Healthcare Musings For August 19, 2022

August 19, 2022

Dear Interested Readers,

 

Burnout and Workforce Challenges 

 

These days, it’s hard to escape the feeling that we must have made some huge mistakes for which we are now paying the price. Most of us grew up with the myth of American exceptionalism. Hollywood fed us a continuous parade of John Wayne-like heroes. There were some faint murmurs of dissent. Dr. King’s movement and Harper Lee’s To Kill a Mockingbird began to suggest there might be problems. Joe McCarthy did not quite fit the picture we wanted to see of ourselves and our leaders, but a lot of people thought he knew what he was talking about. I vaguely remember hearing about “ugly” Americans and the contempt that some Europeans had for wealthy, gauche, loud American tourists. But weren’t we fighting Communism and preserving the hope of freedom around the world? It was great to be a young person in the late fifties and early sixties before John Kennedy, Martin Luther King, Jr, and Robert Kennedy were shot and we lost our way in Vietnam. 

 

In retrospect, we were overlooking a lot of history that deserved closer inspection. Manifest Destiny sounded pretty logical to an eighth-grade American History student who had been raised without want and with the pride of knowing that it was his country that had defeated Hitler, Mussolini, and the Japanese to block the atrocities of fascism, and was currently engaged in the struggle to preserve freedom from the equally disturbing philosophy and sins of communism.

 

Missing from any discussion or analysis in the classroom or in the textbooks was a significant consideration of the human tragedy of slavery or the inequalities precipitated by capitalism without restraint. Those were problems that we had solved, and by the time I thought I was aware of the world, the answers were that we freed the slaves with the Civil War and it was no longer legal for eight-year-olds to work in factories. My history professor in college would accept no other answer on a test to the origin of the Civil War than it was a conflict over “states’ rights.” I was taught that in every way we were leading the way. Unlike many other countries in darker parts of the world, almost everyone in America could read and had a fair shot at realizing their full potential.

 

We were blessed. We were aligned with God and we were certain that our way of life would eventually prevail over evil regimes elsewhere. Anyone who was having a hard time in America was either following a life of sin or they were lazy. Even into the eighties and to this day, Ronald Regan’s view of welfare queens, lazy drug-dependent criminals,  shiftless immigrants, people who lacked the desire to do honest work, and a bloated government that imposes unfair taxes and rules on entrepreneurs who are secular saints was and remains for many, a hugely popular explanation for all that is not quite as we would like it to be. 

 

Suddenly, it seems our economy has been derailed by a pandemic that we were not prepared to manage even after AIDS, Ebola, MERS, SARS, and other warning shots across our medical bow. Now we have the added burden of a war waged by someone neither we nor our European allies should have ever trusted, especially after he annexed Crimea, interfered in our elections, and bamboozled our narcissistic president. In retrospect, it seems we have made a lot of unforced errors that may have had their root in our focus on short-term profits and the comforts that can be enjoyed at the moment.

 

Shipping jobs to southeast Asia, China, and anywhere where local poverty and oppression allowed huge corporate profits even after transportation costs, has left us crippled and vulnerable in ways we had never imagined.  The successes that we enjoyed in the mid-twentieth century at home have been replaced by the diseases of despair. Our middle class has been stressed by the closing of factories, the destruction of communities, and the crimes and addictions of the disillusioned who see no real future for themselves or their children and translate that anger into loyalty and support for politicians who channel their anger into political power for themselves and an ever smaller, and ever richer minority of elites. 

 

What makes it all even more frustrating and frightening is that with each new day the climate seems to be warming faster than our feeble attempts to control it. We have convinced ourselves that natural gas may produce less carbon dioxide pollution than oil and coal, but its production generates methane, and that should worry you. The EPA describes the concern about methane:

 

Methane is the second most abundant anthropogenic GHG after carbon dioxide (CO2), accounting for about 20 percent of global emissions. Methane is more than 25 times as potent as carbon dioxide at trapping heat in the atmosphere. Over the last two centuries, methane concentrations in the atmosphere have more than doubled, largely due to human-related activities. Because methane is both a powerful greenhouse gas and short-lived compared to carbon dioxide, achieving significant reductions would have a rapid and significant effect on atmospheric warming potential.

