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Fox Chase faculty receive grants for cancer research, education
Faculty members at Fox Chase Cancer Center have received grants to promote education about liver cancer, study pancreatic and breast cancer, and examine burnout among physician assistants (PAs).
Eric D. Tetzlaff, a PA at Fox Chase in Philadelphia, has received a 3-year grant from the Association of Physician Assistants in Oncology. With this $15,000 grant, Mr. Tetzlaff plans to conduct a longitudinal study that will explore burnout among PAs working in oncology.
The goals of his study are to “understand the impact of the attitudes of oncology PAs regarding teamwork, expectations for their professional role, type of collaborative practice, organizational context of the job environment, and moral distress, on burnout and career satisfaction,” according to Fox Chase.
Jaye Gardiner, PhD, a postdoctoral researcher in the Edna Cukierman laboratory at Fox Chase, has received a $163,500 grant from the American Cancer Society. With this grant, Dr. Gardiner will investigate the role of tumor stroma in pancreatic cancer.
Dr. Gardiner plans to explore how cancer-associated fibroblasts in the pancreatic stroma “communicate with one another and how this communication is altered in tumor-promoting versus tumor-restricting conditions,” according to Fox Chase.
Dietmar J. Kappes, PhD, a professor of blood cell development and cancer and director of the Transgenic Mouse Facility at Fox Chase, has received a 5-year grant from the National Institutes of Health. With this $626,072 grant, Dr. Kappes will investigate the role of the transcription factor ThPOK in breast cancer.
Dr. Kappes and colleagues previously found a link between high cytoplasmic levels of ThPOK and poor outcomes in breast cancer. Now, Dr. Kappes plans to “further elucidate the role of ThPOK in breast cancer by combining novel animal models and molecular approaches,” according to Fox Chase.
Evelyn González, senior director of the Fox Chase’s Office of Community Outreach, and Shannon Lynch, PhD, who is with the Cancer Prevention and Control program, have received a 2-year grant from the Pennsylvania Department of Human Services.
The pair will use this $125,000 grant to provide liver cancer and hepatitis education to communities in the Philadelphia area with the greatest burden of liver cancer and related risk factors. Dr. Lynch will find these at-risk communities, and the Office of Community Outreach will work with partner groups in those areas to provide bilingual education about hepatitis and how it relates to liver cancer.
Movers in Medicine highlights career moves and personal achievements by hematologists and oncologists. Did you switch jobs, take on a new role, climb a mountain? Tell us all about it at hematologynews@mdedge.com, and you could be featured in Movers in Medicine.
Faculty members at Fox Chase Cancer Center have received grants to promote education about liver cancer, study pancreatic and breast cancer, and examine burnout among physician assistants (PAs).
Eric D. Tetzlaff, a PA at Fox Chase in Philadelphia, has received a 3-year grant from the Association of Physician Assistants in Oncology. With this $15,000 grant, Mr. Tetzlaff plans to conduct a longitudinal study that will explore burnout among PAs working in oncology.
The goals of his study are to “understand the impact of the attitudes of oncology PAs regarding teamwork, expectations for their professional role, type of collaborative practice, organizational context of the job environment, and moral distress, on burnout and career satisfaction,” according to Fox Chase.
Jaye Gardiner, PhD, a postdoctoral researcher in the Edna Cukierman laboratory at Fox Chase, has received a $163,500 grant from the American Cancer Society. With this grant, Dr. Gardiner will investigate the role of tumor stroma in pancreatic cancer.
Dr. Gardiner plans to explore how cancer-associated fibroblasts in the pancreatic stroma “communicate with one another and how this communication is altered in tumor-promoting versus tumor-restricting conditions,” according to Fox Chase.
Dietmar J. Kappes, PhD, a professor of blood cell development and cancer and director of the Transgenic Mouse Facility at Fox Chase, has received a 5-year grant from the National Institutes of Health. With this $626,072 grant, Dr. Kappes will investigate the role of the transcription factor ThPOK in breast cancer.
Dr. Kappes and colleagues previously found a link between high cytoplasmic levels of ThPOK and poor outcomes in breast cancer. Now, Dr. Kappes plans to “further elucidate the role of ThPOK in breast cancer by combining novel animal models and molecular approaches,” according to Fox Chase.
Evelyn González, senior director of the Fox Chase’s Office of Community Outreach, and Shannon Lynch, PhD, who is with the Cancer Prevention and Control program, have received a 2-year grant from the Pennsylvania Department of Human Services.
The pair will use this $125,000 grant to provide liver cancer and hepatitis education to communities in the Philadelphia area with the greatest burden of liver cancer and related risk factors. Dr. Lynch will find these at-risk communities, and the Office of Community Outreach will work with partner groups in those areas to provide bilingual education about hepatitis and how it relates to liver cancer.
Movers in Medicine highlights career moves and personal achievements by hematologists and oncologists. Did you switch jobs, take on a new role, climb a mountain? Tell us all about it at hematologynews@mdedge.com, and you could be featured in Movers in Medicine.
Faculty members at Fox Chase Cancer Center have received grants to promote education about liver cancer, study pancreatic and breast cancer, and examine burnout among physician assistants (PAs).
Eric D. Tetzlaff, a PA at Fox Chase in Philadelphia, has received a 3-year grant from the Association of Physician Assistants in Oncology. With this $15,000 grant, Mr. Tetzlaff plans to conduct a longitudinal study that will explore burnout among PAs working in oncology.
The goals of his study are to “understand the impact of the attitudes of oncology PAs regarding teamwork, expectations for their professional role, type of collaborative practice, organizational context of the job environment, and moral distress, on burnout and career satisfaction,” according to Fox Chase.
Jaye Gardiner, PhD, a postdoctoral researcher in the Edna Cukierman laboratory at Fox Chase, has received a $163,500 grant from the American Cancer Society. With this grant, Dr. Gardiner will investigate the role of tumor stroma in pancreatic cancer.
Dr. Gardiner plans to explore how cancer-associated fibroblasts in the pancreatic stroma “communicate with one another and how this communication is altered in tumor-promoting versus tumor-restricting conditions,” according to Fox Chase.
Dietmar J. Kappes, PhD, a professor of blood cell development and cancer and director of the Transgenic Mouse Facility at Fox Chase, has received a 5-year grant from the National Institutes of Health. With this $626,072 grant, Dr. Kappes will investigate the role of the transcription factor ThPOK in breast cancer.
Dr. Kappes and colleagues previously found a link between high cytoplasmic levels of ThPOK and poor outcomes in breast cancer. Now, Dr. Kappes plans to “further elucidate the role of ThPOK in breast cancer by combining novel animal models and molecular approaches,” according to Fox Chase.
Evelyn González, senior director of the Fox Chase’s Office of Community Outreach, and Shannon Lynch, PhD, who is with the Cancer Prevention and Control program, have received a 2-year grant from the Pennsylvania Department of Human Services.
The pair will use this $125,000 grant to provide liver cancer and hepatitis education to communities in the Philadelphia area with the greatest burden of liver cancer and related risk factors. Dr. Lynch will find these at-risk communities, and the Office of Community Outreach will work with partner groups in those areas to provide bilingual education about hepatitis and how it relates to liver cancer.
Movers in Medicine highlights career moves and personal achievements by hematologists and oncologists. Did you switch jobs, take on a new role, climb a mountain? Tell us all about it at hematologynews@mdedge.com, and you could be featured in Movers in Medicine.
CVS-Aetna merger approval gets poor review from physicians
Physician groups are criticizing a judge’s decision to approve the merger of pharmacy chain CVS Health and health insurer Aetna, saying the deal will raise prices and lower quality.
Judge Richard J. Leon of the U.S. District Court for the District of Columbia allowed the merger to move forward on Sept. 4, ruling that the acquisition was legal under antitrust law. The merger was approved by the Department of Justice in October 2018 on the condition that Aetna sell its Medicare prescription drug plan (PDP) business to independently owned competitor, WellCare Health Plans. Judge Leon has been examining the government’s plan since late 2018.
