harder to manage their own burnout will not work.”

Digital Dilemma

As the report noted, a broad consensus has formed that a major contributor to physician burnout is dissatisfaction and frustration with EHRs, which have become ubiquitous in recent years. While the goal of transitioning to electronic records has been to improve quality of care and patient communication, the results have been mixed at best.

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” said Dr. Ashish Jha, a VA physician and Harvard faculty member. “There is simply no way to achieve the goal of improving healthcare while those on the front lines — our physicians — are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

As Dr. Atul Gawande, a Massachusetts surgeon, writer, researcher, and CEO of the nonprofit healthcare venture formed by Amazon, Berkshire Hathaway, and JP Morgan Chase, recently described it, “a system that promised to increase physicians’ mastery over their work has, instead, increased their work’s mastery over them.”

That’s because the patient encounter is now dominated by the demands of the EHR, undermining the crucial face-to-face interaction that has long been at the core of a satisfying doctor-patient encounter, the report notes, adding that, “for many physicians, EHRs impose a frustrating and non-intuitive workflow that makes excessive cognitive demands and detracts from, rather than reinforces, the goals of good patient care.”

Dr. Ashish Jha

Dr. Ashish Jha

 “The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients.”

In addition, the quantity of mandatory documentation imposed by EHRs — due to regulatory and payer requirements — means physicians typically spend two hours doing computer work for every hour spent face to face with a patient, including numerous hours after work. And they’re frustrated by spending so much time on administrative tasks they feel have little to do with actual patient care.

One promising solution, according to the report, would be to encourage software developers to develop a range of apps that can operate with most, if not all, certified EHR systems.

Improved EHR usability is, in fact, required by law. The 21st Century Cures Act of 2016 mandates the use of open health care APIs (application programming interfaces), which standardize programming interactions, allowing third parties to develop apps that can work with any EHR. This would allow physicians, clinics, and hospitals to customize their workflow and interfaces according to their needs and preferences, promoting rapid innovation and improvements in design.

Another promising but less-developed approach to reducing the HER burden on physicians, the report notes, is the development of artificial intelligence (AI) technologies to support clinical documentation and quality measurements.

Mind Matters

The report spends plenty of time on mental health, and for good reason.

“It is clear that one can’t have a high-performing healthcare system if physicians working within it are not well,” it notes. “Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public.”

To that end, it calls on hospitals and other healthcare organizations to improve access to, and expand, health services for physicians, including mental-health services — while reaching out to doctors and encouraging them to take advantage of such services in order to prevent and manage the symptoms of burnout.

That’s easier said than done, of course, as a stigma still exists around seeking help for mental-health issues.

“Physician institutions — including physician associations, hospitals, and licensing bodies — should take deliberate steps to facilitate appropriate treatment and support without stigma or unnecessary constraints on physicians’ ability to practice,” the report argues.

Last year, the Federation of State Medical Boards (FSMB) adopted a policy reconsidering ‘probing questions’ about a physician’s mental health, addiction, or substance use on applications for medical licensure or renewal, as the existence of such questions may discourage physicians from seeking treatment. “To the extent that such questions are included,” the report says, “those questions should focus on the presence or absence of current impairments that impact physician practice and competence, in the same manner as questions about physical health.”

The FSMB is also calling for state medical boards to offer ‘safe-haven’ non-reporting to applicants for licensure who are receiving appropriate treatment for mental health or substance use. Such non-reporting would be based on monitoring and good standing with the recommendations of the state physician health program (PHP).

Speaking of which, Physician Health Services Inc. (PHS) — a charitable subsidiary of the Massachusetts Medical Society that serves as the PHP for Massachusetts physicians — intends to reach out in a broader way to physicians and hospitals to encourage doctors dealing with burnout and behavioral-health issues to seek appropriate and confidential care.

“Many PHPs in other states have expanded their outreach,” the report notes. “Hospitals and other healthcare institutions should complement and support this effort by acknowledging physicians’ concerns with seeking mental healthcare and clearly identifying avenues and opportunities to receive confidential care, particularly for residents and trainees, who are at a vulnerable stage of their careers.