 

So it may be possible to prove that there is some benefit in the transition to gas, but it is more like substituting Suboxone for heroin than completely solving the problem of addiction. Like it or not, the choice in the end remains simple. We must find solutions to the whole world’s need for energy that don’t pollute the air or eventually suffer, and perhaps succumb in time to Anthropogenic extinction. 

 

Within healthcare, there is a parallel process of self-delusion characterized by a lack of foresight created by the finance and convenience of the moment, a lack of focus on the needs of people, and the possibility of even greater challenges and losses in the future.  As in all matters, we tend to think about the constancy of the status quo we like. If we are concerned about a change in the status quo, we always prefer to imagine it as a slow incremental process that can wait to be addressed. Time and again we fail to recognize or anticipate the reality of sudden large “tectonic change.” We remain vulnerable because of our denial of what is inconvenient or because of our inability to accept that the rate of change can often be geometric rather than linear with a negligent slope. 

 

I don’t want to bore you or appear to be an alarmist, but to the long list of general complaints that I have just registered let me make a list of some of our most pressing healthcare concerns. 

 

1. The cost of care continues to rise and is a problem for all payers whether they are employers, the government, charities, or individuals.
2. Our medical outcomes are the worst in the developed world and what makes this an even greater social sin that undermines the prevalent concept of “American Exceptionalism” is that our bad outcomes are a reflection of economic inequality and the lingering impact of centuries of unaddressed racial injustices that are justified for many by inherent biases and misinformation.
3. We have neglected to properly invest in public health.
4. We have tolerated a system that has performed as a cottage industry to the benefit of the owner without adequate standards of performance or distribution of services that bring to every American many of the benefits that have evolved from public finance. Rural and inner city Americans do not enjoy the equal advantages of scientific progress or even routine care that they would enjoy if they were citizens of countries where there was a robust national healthcare system with or without a parallel system of “private” care. The movements toward consolidation that have occurred over the last thirty years always promise system efficiency and improved satisfaction with lower costs, but rarely deliver anything but corporate profit. Large nonprofit systems are as culpable for these failures as for-profit systems. 
5. We have an operational model that is expensive to maintain, difficult to staff, often focused on low-value activities that yield large profits, neglects essential concerns, and generates cynicism in consumers and providers. 
6. We are the target of the pharmaceutical industry, and less obvious are often excessively charged by medical device and medical data industries that feel entitled to enormous profits that directly add to cost the cost of care while frequently claiming the ability to lower costs by pointing to a few advances and simultaneously threatening to produce no future advances unless they get their due when in fact much of the science that they commercialize was developed with public money. To add to the insult, they sell their products in other parts of the world for less.
7. We have enormous workforce problems that make access to care, outcomes, expense, quality, safety, and equity even harder problems to resolve as professionals disengage, retire early, or underperform. “Burnout” is the institutional equivalent of global warming. It is insidious, difficult to improve, and perpetuated by dependence on realities that are difficult to change. 
8. We do not seem to have the will or the collective organizational skills to make the meaningful changes that a majority of providers, patients, and payers say they want. To paraphrase Atul Gawande, “Once, we were limited by our ignorance and our lack of scientific knowledge. Now, we suffer from our incompetence.”

 

I have recently completed several years of service on the boards of two large well respected medical systems. One was rural and one was an inner city academic/DSH (Disproportionate Share Hospital) system. Both institutions are doing meritorious work under very difficult circumstances and have suffered from or have been hampered by “burnout” that has touched a majority of their healthcare professionals. In fact, workforce issues were the source of tens of millions of dollars of losses experienced by these systems. Rural and DSH systems are not the only victims of workforce problems. Even the richer systems are reporting workforce problems as the origin of new financial strains. MassGeneralBrigham (Partners was a better name) recently reported losses of almost a billion dollars in the last few quarters largely related to workforce issues. 