In his decision, Judge Leon acknowledged that the merger will have widespread effects for millions of patients and noted the many industry stakeholders, consumer groups, and state regulatory bodies have raised concerns about the merger.
“Although [the opposition] raised substantial concerns that warranted serious consideration, CVS’s and the government’s witnesses, when combined with the existing record, persuasively support why the markets at issue are not only very competitive today, but are likely to remain so post merger,” Judge Leon wrote. “Consequently, the harms to the public interest the [opposition] raised were not sufficiently established to undermine the government’s conclusion to the contrary. As such, for all of the above reasons, I have concluded that the proposed settlement is well ‘within the reaches’ of the public interest and the government’s motion ... should therefore be granted.”
Patrice A. Harris, MD, president for the American Medical Association, said the judge’s decision fails patients and will likely raise prices, lower quality, reduce choice, and stifle innovation.
“The American people and our health system will not be served well by allowing a merger that combines health insurance giant Aetna Inc. with CVS Health Corporation,” Dr. Harris said in a statement. “For patients and employers struggling with recurrent increases to health insurance premiums, out-of-pocket costs, and prescription drug prices, it’s hard to find any upside to a merger that leaves them with fewer choices. Nothing in the deal guarantees reductions on insurance premiums or prescription drug costs. As for promised efficiency savings, that money will likely go straight to CVS’s bottom line.”
Angus Worthing, MD, government affairs committee chair for the American College of Rheumatology, said his group is concerned that the merger will hinder progress that has been made toward creating cost transparency and will make it easier for costs savings to remain secret.
“We hope that regulators will now actively watch the conduct of the merged company to ensure patients are protected,” Dr. Worthing said in a statement.
In a statement, CVS noted that CVS Health and Aetna have been one company since November 2018, stating that the court’s action “makes that 100 percent clear.”
“We remain focused on transforming the consumer health care experience in America,” they said.
CVS Health announced it would buy Aetna for $69 billion in 2017 and finalized the acquisition in 2018. CVS Health President and CEO Larry J. Merlo said the combined company would connect consumers with the powerful health resources of CVS Health in communities across the country and Aetna’s network of providers to help remove barriers to high quality care and build lasting relationships with patients.
Assistant Attorney General Makan Delrahim of the Justice Department’s antitrust division said the agency was pleased with the court’s decision to approve the government’s plan and finalize the merger.
“The divestiture of Aetna’s individual PDP business provides a comprehensive remedy to the harms the Justice Department identified,” Mr. Delrahim said in a statement. “The entry of the final judgment protects seniors and other vulnerable customers of individual PDPs from the anticompetitive effects that would have occurred if CVS and Aetna had merged their individual PDP businesses.”
Physician groups are criticizing a judge’s decision to approve the merger of pharmacy chain CVS Health and health insurer Aetna, saying the deal will raise prices and lower quality.
Judge Richard J. Leon of the U.S. District Court for the District of Columbia allowed the merger to move forward on Sept. 4, ruling that the acquisition was legal under antitrust law. The merger was approved by the Department of Justice in October 2018 on the condition that Aetna sell its Medicare prescription drug plan (PDP) business to independently owned competitor, WellCare Health Plans. Judge Leon has been examining the government’s plan since late 2018.
In his decision, Judge Leon acknowledged that the merger will have widespread effects for millions of patients and noted the many industry stakeholders, consumer groups, and state regulatory bodies have raised concerns about the merger.
“Although [the opposition] raised substantial concerns that warranted serious consideration, CVS’s and the government’s witnesses, when combined with the existing record, persuasively support why the markets at issue are not only very competitive today, but are likely to remain so post merger,” Judge Leon wrote. “Consequently, the harms to the public interest the [opposition] raised were not sufficiently established to undermine the government’s conclusion to the contrary. As such, for all of the above reasons, I have concluded that the proposed settlement is well ‘within the reaches’ of the public interest and the government’s motion ... should therefore be granted.”
Patrice A. Harris, MD, president for the American Medical Association, said the judge’s decision fails patients and will likely raise prices, lower quality, reduce choice, and stifle innovation.
“The American people and our health system will not be served well by allowing a merger that combines health insurance giant Aetna Inc. with CVS Health Corporation,” Dr. Harris said in a statement. “For patients and employers struggling with recurrent increases to health insurance premiums, out-of-pocket costs, and prescription drug prices, it’s hard to find any upside to a merger that leaves them with fewer choices. Nothing in the deal guarantees reductions on insurance premiums or prescription drug costs. As for promised efficiency savings, that money will likely go straight to CVS’s bottom line.”
Angus Worthing, MD, government affairs committee chair for the American College of Rheumatology, said his group is concerned that the merger will hinder progress that has been made toward creating cost transparency and will make it easier for costs savings to remain secret.
“We hope that regulators will now actively watch the conduct of the merged company to ensure patients are protected,” Dr. Worthing said in a statement.
In a statement, CVS noted that CVS Health and Aetna have been one company since November 2018, stating that the court’s action “makes that 100 percent clear.”
“We remain focused on transforming the consumer health care experience in America,” they said.
CVS Health announced it would buy Aetna for $69 billion in 2017 and finalized the acquisition in 2018. CVS Health President and CEO Larry J. Merlo said the combined company would connect consumers with the powerful health resources of CVS Health in communities across the country and Aetna’s network of providers to help remove barriers to high quality care and build lasting relationships with patients.
Assistant Attorney General Makan Delrahim of the Justice Department’s antitrust division said the agency was pleased with the court’s decision to approve the government’s plan and finalize the merger.
“The divestiture of Aetna’s individual PDP business provides a comprehensive remedy to the harms the Justice Department identified,” Mr. Delrahim said in a statement. “The entry of the final judgment protects seniors and other vulnerable customers of individual PDPs from the anticompetitive effects that would have occurred if CVS and Aetna had merged their individual PDP businesses.”
Physician groups are criticizing a judge’s decision to approve the merger of pharmacy chain CVS Health and health insurer Aetna, saying the deal will raise prices and lower quality.
Judge Richard J. Leon of the U.S. District Court for the District of Columbia allowed the merger to move forward on Sept. 4, ruling that the acquisition was legal under antitrust law. The merger was approved by the Department of Justice in October 2018 on the condition that Aetna sell its Medicare prescription drug plan (PDP) business to independently owned competitor, WellCare Health Plans. Judge Leon has been examining the government’s plan since late 2018.
In his decision, Judge Leon acknowledged that the merger will have widespread effects for millions of patients and noted the many industry stakeholders, consumer groups, and state regulatory bodies have raised concerns about the merger.
“Although [the opposition] raised substantial concerns that warranted serious consideration, CVS’s and the government’s witnesses, when combined with the existing record, persuasively support why the markets at issue are not only very competitive today, but are likely to remain so post merger,” Judge Leon wrote. “Consequently, the harms to the public interest the [opposition] raised were not sufficiently established to undermine the government’s conclusion to the contrary. As such, for all of the above reasons, I have concluded that the proposed settlement is well ‘within the reaches’ of the public interest and the government’s motion ... should therefore be granted.”
Patrice A. Harris, MD, president for the American Medical Association, said the judge’s decision fails patients and will likely raise prices, lower quality, reduce choice, and stifle innovation.
“The American people and our health system will not be served well by allowing a merger that combines health insurance giant Aetna Inc. with CVS Health Corporation,” Dr. Harris said in a statement. “For patients and employers struggling with recurrent increases to health insurance premiums, out-of-pocket costs, and prescription drug prices, it’s hard to find any upside to a merger that leaves them with fewer choices. Nothing in the deal guarantees reductions on insurance premiums or prescription drug costs. As for promised efficiency savings, that money will likely go straight to CVS’s bottom line.”
Angus Worthing, MD, government affairs committee chair for the American College of Rheumatology, said his group is concerned that the merger will hinder progress that has been made toward creating cost transparency and will make it easier for costs savings to remain secret.
“We hope that regulators will now actively watch the conduct of the merged company to ensure patients are protected,” Dr. Worthing said in a statement.
In a statement, CVS noted that CVS Health and Aetna have been one company since November 2018, stating that the court’s action “makes that 100 percent clear.”