Finally, the report calls for the appointment of executive-level chief wellness officers (CWOs) at all healthcare organizations. “CWOs must be tasked with studying and assessing physician burnout at their institutions, and with consulting physicians to design, implement, and continually improve interventions to reduce burnout.”

“Patients do not like being cared for by physicians who are experiencing symptoms of burnout, which is significantly correlated with reduced patient satisfaction in the primary-care context. Evidence further suggests that burnout is associated with increasing medical errors.”

The key responsibilities of the chief wellness officer, in addition to acting as an advocate and organizational focal point, may include studying the scope and severity of burnout across the institution; reporting findings on wellness and physician satisfaction as part of institutional quality-improvement goals; presenting findings, trends, and strategies to CEOs and boards of directors; and exploring technological and staffing interventions like scribes, voice-recognition technology, workflow improvements, and EHR customization to reduce the administrative burden on doctors, just to name a few.

CWOs could benefit physicians not just in hospitals, the report continues, but across health systems, and in affiliated practices. “Departments, units, and practices can survey for burnout, begin to identify their areas of focus and barriers to success, and collectively develop solutions. The CWO can help lead this process and provide best practices and other supports.”

Lives in the Balance

In the end, physician burnout is a problem with many triggers, which is why the authors of “A Crisis in Health Care” encourage a multi-pronged approach to counter it. But it’s also an issue with many potential consequences, not just for doctors and their employers.

“Patients do not like being cared for by physicians who are experiencing symptoms of burnout, which is significantly correlated with reduced patient satisfaction in the primary-care context,” the report notes. “Evidence further suggests that burnout is associated with increasing medical errors.”

Dr. Steven Defossez, a practicing radiologist and vice president for Clinical Integration at the Massachusetts Health and Hospital Assoc., said hospitals in the Commonwealth place a high priority on the safety and well-being of patients, so combating burnout will continue to be an area of focus.

“In particular, we recognize the need to further empower healthcare providers and support their emotional, physical, social, and intellectual health,” he said. “This report and its recommendations offer an important advance toward ensuring that physicians are able to bring their best selves to their life-saving work.”

Joseph Bednar can be reached at [email protected]

Opinion

Opinion

By Tom Flanagan

Burnout among the nation’s physicians has become so pervasive that a new paper published by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society, and the Massachusetts Health and Hospital Assoc. has deemed the condition a public health crisis.

In a 2018 survey conducted by Merritt-Hawkins, 78% of physicians surveyed said they experience some symptoms of professional burnout.

The paper includes directives aimed at curbing the prevalence of burnout among physicians and other care providers, including the appointment of an executive-level chief wellness officer at every major healthcare organization, proactive mental-health treatment and support for caregivers experiencing burnout, and improvements to the efficiency of electronic health records. 

In a 2018 survey conducted by Merritt-Hawkins, 78% of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization, and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession. 

“The issue of burnout is something we take incredibly seriously because physician wellbeing is linked to providing quality care and favorable outcomes for our patients,” said Dr. Alain Chaoui, a practicing family physician and president of the Massachusetts Medical Society.  “We need our healthcare institutions to recognize burnout at the highest level and to take active steps to survey physicians for burnout and then identify and implement solutions. We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.” 

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout. Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000 and $1,000.000.

The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” said Dr. Ashish Jha, a Veterans Affairs physician and Harvard faculty member. “There is simply no way to achieve the goal of improving healthcare while those on the front lines — our physicians — are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.” 

The full report is available at www.massmed.org.

Tom Flanagan is Media Relations manager for the Massachusetts Medical Society.

Health Care

A Different Kind of Health Crisis

Dr. Gaurav Chawla

Dr. Gaurav Chawla describes suicide as “a very unfortunate, tragic outcome of a complex set of circumstances.”

It’s a common, but certainly not universal, refrain when an individual takes his or her own life.