 

Against ongoing concerns about the future of healthcare because of its workforce issues, I was delighted to see that our Surgeon General, Vivek H. Murthy, MD, MBA., a former member of the staff of the Brigham, had an article in the “Perspectives” section of this week’s New England Journal of Medicine that was entitled “Confronting Health Worker Burnout and Well-Being.”

 

Dr. Murthy begins by referencing the pandemic, but burnout has a long history. In 1993 Robert Coles wrote A Call to Service: A witness to Idealism which I read about the time it was published. I was profoundly moved because I could relate to his description of the “emotional  costs of service,” what we would now call “burnout.”  The book did not get the greatest review in the New York Times but it gave me insight into what I was experiencing then and what I think so many caregivers experience now. Murthy writes:

 

Early in the Covid-19 pandemic, when much of U.S. society shut down, health workers put their own safety on the line and kept going to work to care for patients. Although their communities initially banged on pots, cheered from their balconies, and put up thank-you signs, the pots have long since stopped clanging. Expressions of gratitude have too often been replaced by hostility, anger, and even death threats toward health workers, as health misinformation has exploded, eroding trust in science and public health experts. Yet doctors, nurses, pharmacists, social workers, respiratory therapists, hospital security officers, and staff members of health care and public health organizations continue showing up to battle the pandemic and its sequelae — long Covid, mental health strain, widening health disparities, and 2 years’ worth of deferred care for myriad conditions.

The toll on our health workers is alarming. Thousands of them have died from Covid. More than half of health workers report symptoms of burnout, and many are contending with insomnia, depression, anxiety, post-traumatic stress disorder, or other mental health challenges.

…Burnout manifests in individuals, but it’s fundamentally rooted in systems. And health worker burnout was a crisis long before Covid-19 arrived. Causes include inadequate support, escalating workloads and administrative burdens, chronic underinvestment in public health infrastructure, and moral injury from being unable to provide the care patients need. Burnout is not only about long hours. It’s about the fundamental disconnect between health workers and the mission to serve that motivates them.

 

I bolded “but it’s fundamentally rooted in systems” because unless we look at burnout as a systems issue more than evidence of individual frailty or lack of commitment, we will surely never find an adequate solution or even begin to understand it as one of the greatest threats we face as the providers of care to the nation. You can forget having patient-centered care that is safe, equitable, efficient, effective, and timely if your workforce is suffering from an epidemic of burnout. One lesson I learned a long time ago was to begin the analysis of any personal problem by asking the question, “What part of the problem am I?” I think that wisdom is applicable to groups as well as individuals. In references to the problem  of burnout the question becomes “What part of the problem are we?” In a way, Murthy indirectly follows that process, but he has more introductory concerns.

 

…Health worker burnout is a serious threat to the nation’s health and economic security.

The time for incremental change has passed. We need bold, fundamental change that gets at the roots of the burnout crisis. We need to take care of our health workers and the rising generation of trainees.

On May 23, 2022, I issued a Surgeon General’s Advisory on health worker burnout and well-being, declaring this crisis a national priority and calling the nation to action with specific directives for health systems, insurers, government, training institutions, and other stakeholders…

 

Murthy is a man of compassion and he continues by looking at the impact on individuals as his first concern: 

 

Addressing health worker well-being requires first valuing and protecting health workers. That means ensuring that they receive a living wage, access to health insurance, and adequate sick leave. It also means health workers should never again go without adequate personal protective equipment (PPE) as they have during the pandemic…Furthermore, we need strict workplace policies to protect staff from violence: according to National Nurses United, 8 in 10 health workers report having been subjected to physical or verbal abuse during the pandemic.