“We remain focused on transforming the consumer health care experience in America,” they said.
CVS Health announced it would buy Aetna for $69 billion in 2017 and finalized the acquisition in 2018. CVS Health President and CEO Larry J. Merlo said the combined company would connect consumers with the powerful health resources of CVS Health in communities across the country and Aetna’s network of providers to help remove barriers to high quality care and build lasting relationships with patients.
Assistant Attorney General Makan Delrahim of the Justice Department’s antitrust division said the agency was pleased with the court’s decision to approve the government’s plan and finalize the merger.
“The divestiture of Aetna’s individual PDP business provides a comprehensive remedy to the harms the Justice Department identified,” Mr. Delrahim said in a statement. “The entry of the final judgment protects seniors and other vulnerable customers of individual PDPs from the anticompetitive effects that would have occurred if CVS and Aetna had merged their individual PDP businesses.”
New study confirms rise in U.S. suicide rates, particularly in rural areas
County-by-county analysis cites links to higher density of gun shops, other factors
Suicide rates in the United States climbed from 1999 to 2016, a new cross-sectional study found, and the increases were highest in rural areas.
“These findings are consistent with previous studies demonstrating higher and more rapidly increasing suicide rates in rural areas and are of considerable interest in light of the work by [Anne] Case and [Angus] Deaton,” wrote Danielle L. Steelesmith, PhD, and associates. “While increasing rates of suicide are well documented, little is known about contextual factors associated with county-level suicide rates.” The findings appear in JAMA Network Open.
To examine those contextual factors, Dr. Steelesmith, of the department of psychiatry and behavioral health at the Ohio State University, Columbus, and associates analyzed county-by-county suicide statistics from 1999 to 2016 for adults aged 25-64 years, noting that they “focused on this age range because most studies on mortality trends have focused on this age range.”
The researchers developed 3-year suicide averages for counties for rate “stabilization” purposes. They placed the counties into four categories (large metropolitan, small metropolitan, micropolitan, and rural), and used various data sources to gather various types of statistics about the communities.
Most of those who died by suicide were men (77%), and most (51%) were aged 45-64 years. The median suicide rate per county rose from 15 per 100,000 (1999-2001) to 21 per 100,000 (2014-2016), reported Dr. Steelesmith and associates.
Rural counties only made up 2% of the suicides, compared with 81% in large and small metropolitan counties, but suicide rates were “increasing most rapidly in rural areas, although all county types saw increases during the period studied,” Dr. Steelesmith and associates wrote.
They added that “counties with the highest excess risk of suicide tended to be in Western states (e.g., Colorado, New Mexico, Utah, and Wyoming), Appalachia (e.g., Kentucky, Virginia, and West Virginia), and the Ozarks (e.g., Arkansas and Missouri).”
In addition to the connections between increasing suicide rates, living in a rural area, and a higher density of gun shops, the researchers cited other contextual factors. Among those factors were higher median age and higher percentages of non-Hispanic whites, numbers of residents without health insurance, and veterans. They also found links between higher suicide rates and worse numbers on indexes designed to measure social capital; social fragmentation; and deprivation, a measure encompassing lower education, employment levels, and income.
“Long-term and persistent poverty appears to be more entrenched and economic opportunities more constrained in rural areas,” Dr. Steelesmith and associates wrote. “Greater social isolation, challenges related to transportation and interpersonal communication, and associated difficulties accessing health and mental health services likely contribute to the disproportionate association of deprivation with suicide in rural counties.”
Dr. Steelesmith and associates cited several limitations. One key limitation is that, because the study looked only at adults aged 25-64 years, the results might not be generalizable to youth or elderly adults.
No study funding was reported. One study author reported serving on the scientific advisory board of Clarigent Health and receiving grant support from the National Institute of Mental Health outside of the submitted work. No other disclosures were reported.
SOURCE: Steelesmith DL et al. JAMA Netw Open. 2019 Sep 6. doi: 10.1001/jamanetworkopen.2019.10936.
County-by-county analysis cites links to higher density of gun shops, other factors
County-by-county analysis cites links to higher density of gun shops, other factors
Suicide rates in the United States climbed from 1999 to 2016, a new cross-sectional study found, and the increases were highest in rural areas.
“These findings are consistent with previous studies demonstrating higher and more rapidly increasing suicide rates in rural areas and are of considerable interest in light of the work by [Anne] Case and [Angus] Deaton,” wrote Danielle L. Steelesmith, PhD, and associates. “While increasing rates of suicide are well documented, little is known about contextual factors associated with county-level suicide rates.” The findings appear in JAMA Network Open.
To examine those contextual factors, Dr. Steelesmith, of the department of psychiatry and behavioral health at the Ohio State University, Columbus, and associates analyzed county-by-county suicide statistics from 1999 to 2016 for adults aged 25-64 years, noting that they “focused on this age range because most studies on mortality trends have focused on this age range.”
The researchers developed 3-year suicide averages for counties for rate “stabilization” purposes. They placed the counties into four categories (large metropolitan, small metropolitan, micropolitan, and rural), and used various data sources to gather various types of statistics about the communities.
Most of those who died by suicide were men (77%), and most (51%) were aged 45-64 years. The median suicide rate per county rose from 15 per 100,000 (1999-2001) to 21 per 100,000 (2014-2016), reported Dr. Steelesmith and associates.
Rural counties only made up 2% of the suicides, compared with 81% in large and small metropolitan counties, but suicide rates were “increasing most rapidly in rural areas, although all county types saw increases during the period studied,” Dr. Steelesmith and associates wrote.
They added that “counties with the highest excess risk of suicide tended to be in Western states (e.g., Colorado, New Mexico, Utah, and Wyoming), Appalachia (e.g., Kentucky, Virginia, and West Virginia), and the Ozarks (e.g., Arkansas and Missouri).”
In addition to the connections between increasing suicide rates, living in a rural area, and a higher density of gun shops, the researchers cited other contextual factors. Among those factors were higher median age and higher percentages of non-Hispanic whites, numbers of residents without health insurance, and veterans. They also found links between higher suicide rates and worse numbers on indexes designed to measure social capital; social fragmentation; and deprivation, a measure encompassing lower education, employment levels, and income.
“Long-term and persistent poverty appears to be more entrenched and economic opportunities more constrained in rural areas,” Dr. Steelesmith and associates wrote. “Greater social isolation, challenges related to transportation and interpersonal communication, and associated difficulties accessing health and mental health services likely contribute to the disproportionate association of deprivation with suicide in rural counties.”
Dr. Steelesmith and associates cited several limitations. One key limitation is that, because the study looked only at adults aged 25-64 years, the results might not be generalizable to youth or elderly adults.
No study funding was reported. One study author reported serving on the scientific advisory board of Clarigent Health and receiving grant support from the National Institute of Mental Health outside of the submitted work. No other disclosures were reported.
SOURCE: Steelesmith DL et al. JAMA Netw Open. 2019 Sep 6. doi: 10.1001/jamanetworkopen.2019.10936.
Suicide rates in the United States climbed from 1999 to 2016, a new cross-sectional study found, and the increases were highest in rural areas.
“These findings are consistent with previous studies demonstrating higher and more rapidly increasing suicide rates in rural areas and are of considerable interest in light of the work by [Anne] Case and [Angus] Deaton,” wrote Danielle L. Steelesmith, PhD, and associates. “While increasing rates of suicide are well documented, little is known about contextual factors associated with county-level suicide rates.” The findings appear in JAMA Network Open.
To examine those contextual factors, Dr. Steelesmith, of the department of psychiatry and behavioral health at the Ohio State University, Columbus, and associates analyzed county-by-county suicide statistics from 1999 to 2016 for adults aged 25-64 years, noting that they “focused on this age range because most studies on mortality trends have focused on this age range.”
The researchers developed 3-year suicide averages for counties for rate “stabilization” purposes. They placed the counties into four categories (large metropolitan, small metropolitan, micropolitan, and rural), and used various data sources to gather various types of statistics about the communities.