Friends and relatives will say they didn’t see any signs that this was coming, said Kate Hildreth-Fortin, program director, Emergency Service & Mobile Crisis Intervention with Behavioral Health Network (BHN). Or they’ll say that they could not see any apparent reason for this outcome, that the individual in question seemed outwardly happy and was enjoying life.

That’s what people said about celebrity chef Anthony Bourdain, designer Kate Spade, comedian Robin Williams, and countless others, famous and not at all famous.

“But almost always, there are warning signs, and there are reasons,” said Hildreth-Fortin, one of many who spoke with BusinessWest about a subject that is timely, immensely complicated, and a true healthcare crisis probably on the same level as the one involving opioid addiction.

“If you think about the cost society pays due to undiagnosed mental-health conditions, due to emotional crises and stressors leading to loss of function and ultimately to suicide, and how many lives are directed affected by suicide … when you think about all that, this is a public health crisis.”

Timely not just because of those celebrity suicides several months ago — although they always help bring attention to the problem — and not just because of a recent report from the Centers for Disease Control and Prevention on the growing problem.

It’s timely because the numbers continue to rise, as does the overall toll from suicide, which goes well beyond the individuals who take their own life, said Dr. Gaurav Chawla, chief medical officer at Providence Behavioral Health Hospital, part of Trinity Health Of New England, who estimated that six lives are directly impacted by each suicide.

“If you think about the cost society pays due to undiagnosed mental-health conditions, due to emotional crises and stressors leading to loss of function and ultimately to suicide,” he went on, “and how many lives are directed affected by suicide … when you think about all that, this is a public health crisis.”

Getting back to the numbers, they are eye-opening and quite alarming:

• The most recent surveys show there are 45,000 completed suicides in the U.S. every year;

• That number has steadily risen since the start of this millennium, with suicides up a total of 28% since 2000;

• Massachusetts has the third-lowest suicide rate in the nation, but the rate of suicides in the Bay State has increased 35% since 1999, well above the national average;

• Women attempt suicide at a higher rate than men, but men complete suicide at a higher rate than women;

• Firearms are used in more than 50% of suicide attempts;

• Middle-aged white men (those in their 40s to mid-50s) have the highest suicide rate, particularly when they are single, but there is another peak involving individuals over 84; and

• Among individuals ages 14-34, suicide is the second-leading cause of death after accidents.

Perhaps as disturbing and frustrating as the numbers themselves are the forces behind them. They are numerous, often difficult to see, and very difficult to combat.

But there are common denominators of a sort. For starters, suicide usually results from a combination of factors, not one in particular, said Chawla, who summed things up succinctly, noting that “there is never one reason for someone to take their life; suicide is a very unfortunate, tragic outcome of a complex set of circumstances.

Kate Hildreth-Fortin

In almost all cases, Kate Hildreth-Fortin says, there are warning signs with someone contemplating suicide.

“You will often see the assumption that undiagnosed mental illness or inadequately recognized or treated mental illness is the cause,” he went on. “However, that is a myth; 50% of the suicides do not have a diagnosed mental illness behind them.”

As for what is behind them, that list is obviously quite long, said Hildreth-Fortin, and could include biological and genetic factors, increasing stresses of life, relationship crises, financial and occupational stressors, poor coping styles, increased substance use, and many others.

Another common denominator is that those contemplating suicide generally feel trapped in a life that does not bring them happiness or make them fulfilled, said those we spoke with, adding that this descriptive phrase can be applied to people at every age, every income bracket, and every walk of life.

Slicing through it all, such individuals need a way out of that trap and can’t find one or are unwilling to try, said Chawla.

“Suicide is a confluence of circumstances that lead one to conclude that they’re trapped in a hopeless circumstance, sometimes without purpose, in a painful existence from which there is no other way out,” he told BusinessWest.

Meanwhile, providing a way out, especially to those suffering from behavioral-health issues (and that’s a large percentage of those who contemplate or complete suicide) is made more difficult by the persistent stigma attached to seeking help for such conditions, and then finding help in a system plagued by a shortage of resources.