 

Murthy understands that burnout should be seen as a “systems issue.” Burnout is not the result of individual frailty. Murthy has four other points that he wants to make.

 

Second, we must reduce administrative burdens that stand between health workers and their patients and communities. One study found that in addition to spending 1 to 2 hours each night doing administrative work, outpatient physicians spend nearly 2 hours on the electronic health record and desk work during the day for every 1 hour spent with patients — a trend widely lamented by clinicians and patients alike.

 

I would add that administrative burdens are largely driven by our systems of finance and management. We pay mostly for acts performed, and not much for outcomes, satisfaction, timely access, or quality. Professionals lose valuable hours of their lives that are stolen by our dysfunctional systems as they enter data to justify charges more than support decision-making or communication with other providers. The truth be known, much of the clutter that is entered into the EMR to rack up payments is a barrier to efficient care and fuel for burnout. Time diverted from patients and personal concerns toward “bean counting” activities is a chronic complaint of a majority of healthcare professionals. It does not have to be that way. I never needed to spend my evenings or weekends typing notes that justified billings or the tests and procedures my patients needed as long as my practice was capitated and I was salaried.

 

I don’t think the problem is the electronic medical record. I think the problem is the fee-for-service finance of healthcare and the RVU system of compensation that requires detailed justifications for compensation. I am convinced that our finance system drives overuse and misuse of medical resources and contributes to waste and professional burnout while failing to improve outcomes or patient satisfaction. Murthy continues:

 

Third, we need to increase access to mental health care for health workers. Whether because of a lack of health insurance coverage, insurance networks with too few mental health care providers, or a lack of schedule flexibility for visits, health workers are having a hard time getting mental health care. Expanding the mental health workforce, strengthening the mental health parity laws directed at insurers, and utilizing virtual technology to bring mental health care to workers where they are and on their schedule are essential steps.

 

There is a little ambiguity here. I hope that Murthy recognizes that mental health for healthcare workers is important but they also need easier access for mental health serivces for their patients. I think we need to invest much more in mental health services for both providers and patients. Ironically, the recently passed federal gun legislation may be a much-needed boon to community mental health resources. 

 

Murthy’s next suggestion is a good one but it will take decades to make a dent in our current workforce shortages. We need to produce more professionals, but we also need to redesign our systems of care to more effectively use the professionals that we have. 

 

Fourth, we can strengthen public investments in the workforce and public health. Expanding public funding to train more clinicians and public health workers is critical. Increased funding to strengthen the health infrastructure of communities — from sustained support for local public health departments to greater focus on addressing social determinants of health such as housing and food insecurity — advances health equity and reduces the demands on our health care system. The recent announcement by the Centers for Disease Control and Prevention of $3 billion in grant programs to support public health infrastructure, data systems, and workforce is the type of investment that’s needed.

 

One of the reasons that I was a strong proponent of Lean was that it drew healthcare professionals together to use their collective wisdom to solve systems problems. The activities were collaborative. They were satisfying. Time and time again I saw individuals who were coerced into participating in an improvement effort become transformed and rejuvenated by their participation. I even heard people say that they had been considering quitting or retiring early before they were “forced” to participate in a Lean improvement event. I saw people who had worked in isolation in the same building or even a few doors apart without ever interacting become friends or more collegial colleagues because it was obvious through their time together that they shared the same concerns and were willing to work together for shared objectives.

 

I think Murthy is suggesting more traditional mental health supports and a ground-up revamping of how we train and support professionals. I don’t disagree, but I am still saying that there is real power in bringing us together in ways that allow us to use what health professionals have learned working in a dysfunctional system to improve the overall system of care.

 

Murthy’s fifth point embraces the reality that not only is there implicit bias in the practice of medicine that impact the care some patients recieve, there are also biases and cultural issues within the practice of medicine and our training programs that harm us all and must be addressed.