Most of those who died by suicide were men (77%), and most (51%) were aged 45-64 years. The median suicide rate per county rose from 15 per 100,000 (1999-2001) to 21 per 100,000 (2014-2016), reported Dr. Steelesmith and associates.
Rural counties only made up 2% of the suicides, compared with 81% in large and small metropolitan counties, but suicide rates were “increasing most rapidly in rural areas, although all county types saw increases during the period studied,” Dr. Steelesmith and associates wrote.
They added that “counties with the highest excess risk of suicide tended to be in Western states (e.g., Colorado, New Mexico, Utah, and Wyoming), Appalachia (e.g., Kentucky, Virginia, and West Virginia), and the Ozarks (e.g., Arkansas and Missouri).”
In addition to the connections between increasing suicide rates, living in a rural area, and a higher density of gun shops, the researchers cited other contextual factors. Among those factors were higher median age and higher percentages of non-Hispanic whites, numbers of residents without health insurance, and veterans. They also found links between higher suicide rates and worse numbers on indexes designed to measure social capital; social fragmentation; and deprivation, a measure encompassing lower education, employment levels, and income.
“Long-term and persistent poverty appears to be more entrenched and economic opportunities more constrained in rural areas,” Dr. Steelesmith and associates wrote. “Greater social isolation, challenges related to transportation and interpersonal communication, and associated difficulties accessing health and mental health services likely contribute to the disproportionate association of deprivation with suicide in rural counties.”
Dr. Steelesmith and associates cited several limitations. One key limitation is that, because the study looked only at adults aged 25-64 years, the results might not be generalizable to youth or elderly adults.
No study funding was reported. One study author reported serving on the scientific advisory board of Clarigent Health and receiving grant support from the National Institute of Mental Health outside of the submitted work. No other disclosures were reported.
SOURCE: Steelesmith DL et al. JAMA Netw Open. 2019 Sep 6. doi: 10.1001/jamanetworkopen.2019.10936.
FROM JAMA NETWORK OPEN
Rules of incivility
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Advanced team-based care: How we made it work
Leaders in health care and practicing physicians recognize the need for changes in how health care is delivered.1-3 Despite this awareness, though, barriers to meaningful change persist and the current practice environment wherein physicians must routinely spend 2 hours on electronic health records (EHRs) and desk work for every hour of direct face time with patients4 is driving trainees away from ambulatory specialties and is contributing to physicians’ decisions to reduce their practices to part-time, retire early, or leave medicine altogether.5,6 Those who persevere in this environment with heavy administrative burdens run the increasing risk of burnout.7
Some physicians and practices are responding by taking creative measures to reform the way patient care is delivered. Bellin Health—a 160-provider, multispecialty health system in northeast Wisconsin where one of the authors (JJ) works—introduced an advanced team-based care (aTBC) model between November 2014 and November 2018, starting with our primary care providers. The development and introduction of this new model arose from an iterative, multidisciplinary process driven by the desire to transform the Triple Aim—enhancing patient experience, improving population health, and reducing costs—into a Quadruple Aim8 by additionally focusing on improving the work life of health care providers, which, in turn, will help achieve the first 3 goals. In introducing an aTBC model, Bellin Health focused on 3 elements: office visit redesign, in-basket management redesign, and the use of extended care team members and system and community resources to assist in the care of complex and high-risk patients.
Herein we describe the 3 components of our aTBC model,1,9 identify the barriers that existed in the minds of multiple stakeholders (from patients to clinicians and Bellin executives), and describe the strategies that enabled us to overcome these barriers.
The impetus behind our move to aTBC
Bellin Health considered a move to an aTBC model to be critical in light of factors in the health care environment, in general, and at Bellin, in particular. The factors included
- an industry-wide shift to value-based payments, which requires new models for long-term financial viability.
- recognition that physician and medical staff burnout leads to lower productivity and, in some cases, workforce losses.5,6 Replacing a physician in a practice can be difficult and expensive, with cost estimates of $500,000 to more than $1 million per physician.10,11
- a belief that aTBC could help the Bellin Health leadership team meet its organizational goals of improved patient satisfaction, achieve gains in quality measures, enhance engagement and loyalty among patients and employees, and lower recruitment costs.
A 3-part aTBC initiative
■ Part 1: Redesign the office visit
We redesigned staffing and workflow for office visits to maximize the core skills of physicians, which required distributing ancillary tasks among support staff. We up-trained certified medical assistants (CMAs) and licensed practical nurses (LPNs) to take on the new role of care team coordinator (CTC) and optimized the direct clinical support ratio for busier physicians. For physicians who were seeing 15 to 19 patients a day, a ratio of 3 CTCs to 2 physicians was implemented; for those seeing 20 or more patients a day, we used a support ratio of 2:1.
The role of CTC was designed so that he or she would accompany a patient throughout the entire appointment. Responsibilities were broken out as follows:
Pre-visit. Before the physician enters the room, the CTC would now perform expanded rooming functions including pending orders, refill management, care gap closure using standing orders, agenda setting, and preliminary documentation.12
Visit. The CTC would now hand off the patient to the physician and stay in the room to document details of the visit and record new orders for consults, x-ray films, referrals, or prescriptions.13 This intensive EHR support was established to ensure that the physician could focus directly on the patient without the distraction of the computer.
Continue to: Post-visit
Post-visit. After a physician leaves a room, the CTC was now charged with finishing the pending orders, setting up the patient’s next appointment and pre-visit labs, reviewing details of the after-visit summary, and doing any basic health coaching with the patient. During this time, the physician would use the co-location space to review and edit the documentation, cosign the orders and prescriptions submitted by the CTC, and close the chart before going into the next room with the second CTC. The need to revisit these details after clinic hours was eliminated.
Another change … The role of our phone triage registered nurses (RN) was expanded. Care team RNs began providing diabetes counseling, blood pressure checks, annual wellness visits (AWV), and follow-up through the Centers for Medicare and Medicaid Services (CMS)'s Chronic Care Management and Transitional Care Management programs.
■ Part 2: Redesign between-visit in-basket management
Responding to an increasing number of inbox messages had become overwhelming for our physicians. Bellin Health’s management was aware that strategic delegation of inbox messages could save an hour or more of a physician’s time each day.14 Bellin implemented a procedure whereby inbox test results would be handled by the same CTC who saw the patient, thereby extending continuity. If the results were normal, the CTC would contact the patient. If the results were abnormal, the physician and the CTC would discuss them and develop a plan. Co-location of the RN, the CTC, and the physician would leverage face-to-face communication and make in-basket management more efficient.
■ Part 3: Redesign population health management
We developed an Extended Care Team (ECT), including social workers, clinical pharmacists, RN care coordinators, and diabetes educators, to assist with the care of patients with high-risk disorders or otherwise complex issues. These team members would work closely with the CTC, care team RN, and physician to review patients, develop plans of care, optimize management, and improve outcomes. Patients would be identified as candidates for potential ECT involvement based on the physician’s judgment in consultation with an EHR-based risk score for hospitalization or emergency department visit.
As we developed new processes, such as screening for determinants of health, we engaged additional system and community resources to help meet the needs of our patients.
Continue to: A look at stakeholder concerns and overcoming the barriers
A look at stakeholder concerns and overcoming the barriers
Critical to our success was being attentive to the concerns of our stakeholders and addressing them. Along the way, we gained valuable implementation insights, which we share here along with some specifics about how, exactly, we did things at Bellin.
Patients
Some patients expressed hesitation at having a person other than their physician in the exam room. They worried that the intimacy and privacy with their physician would be lost. In light of this, we gave patients the option not to have the CTC remain in the room. However, patients quickly saw the value of this team-based care approach and seldom asked to be seen without the CTC.
Throughout the process, we surveyed patients for feedback on their experiences. Comments indicated that the presence of the CTC in our team-based model led to positive patient experiences:
My physician is fully attentive. Patients appreciated that physicians were not distracted by the computer in the exam room. “I feel like I’ve got my doctor back” has been a common refrain.
The office staff is more responsive. The CTC, having been present during the appointment, has a deeper understanding of the care plan and can respond to calls or emails between visits, thereby reducing the time patients must wait for answers. One patient commented that, “I love [the doctor’s] team; his nurses are willing to answer every question I have.”