These are the reasons why this is a healthcare crisis, even if the same politicians who are quick to give such a label to the opioid epidemic are mysteriously reluctant to do the same with suicide.

For this issue, BusinessWest takes a long, hard look at suicide, going beyond the numbers in a quest to explain why they continue to rise, and also looking at how area professionals are helping those who are in that aforementioned ‘trap’ and need a way out.

A Failure of the System

Hildreth-Fortin, like the others we spoke with, said that, while it is somewhat regrettable that it often takes celebrity suicides like Bourdain’s and Spade’s to bring heavy media attention to the problem of suicide, she’s happy for the attention and a chance to bring the conversations to the forefront, instead of the background, where they have been for too long.

That’s because a brighter light needs to be shone on this crisis to bring about any kind of change in the current trends. With that attention, she said, there is hope that the stigma attached to mental-health issues and seeking help for them might be diminished; hope that more resources might be brought to bear to address the crisis, as has happened with opioid addiction; hope that friends and loved ones might become aware of the warning signs — what to do when they see and hear them; and hope that those feeling trapped might be more persistent in finding a way out.

That’s a lot of hoping, but in this battle, those fighting it will take whatever help they can get, especially with regard to that stigma concerning mental health.

“Suicide is a word we use every day; it’s something we deal with every day,” said Hildreth-Fortin, whose program handles roughly 1,300 assessments a month, and 70% of these individuals, in her estimation, have suicidal thoughts. “There’s a lot we can do with prevention; we need to reduce the stigma, improve education, and treat suicide the same way we would diabetes — ‘what can we do to help someone?’”

Chawla agreed, and said the stigma attached to both suicide and mental illness and seeking help for it often contributes to a lack of understanding concerning why someone commits suicide.

That is certainly the case with celebrities such as Bourdain, Williams, and others, he went on, adding that, to most of the rest of the world, these people seem happy and content with their lives.

But it’s not the world’s perception of these individuals that matters; it’s how they view themselves, and this is true of people across all income levels and social strata.

“It’s about perceptions of who you are, how you fit in your world, and how meaningful you find your existence,” he said. “That’s what ultimately leads to or doesn’t lead to such acts.”

But while suicide is seemingly an individual act, it isn’t, and each act represents more than one person choosing that tragic outcome.

“Suicide is taken as one event by one individual, and that’s not what it is,” said Chawla. “It is the final outcome of the failure of the system. Along the way, there are many lives affected, there’s a lot of loss of function, and there is opportunity that’s missed.”

Hildreth-Fortin and others at BHN agreed, and said one huge key to perhaps reducing the number of suicides is to seize opportunities rather than miss them.

And there is quite a bit that goes into this equation, she noted, listing everything from proper training of police officers, teachers, and others to being aware of the many warning signs; from knowing what questions to ask those at risk (and asking them) to knowing how to respond to the answers to those questions.

And this means not overreacting or underreacting, and, above all, connecting people at risk with services that provide help, said Hildreth-Fortin, who, like Matthew Leone, assistant program director of the crisis unit at BHN, is trained in something called QPR, which stands for question, persuade, refer — the three basic steps in suicide prevention.

“This is training given to anyone in recognizing the risk factors, how to persuade the person to get help, and how to refer that person for help,” Leone explained, adding that, in his role, he does a lot of training in the community on how to recognize suicide.

Which brings him to those warning signs. There are many to watch for, some subtle, some most definitely not, he said.

“This is training given to anyone in recognizing the risk factors, how to persuade the person to get help, and how to refer that person for help”

They could and often do include people saying ‘goodbye’ or ‘nice to know you’ on Facebook and other platforms, individuals giving away possessions, young people suddenly drawing up a will, people losing interest in things they enjoy doing, a decrease in performance at school, and many others.

“A more overt sign might be when they start stockpiling medication or another means of following through on their plan,” Leone went on, adding that, in addition to these warning signs, which are clearly red flags, there are also risk factors.

And there are many of those, he said, starting with being a middle-age male. Others include financial distress, depression, divorce, loss of a job, being given a terminal diagnosis, and, of course, a combination of some of these.