 

Fifth, we need to build a culture that supports well-being. It’s time to break the traditional silence surrounding the suffering of health workers. As gratifying as our work is, it can also be profoundly isolating, especially when we feel we can’t let our colleagues know if we’re not OK — a feeling that millions of health workers, including me, have had during our careers. Culture change must start in our training institutions, where the seeds of well-being can be planted early. It also requires leadership by example in health systems and departments of public health. Licensing bodies must adopt an approach to burnout that doesn’t punish health workers for reporting mental health concerns or seeking help and that protects their privacy. Finally, many health workers still face undue bias and discrimination based on their race, gender, or disability. Building a culture of inclusion, equity, and respect is critical for workforce morale.

 

Murthy has a lot to say about what has been done. He details what he thinks the opportunities are, and what the Biden administration is trying to do. I know the problem is even bigger than he dared to describe. I fear that the corrections will take decades to yield results. The consequences of not acting soon and with significant resources will lead to potentially devastating outcomes. He ends by suggesting the consequences of failing to act. To act we must overcome many barriers. The energy to solve the problems that lead to burnout must come from a consideration of the jeopardy ahead of us, and the moral obligation we have to address the problems that make the difficult job of delivering care unnecessarily more difficult than it has to be. 

 

As a nation, we cannot allow ourselves to fail health workers and the communities they serve. We must build on these steps, boldly taking on entrenched interests, bureaucratic inertia, and the status quo. Health workers throughout the country have told me they are reaching their breaking point — that “something has to change.” They are right. May our country never forget our moral obligation to care for those who have sacrificed so greatly to care for us.

 

I say “Amen” to Murthy’s statements. We must effectively address burnout. The root causes lie more in our system of care than in the individuals who suffer from the difficulties of practicing in a very dysfunctional system of care. We have much work to do.

 

The End of The Rainbow Is On Stanley Point 

 

It has been a strange summer of warmer than usual weather. The heat has been associated with a “mini drought” in New Hampshire which has been at its worst in southern New Hampshire where there have been recent fires. I live mid-state so things have not been “crackling” in my neighborhood, but it has been dry. In the midst of our recent heat wave, there were many oppressively humid days. On a few days, there were violent downpours with thunder and lightning in the late afternoon and evenings. We had an extended power outage one evening. Lightning felled a tree in my yard. On one late afternoon a storm came through like an out-of-control locomotive, but in less than a half hour the sky was bright and we had a gorgeous double rainbow. As you can see in today’s header, the dominant rainbow seemed to touchdown on conservation land at the neck of Stanley Point. I did not have enough confidence in the myth that there is a pot of gold at the end of the rainbow to motivate me to get in my kayak and go look for the pot. 

 

I have now seen at least two and perhaps three double rainbows in the same general area. I don’t think that I ever saw a double rainbow until I moved to New Hampshire. Obviously, rainbows have a scientific explanation. They have amazed us for as long as we have existed as a species. They have mythological and spiritual significance. The Bible says that the rainbow is God’s promise that He will never again destroy the world with water. Does that mean that the next time it is going to be by fire? Sometimes I wonder if we aren’t warming up for a reason. Rainbows generally imply a fresh start and good things to come.

 

If a single rainbow is a sign of hope, a double rainbow must be better. There is a scientific explanation for double rainbows. What I had not noticed before, but is observable in the photo is that the order of the colors is reversed in the second rainbow. Less obvious is the slightly darker sky which you can appreciate in the picture between the rainbows that is called Alexander’s band. The phenomenon is named for Alexander of Aphrodisias who first described it almost two thousand years ago. Who knew? What is most interesting to me is that if a rainbow means good things and hope, a double rainbow has even greater spiritual dividends. It does not surprise me that beyond a fresh start and good luck, a double rainbow suggests harmony and healing! 

 

What do we need more right now than harmony and healing? We need many double rainbows!  I am on the lookout for more!

Be Well,

Gene