Continue to: I increasingly feel that I'm understood
I increasingly feel that I’m understood. We have seen patients develop meaningful relationships with other team members, confiding in them in ways that they hadn’t always done with physicians and advanced practice clinicians (APCs). Team members, in turn, have added valuable insights that help optimize patients’ care. In particular, the care of patients with multiple needs has been enhanced with the addition of ECT members who work with the core team and use their expertise to optimize the care of these patients.
Certified medical assistants and licensed practical nurses
Bellin’s leadership knew that team documentation could cause stress for the CMA, who, acting as a CTC, wanted to avoid misrepresenting details of the clinical encounter.13 Adding to the stress were other duties that would need to be learned, including agenda setting, refill management, care gap closure, and health coaching. With thorough training and preparation, many—but not all—of our CMAs and LPNs were able to successfully make the transition and flourish.
Implementation strategies
Provide thorough training. Our training process started 8 weeks before it was time to “go live.” There were weekly hour-long training sessions in population health basics, team culture and change management, documentation basics, and new roles and responsibilities. In the final week, the entire aTBC team sat together for 3 days of EHR training. All new teams shadowed existing teams to get a clear picture of the new processes.
Create a community of support. As our CMAs adapted to their new CTC roles, it was critical that they had support from experienced CTCs. Encouragement and patience from physicians were—and are—essential for CTCs to develop confidence in their new roles.
Enable ongoing feedback. We introduced weekly team meetings to enhance team communication and dynamics. Forums for all roles are held periodically to facilitate discussion, share learning, and enable support between teams.
Continue to: Use EHR tools to facilitate this work
Use EHR tools to facilitate this work. Using standard templates and documentation tools helped CTCs develop the confidence needed to thrive in their new role. Knowing these tools were available helped CTCs become effective in helping the team manage the between-visit work.
Monitor workload. As we developed more workflows and processes, we took care to monitor the amount of additional work for those in this role. We offloaded work whenever possible. For example, coordinated refill management at time of service, coupled with a back-up centralized refill system, can significantly decrease the number of refill requests made to CTCs. We continue to adjust staffing, where appropriate, to provide adequate support for those in this valuable role.
Be prepared for turnover. As CTCs became empowered in their new roles, some decided to advance their training into other roles. We developed a plan for replacing and training new staff. Higher pay can also be used to help attract and retain these staff members. Bellin uses LPNs in this role to ensure adequate staffing. Other health systems have developed a tier system for CMAs to improve retention.
Registered nurses
Before our move to an aTBC model, our office RNs primarily managed phone triage. Now the nurses were enlisted to play a more active role in patient care and team leadership. Although it was a dramatic departure from prior responsibilities, the majority of Bellin’s RNs have found increased satisfaction in taking on direct patient care.
Implementation strategies
Define new roles and provide training. In addition to participating in acute patient visits, consider ways that care team RNs can expand responsibilities as they pertain to disease counseling, population health management, and team leadership.15 At Bellin, the expanded role of the RN is evident in diabetes education and Medicare AWVs. Specifically, RNs now provide diabetes education to appropriate patients following a warm handoff from the physician at the time of the visit. RNs now also complete Medicare AWVs, which frees up physicians for other tasks and helps ensure sustainability for the new RN roles. Rates of completed AWVs at Bellin are now more than 70%, compared with reported national rates of less than 30%.16
Continue to: Maximize co-location
Maximize co-location. It is helpful to have the team members whose work is closely related—such as the CTCs and the RN for the team—to be situated near each other, rather than down a hall or in separate offices. Since the RN is co-located with the core teams at Bellin, there is now greater opportunity for verbal interaction, rather than just electronic communications, for matters such as triage calls and results management. RNs also provide a valuable resource for CMAs and LPNs, as well as help oversee team management of the in-basket.
Evaluate sustainability. Additional roles for the RNs required additional RN staffing. We assessed the new workload duties and balanced that against potential revenue from RN visits. This analysis indicated that an optimal ratio was 1 RN to every 3000 patients. This would allow an adequate number of RNs to fulfill additional roles and was financially sustainable with the goal of 4 billable RN visits per day.
Physicians
Bellin’s leadership recognized that some physicians might perceive team-based care as eroding their primary responsibility for patients’ care. Physicians have historically been trained in a model based on the primacy of the individual physician and that can be a hurdle to embracing team culture as a new paradigm of care. Several strategies helped us and can help others, too.
Implementation strategies
Cultivate trust. Thorough training of CTCs and RNs is critical to helping physicians develop trust and reliance in the team. The physician retains final authority over the team for cosigning orders, editing and finalizing documentation, and overseeing results management. Physicians invested in training and educating their staff will reap the rewards of a highly functioning, more satisfied team.
Encourage leadership. This can be a cultural shift for physicians, yet it is critical that they take a leadership role in this transformation.17 Physicians and their team leaders attended training sessions in team culture and change management. Prior to the go-live date, team leaders also met with the physician individually to explore their concerns and discuss ways to effectively lead and support their teams.
Continue to: Urge acceptance of support
Urge acceptance of support. The complexity of patient care today makes it difficult for a physician to manage all of a patient’s needs single-handedly. Complexity arises from the variety of plan co-pays and deductibles, the number of patients with chronic diseases, and the increased emphasis on improving quality measures.18 Enhanced support during any office visit and the extra support of an ECT for complex patients improves the ability of the physician to more effectively meet the needs of the patient.
Emphasize the benefit of an empowered team. The demands of the EHR on physicians and the resultant frustrations are well chronicled.4,19-22 Strategically delegating much of this work to other team members allows the physician to focus on the patient and perform physician-level work. At Bellin, we observed that our most successful care teams were those in which the physician fully accepted team-based care principles and empowered the staff to work at the top of their skill set.
Advanced practice clinicians
APCs in our system had traditionally practiced in 1 of 3 ways: independently handling defined panels with physician supervision; handling overflow or acute visits; or working collaboratively with a supervising physician to share a larger “team panel.” The third approach has become our preferred model. aTBC provides opportunities for APCs to thrive and collaborate with the physician to provide excellent care for patients.
APCs underwent the same process changes as physicians, including appropriate CTC support. Implementation strategies for APCs were similar to those that were useful for physicians.
Risk management professionals
At Bellin, we found that risk-management professionals had concerns about the scope of practice assigned to various team members, particularly regarding documentation. CMS allows for elements of a patient visit to be documented by CMAs and other members of the care team in real time as authorized by the physician.23,24 CTCs at Bellin also have other clinical duties in patient and EHR management. aTBC practices generally prefer the term team documentation over scribing, since it more accurately reflects the scope of the CTC’s work.
Continue to: Implementation strategies
Implementation strategies
Clarify regulatory issues. Extensive use of standing orders and protocols allowed us to increase involvement of various team members. State laws vary in what functions CMAs and LPNs are allowed to perform, so it is important to check your state guidelines.25 There is a tendency for some risk managers to overinterpret regulations. Challenge them to provide exact documentation from regulatory agencies to support their decisions.
Give assurances of physician oversight and processes. The physician assumes responsibility for standing orders, protocols, and documentation. We made sure that we had clear and consistent processes in place and worked closely with our risk managers as we developed our model. aTBC provides checks and balances to ensure accurate records, since team members are able to contribute and check for accuracy. A recent study suggested that CMAs perform documentation that is of equal or higher quality than that performed by the physician.26
Financial leadership
Like any organization adopting aTBC, Bellin’s leadership was concerned about the expense of adopting this approach. However, the leadership also recognized that the transition to aTBC could increase revenue by more than the increased staffing costs. In addition, we expected that capacity, access, continuity, and financial margins would increase.2,3,27,28 We also anticipated a decrease in downstream services, such as unnecessary tests, emergency department visits, and hospitalizations—a benefit of accountable care payment models.