Questions and Answers

The next part of the equation is knowing what to do when warning signs are recognized, or with someone who outwardly seems at risk, said Hildreth-Fortin.

She acknowledged that having a conversation with such an individual and asking the questions that need to be asked is awkward and often very difficult (some fear that just asking the questions can help promote a suicidal act) but it needs to be done.

“A big piece of QPR training is teaching people how to ask the question, to get someone comfortable with asking someone if they’re suicidal,” she said, adding that this training is often given to first responders and educators, but parents, spouses, friends, and employers also fall into the category of individuals who need to ask questions and need to know how to ask and also how to respond.

Questions should focus on what thoughts people are having, how often they’re having them, and whether they’ve acted on these thoughts in any way before, said Hallie-Beth Hollister, assistant program director, Community Relations for BHN, adding that the answers will generally reveal just how at-risk someone might be.

Jenni Pothier

Jenni Pothier says those working with those contemplating suicide need to create a comfortable, non-judgmental, open space for dialogue to occur.

One key, she went on, is not asking leading questions that would enable the individual to give the answers the questioner might be looking for.

“Don’t say, ‘you’re not thinking of killing yourself, right?’” she said by way of example.

But, as noted, recognizing warning signs and asking the right questions are only parts of the equation. Responding to the signs and the questions to the answers is another big part, said Leone, adding that that many people balk at asking questions, or especially difficult and specific questions, because of anxiety about the answer.

“‘What do I do if the answer is yes?’” is a question that unnerves many, he went on, adding that there’s a reason for this; the response can be complex.

“We talk with people all day who mention that they’ve having suicidal thoughts,” he explained. “Some have the intent to follow through, others do not; some have vague suicidal ideation where there’s no real plan to it.”

Which is why overreaction is possible and should be avoided.

“Many times, with suicide, when someone says they’re having those thoughts, instead of starting a conversation, it ends the conversation,” he explained. “People will jump in and say, ‘we need to get them to the hospital, we need to get them help now,’ when the person is just reaching out to talk about it for help.

“And this overreaction can have a negative effect to it because then the next time the person is experiencing those thoughts, they may not say anything,” he went on, adding that the key is generating the proper response given the individual’s risk factors, warning signs, the strength of the connections in his or her life, and other factors.

Jenni Pothier, director of the Tenancy Preservation program for Springfield-based Mental Health Associates, agreed. In the course of her work, which involves helping individuals who are at risk of homelessness — a stressful situation to say the least — the subject of suicide often comes up.

“Because we know that suicide includes risk factors like poverty, experiencing potential homelessness, and a lack of access to resources, people are in crisis,” she explained. “So we’re assessing people regularly for suicide.”

And those assessments involve asking those questions mentioned above, asking them in an effective way, and responding in the appropriate manner.

“As practitioners and clinicians in the community, you need to create comfortable, non-judgmental, and open spaces for dialogue to occur,” she explained, “so people can express to you how they’re feeling without the fear of the stigma or that you’re going to instantly call 911 to get them hospitalized if they say they’re contemplating suicide or having suicidal ideations.”

Bottom Line

As she talked with BusinessWest about suicide and, more specifically, the problems many have with asking the questions that must of asked of someone at risk, Hildreth-Fortin related the story about an educator who, during a QPR training session, admitted not only that she would have difficulty asking such questions, but also that she would be upset if someone put those questions to her child.

“I had a real hard time responding to her, because it spoke so greatly to the stigma attached to this,” she said. “If your child had a stomach ache, you wouldn’t have a problem with him going to the nurse. You talk about what hurts, what kind of pain it is … we have to treat suicide the same way we would any medical symptom. We have to talk about it.”

It will take a confluence of factors and a great deal of resources to reverse the current trends on suicide, but getting people to talk about it and respond to the talk is the big first step, said Chawla, adding that only by doing so can those missed opportunities he mentioned become real opportunities to do something about a true healthcare crisis.

George O’Brien can be reached at [email protected]