Our efforts have been successful from a financial point of view. We attribute the financial sustainability that we have experienced to 4 factors:
1. Increased productivity. We knew that the increased efficiency of team-based care enables physicians to see 1 to 2 more patients per half day, and sometimes more.3,28,29 An increase of at least 1 patient visit per half-day was expected of our physicians and APCs on aTBC. In addition, they were expected to support the care team RN in achieving at least 4 billable visits per day. Our current level of RN visits is at 3.5 per nurse per day. There is significant variability in the increase of patients seen by a physician per day, ranging from 1 to 4 additional patients. These increased visits have helped us achieve financial viability, even in a predominantly fee-for-service environment.
2. More thorough service. The ability to keep patients in primary care and to focus on the patient’s full range of needs has led to higher levels of service and, consequently, to appropriately higher levels of billing codes. For example, Bellin’s revenue from billing increased by $724 per patient, related (in part) to higher rates of immunizations, cancer screenings with mammography, and colonoscopies.
Continue to: 3. New billable services
3. New billable services. Billing for RN blood pressure checks, AWVs, and extended care team services have helped make aTBC at Bellin financially feasible. Revenue from RN visits, for example, was $630,000 in 2018.
4. Improved access for patients. Of the 130 primary care providers now on aTBC, 15 (11.5%) had closed their practices to new patients before aTBC. Now, all of their practices are open to new patients, which has improved access to care. In a 2018 patient access survey, 96.6% of patients obtained an appointment as soon as they thought it was needed, compared with 70.7% of patients before the transition to aTBC.
Greater opportunity for financial sustainability. The combination of improved quality measures and decreased cost of care in the Bellin aTBC bodes well for future success in a value-based world. We have realized a significant increase in value-based payments for improved quality, and in our Next Gen Accountable Care Organization (ACO) patients, we have seen a decrease of $29 in per-member-per-month costs, likely due to the use of nonphysicians in expanded roles. In addition, hospital admissions have decreased by 5% due to the ability of ambulatory teams to manage more complex patients in the office setting. This model has also allowed physicians and APCs to increase their panel size, another key value-based metric. From 2016 to 2018, panel size for primary care providers increased by an average of 8%.
Enhanced ability to retain and recruit. Several of Bellin’s primary care recruits indicated that they had interviewed only at practices incorporating team-based care. This trend may increase as residencies transition to team-based models of care.
So how did we do?
Metrics of Bellin’s aTBC success
By the end of 2018, all 130 primary care physicians and APCs at Bellin had made the transition to this model, representing family medicine, internal medicine, and pediatrics. We have now begun the transition of our non-primary care specialties to team-based care.
Continue to: In the aTBC model...
In the aTBC model, the percentage of patients receiving age-appropriate screening is higher than before in every domain we measure (FIGURE 1). There has also been improvement in major quality metrics (FIGURE 2).
In a survey done in Spring 2018 by St. Norbert College Strategic Research Center, provider satisfaction increased, with 83% of physicians having made the transition to an aTBC practice moderately or very satisfied with their Bellin Health experience, compared with 70% in the traditional model. More recent 2019 survey data show a satisfaction rate of 90% for team-based care providers. Finally, in our aTBC model—in CMS’s Next-Gen ACO initiative—the cost per patient per month is significantly less than for those in a non-team-based care model ($796 vs $940).
CORRESPONDENCE
James Jerzak, MD, 1630 Commanche Ave, Green Bay, WI 54313; james.jerzak@bellin.org.
ACKNOWLEDGEMENTS
The authors would like to thank Lindsey E. Carlasare, MBA, from the American Medical Association, and Brad Wozney, MD, Kathy Kerscher, and Christopher Elfner from Bellin Health, for their contributions to the content and review of this manuscript.
1. Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.
2. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
3. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-29.
4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760.
5. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91:422-431.
6. Sinsky CA, Dyrbye LN, West CP, et al. Professional satisfaction and the career plans of US physicians. Mayo Clin Proc. 2017;92:1625-1635.
7. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.
8. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
9. Sinsky CA, Sinsky TA, Althaus D, et al. Practice profile. ‘Core teams’: nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood). 2010;29:966-968.
10. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
11. Association for Advancing Physician and Provider Recruitment. Schutte L. What you don’t know can cost you: building a business case for recruitment and retention best practices. 2012. https://member.aappr.org/general/custom.asp?page=696. Accessed June 20, 2019.
12. American Medical Association. AMA STEPS Forward. Expanded rooming and discharge protocols. https://edhub.ama-assn.org/steps-forward/module/2702600. Accessed June 20, 2019.
13. American Medical Association. AMA STEPS Forward. Team documentation. https://edhub.ama-assn.org/steps-forward/module/2702598?resultClick=3&bypassSolrId=J_2702598. Accessed June 20, 2019.
14. American Medical Association. AMA STEPS Forward. EHR in-basket restructuring for improved efficiency. https://edhub.ama-assn.org/steps-forward/module/2702694?resultClick=3&bypassSolrId=J_2702694. Accessed June 20, 2019.
15. California Health Care Foundation. Bodenheimer T, Bauer L, Olayiwola JN. RN role reimagined: how empowering registered nurses can improve primary care. https://www.chcf.org/publication/rn-role-reimagined-how-empowering-registered-nurses-can-improve-primary-care/. Accessed June 20, 2019.
16. Chung S, Lesser LI, Lauderdale DS, et al. Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate. Health Aff (Millwood). 2015;34:11-20.
17. American Medical Association. AMA Policy H-160.912. The structure and function of interprofessional health care teams. https://policysearch.ama-assn.org/policyfinder/detail/The%20Structure%20and%20Function%20of%20Interprofessional%20Health%20Care%20Teams?uri=%2FAMADoc%2FHOD.xml-0-727.xml. Accessed June 20, 2019.
18. Milani RV, Lavie CJ. Health care 2020: reengineering health care delivery to combat chronic disease. Am J Med. 2015;128:337-343.
19. Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31:1591-1594.
20. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21:e100-e106.
21. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848.
22. RAND Corporation. Friedberg MW, Chen PG, Ban Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. https://www.rand.org/pubs/research_reports/RR439.html. Accessed June 20, 2019.
23. Evaluation and Management (E/M) visit frequently asked questions (FAQs): physician fee schedule (PPS). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf. Accessed August 27, 2019.
24. Centers for Medicare & Medicaid Services. Scribe services signature requirements. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals-Items/R713PI.html. Accessed June 20, 2019.
25. American Association of Medical Assistants. State scope of practice laws. http://www.aama-ntl.org/employers/state-scope-of-practice-laws. Accessed June 20, 2019.
26. Misra-Hebert AD, Amah L, Rabovsky A, et al. Medical scribes: how do their notes stack up? J Fam Pract. 2016;65:155-159.
27. Arya R, Salovich DM, Ohman-Strickland P, et al. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17:490-494.
28. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.
29. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15:35-40.
Leaders in health care and practicing physicians recognize the need for changes in how health care is delivered.1-3 Despite this awareness, though, barriers to meaningful change persist and the current practice environment wherein physicians must routinely spend 2 hours on electronic health records (EHRs) and desk work for every hour of direct face time with patients4 is driving trainees away from ambulatory specialties and is contributing to physicians’ decisions to reduce their practices to part-time, retire early, or leave medicine altogether.5,6 Those who persevere in this environment with heavy administrative burdens run the increasing risk of burnout.7
Some physicians and practices are responding by taking creative measures to reform the way patient care is delivered. Bellin Health—a 160-provider, multispecialty health system in northeast Wisconsin where one of the authors (JJ) works—introduced an advanced team-based care (aTBC) model between November 2014 and November 2018, starting with our primary care providers. The development and introduction of this new model arose from an iterative, multidisciplinary process driven by the desire to transform the Triple Aim—enhancing patient experience, improving population health, and reducing costs—into a Quadruple Aim8 by additionally focusing on improving the work life of health care providers, which, in turn, will help achieve the first 3 goals. In introducing an aTBC model, Bellin Health focused on 3 elements: office visit redesign, in-basket management redesign, and the use of extended care team members and system and community resources to assist in the care of complex and high-risk patients.
Herein we describe the 3 components of our aTBC model,1,9 identify the barriers that existed in the minds of multiple stakeholders (from patients to clinicians and Bellin executives), and describe the strategies that enabled us to overcome these barriers.
The impetus behind our move to aTBC
Bellin Health considered a move to an aTBC model to be critical in light of factors in the health care environment, in general, and at Bellin, in particular. The factors included
- an industry-wide shift to value-based payments, which requires new models for long-term financial viability.
- recognition that physician and medical staff burnout leads to lower productivity and, in some cases, workforce losses.5,6 Replacing a physician in a practice can be difficult and expensive, with cost estimates of $500,000 to more than $1 million per physician.10,11
- a belief that aTBC could help the Bellin Health leadership team meet its organizational goals of improved patient satisfaction, achieve gains in quality measures, enhance engagement and loyalty among patients and employees, and lower recruitment costs.
A 3-part aTBC initiative
■ Part 1: Redesign the office visit
We redesigned staffing and workflow for office visits to maximize the core skills of physicians, which required distributing ancillary tasks among support staff. We up-trained certified medical assistants (CMAs) and licensed practical nurses (LPNs) to take on the new role of care team coordinator (CTC) and optimized the direct clinical support ratio for busier physicians. For physicians who were seeing 15 to 19 patients a day, a ratio of 3 CTCs to 2 physicians was implemented; for those seeing 20 or more patients a day, we used a support ratio of 2:1.
The role of CTC was designed so that he or she would accompany a patient throughout the entire appointment. Responsibilities were broken out as follows:
Pre-visit. Before the physician enters the room, the CTC would now perform expanded rooming functions including pending orders, refill management, care gap closure using standing orders, agenda setting, and preliminary documentation.12
Visit. The CTC would now hand off the patient to the physician and stay in the room to document details of the visit and record new orders for consults, x-ray films, referrals, or prescriptions.13 This intensive EHR support was established to ensure that the physician could focus directly on the patient without the distraction of the computer.
Continue to: Post-visit
Post-visit. After a physician leaves a room, the CTC was now charged with finishing the pending orders, setting up the patient’s next appointment and pre-visit labs, reviewing details of the after-visit summary, and doing any basic health coaching with the patient. During this time, the physician would use the co-location space to review and edit the documentation, cosign the orders and prescriptions submitted by the CTC, and close the chart before going into the next room with the second CTC. The need to revisit these details after clinic hours was eliminated.
Another change … The role of our phone triage registered nurses (RN) was expanded. Care team RNs began providing diabetes counseling, blood pressure checks, annual wellness visits (AWV), and follow-up through the Centers for Medicare and Medicaid Services (CMS)'s Chronic Care Management and Transitional Care Management programs.
■ Part 2: Redesign between-visit in-basket management
Responding to an increasing number of inbox messages had become overwhelming for our physicians. Bellin Health’s management was aware that strategic delegation of inbox messages could save an hour or more of a physician’s time each day.14 Bellin implemented a procedure whereby inbox test results would be handled by the same CTC who saw the patient, thereby extending continuity. If the results were normal, the CTC would contact the patient. If the results were abnormal, the physician and the CTC would discuss them and develop a plan. Co-location of the RN, the CTC, and the physician would leverage face-to-face communication and make in-basket management more efficient.
■ Part 3: Redesign population health management
We developed an Extended Care Team (ECT), including social workers, clinical pharmacists, RN care coordinators, and diabetes educators, to assist with the care of patients with high-risk disorders or otherwise complex issues. These team members would work closely with the CTC, care team RN, and physician to review patients, develop plans of care, optimize management, and improve outcomes. Patients would be identified as candidates for potential ECT involvement based on the physician’s judgment in consultation with an EHR-based risk score for hospitalization or emergency department visit.
As we developed new processes, such as screening for determinants of health, we engaged additional system and community resources to help meet the needs of our patients.
Continue to: A look at stakeholder concerns and overcoming the barriers
A look at stakeholder concerns and overcoming the barriers
Critical to our success was being attentive to the concerns of our stakeholders and addressing them. Along the way, we gained valuable implementation insights, which we share here along with some specifics about how, exactly, we did things at Bellin.
Patients
Some patients expressed hesitation at having a person other than their physician in the exam room. They worried that the intimacy and privacy with their physician would be lost. In light of this, we gave patients the option not to have the CTC remain in the room. However, patients quickly saw the value of this team-based care approach and seldom asked to be seen without the CTC.
Throughout the process, we surveyed patients for feedback on their experiences. Comments indicated that the presence of the CTC in our team-based model led to positive patient experiences:
My physician is fully attentive. Patients appreciated that physicians were not distracted by the computer in the exam room. “I feel like I’ve got my doctor back” has been a common refrain.
The office staff is more responsive. The CTC, having been present during the appointment, has a deeper understanding of the care plan and can respond to calls or emails between visits, thereby reducing the time patients must wait for answers. One patient commented that, “I love [the doctor’s] team; his nurses are willing to answer every question I have.”
Continue to: I increasingly feel that I'm understood
I increasingly feel that I’m understood. We have seen patients develop meaningful relationships with other team members, confiding in them in ways that they hadn’t always done with physicians and advanced practice clinicians (APCs). Team members, in turn, have added valuable insights that help optimize patients’ care. In particular, the care of patients with multiple needs has been enhanced with the addition of ECT members who work with the core team and use their expertise to optimize the care of these patients.
Certified medical assistants and licensed practical nurses
Bellin’s leadership knew that team documentation could cause stress for the CMA, who, acting as a CTC, wanted to avoid misrepresenting details of the clinical encounter.13 Adding to the stress were other duties that would need to be learned, including agenda setting, refill management, care gap closure, and health coaching. With thorough training and preparation, many—but not all—of our CMAs and LPNs were able to successfully make the transition and flourish.
Implementation strategies
Provide thorough training. Our training process started 8 weeks before it was time to “go live.” There were weekly hour-long training sessions in population health basics, team culture and change management, documentation basics, and new roles and responsibilities. In the final week, the entire aTBC team sat together for 3 days of EHR training. All new teams shadowed existing teams to get a clear picture of the new processes.
Create a community of support. As our CMAs adapted to their new CTC roles, it was critical that they had support from experienced CTCs. Encouragement and patience from physicians were—and are—essential for CTCs to develop confidence in their new roles.
Enable ongoing feedback. We introduced weekly team meetings to enhance team communication and dynamics. Forums for all roles are held periodically to facilitate discussion, share learning, and enable support between teams.
Continue to: Use EHR tools to facilitate this work
Use EHR tools to facilitate this work. Using standard templates and documentation tools helped CTCs develop the confidence needed to thrive in their new role. Knowing these tools were available helped CTCs become effective in helping the team manage the between-visit work.
Monitor workload. As we developed more workflows and processes, we took care to monitor the amount of additional work for those in this role. We offloaded work whenever possible. For example, coordinated refill management at time of service, coupled with a back-up centralized refill system, can significantly decrease the number of refill requests made to CTCs. We continue to adjust staffing, where appropriate, to provide adequate support for those in this valuable role.
Be prepared for turnover. As CTCs became empowered in their new roles, some decided to advance their training into other roles. We developed a plan for replacing and training new staff. Higher pay can also be used to help attract and retain these staff members. Bellin uses LPNs in this role to ensure adequate staffing. Other health systems have developed a tier system for CMAs to improve retention.
Registered nurses
Before our move to an aTBC model, our office RNs primarily managed phone triage. Now the nurses were enlisted to play a more active role in patient care and team leadership. Although it was a dramatic departure from prior responsibilities, the majority of Bellin’s RNs have found increased satisfaction in taking on direct patient care.
Implementation strategies
Define new roles and provide training. In addition to participating in acute patient visits, consider ways that care team RNs can expand responsibilities as they pertain to disease counseling, population health management, and team leadership.15 At Bellin, the expanded role of the RN is evident in diabetes education and Medicare AWVs. Specifically, RNs now provide diabetes education to appropriate patients following a warm handoff from the physician at the time of the visit. RNs now also complete Medicare AWVs, which frees up physicians for other tasks and helps ensure sustainability for the new RN roles. Rates of completed AWVs at Bellin are now more than 70%, compared with reported national rates of less than 30%.16
Continue to: Maximize co-location
Maximize co-location. It is helpful to have the team members whose work is closely related—such as the CTCs and the RN for the team—to be situated near each other, rather than down a hall or in separate offices. Since the RN is co-located with the core teams at Bellin, there is now greater opportunity for verbal interaction, rather than just electronic communications, for matters such as triage calls and results management. RNs also provide a valuable resource for CMAs and LPNs, as well as help oversee team management of the in-basket.
Evaluate sustainability. Additional roles for the RNs required additional RN staffing. We assessed the new workload duties and balanced that against potential revenue from RN visits. This analysis indicated that an optimal ratio was 1 RN to every 3000 patients. This would allow an adequate number of RNs to fulfill additional roles and was financially sustainable with the goal of 4 billable RN visits per day.
Physicians
Bellin’s leadership recognized that some physicians might perceive team-based care as eroding their primary responsibility for patients’ care. Physicians have historically been trained in a model based on the primacy of the individual physician and that can be a hurdle to embracing team culture as a new paradigm of care. Several strategies helped us and can help others, too.
Implementation strategies
Cultivate trust. Thorough training of CTCs and RNs is critical to helping physicians develop trust and reliance in the team. The physician retains final authority over the team for cosigning orders, editing and finalizing documentation, and overseeing results management. Physicians invested in training and educating their staff will reap the rewards of a highly functioning, more satisfied team.
Encourage leadership. This can be a cultural shift for physicians, yet it is critical that they take a leadership role in this transformation.17 Physicians and their team leaders attended training sessions in team culture and change management. Prior to the go-live date, team leaders also met with the physician individually to explore their concerns and discuss ways to effectively lead and support their teams.
Continue to: Urge acceptance of support
Urge acceptance of support. The complexity of patient care today makes it difficult for a physician to manage all of a patient’s needs single-handedly. Complexity arises from the variety of plan co-pays and deductibles, the number of patients with chronic diseases, and the increased emphasis on improving quality measures.18 Enhanced support during any office visit and the extra support of an ECT for complex patients improves the ability of the physician to more effectively meet the needs of the patient.
Emphasize the benefit of an empowered team. The demands of the EHR on physicians and the resultant frustrations are well chronicled.4,19-22 Strategically delegating much of this work to other team members allows the physician to focus on the patient and perform physician-level work. At Bellin, we observed that our most successful care teams were those in which the physician fully accepted team-based care principles and empowered the staff to work at the top of their skill set.
Advanced practice clinicians
APCs in our system had traditionally practiced in 1 of 3 ways: independently handling defined panels with physician supervision; handling overflow or acute visits; or working collaboratively with a supervising physician to share a larger “team panel.” The third approach has become our preferred model. aTBC provides opportunities for APCs to thrive and collaborate with the physician to provide excellent care for patients.
APCs underwent the same process changes as physicians, including appropriate CTC support. Implementation strategies for APCs were similar to those that were useful for physicians.
Risk management professionals
At Bellin, we found that risk-management professionals had concerns about the scope of practice assigned to various team members, particularly regarding documentation. CMS allows for elements of a patient visit to be documented by CMAs and other members of the care team in real time as authorized by the physician.23,24 CTCs at Bellin also have other clinical duties in patient and EHR management. aTBC practices generally prefer the term team documentation over scribing, since it more accurately reflects the scope of the CTC’s work.
Continue to: Implementation strategies
Implementation strategies
Clarify regulatory issues. Extensive use of standing orders and protocols allowed us to increase involvement of various team members. State laws vary in what functions CMAs and LPNs are allowed to perform, so it is important to check your state guidelines.25 There is a tendency for some risk managers to overinterpret regulations. Challenge them to provide exact documentation from regulatory agencies to support their decisions.
Give assurances of physician oversight and processes. The physician assumes responsibility for standing orders, protocols, and documentation. We made sure that we had clear and consistent processes in place and worked closely with our risk managers as we developed our model. aTBC provides checks and balances to ensure accurate records, since team members are able to contribute and check for accuracy. A recent study suggested that CMAs perform documentation that is of equal or higher quality than that performed by the physician.26
Financial leadership
Like any organization adopting aTBC, Bellin’s leadership was concerned about the expense of adopting this approach. However, the leadership also recognized that the transition to aTBC could increase revenue by more than the increased staffing costs. In addition, we expected that capacity, access, continuity, and financial margins would increase.2,3,27,28 We also anticipated a decrease in downstream services, such as unnecessary tests, emergency department visits, and hospitalizations—a benefit of accountable care payment models.
Our efforts have been successful from a financial point of view. We attribute the financial sustainability that we have experienced to 4 factors:
1. Increased productivity. We knew that the increased efficiency of team-based care enables physicians to see 1 to 2 more patients per half day, and sometimes more.3,28,29 An increase of at least 1 patient visit per half-day was expected of our physicians and APCs on aTBC. In addition, they were expected to support the care team RN in achieving at least 4 billable visits per day. Our current level of RN visits is at 3.5 per nurse per day. There is significant variability in the increase of patients seen by a physician per day, ranging from 1 to 4 additional patients. These increased visits have helped us achieve financial viability, even in a predominantly fee-for-service environment.
2. More thorough service. The ability to keep patients in primary care and to focus on the patient’s full range of needs has led to higher levels of service and, consequently, to appropriately higher levels of billing codes. For example, Bellin’s revenue from billing increased by $724 per patient, related (in part) to higher rates of immunizations, cancer screenings with mammography, and colonoscopies.
Continue to: 3. New billable services
3. New billable services. Billing for RN blood pressure checks, AWVs, and extended care team services have helped make aTBC at Bellin financially feasible. Revenue from RN visits, for example, was $630,000 in 2018.
4. Improved access for patients. Of the 130 primary care providers now on aTBC, 15 (11.5%) had closed their practices to new patients before aTBC. Now, all of their practices are open to new patients, which has improved access to care. In a 2018 patient access survey, 96.6% of patients obtained an appointment as soon as they thought it was needed, compared with 70.7% of patients before the transition to aTBC.
Greater opportunity for financial sustainability. The combination of improved quality measures and decreased cost of care in the Bellin aTBC bodes well for future success in a value-based world. We have realized a significant increase in value-based payments for improved quality, and in our Next Gen Accountable Care Organization (ACO) patients, we have seen a decrease of $29 in per-member-per-month costs, likely due to the use of nonphysicians in expanded roles. In addition, hospital admissions have decreased by 5% due to the ability of ambulatory teams to manage more complex patients in the office setting. This model has also allowed physicians and APCs to increase their panel size, another key value-based metric. From 2016 to 2018, panel size for primary care providers increased by an average of 8%.
Enhanced ability to retain and recruit. Several of Bellin’s primary care recruits indicated that they had interviewed only at practices incorporating team-based care. This trend may increase as residencies transition to team-based models of care.
So how did we do?
Metrics of Bellin’s aTBC success
By the end of 2018, all 130 primary care physicians and APCs at Bellin had made the transition to this model, representing family medicine, internal medicine, and pediatrics. We have now begun the transition of our non-primary care specialties to team-based care.
Continue to: In the aTBC model...
In the aTBC model, the percentage of patients receiving age-appropriate screening is higher than before in every domain we measure (FIGURE 1). There has also been improvement in major quality metrics (FIGURE 2).
In a survey done in Spring 2018 by St. Norbert College Strategic Research Center, provider satisfaction increased, with 83% of physicians having made the transition to an aTBC practice moderately or very satisfied with their Bellin Health experience, compared with 70% in the traditional model. More recent 2019 survey data show a satisfaction rate of 90% for team-based care providers. Finally, in our aTBC model—in CMS’s Next-Gen ACO initiative—the cost per patient per month is significantly less than for those in a non-team-based care model ($796 vs $940).
CORRESPONDENCE
James Jerzak, MD, 1630 Commanche Ave, Green Bay, WI 54313; james.jerzak@bellin.org.
ACKNOWLEDGEMENTS
The authors would like to thank Lindsey E. Carlasare, MBA, from the American Medical Association, and Brad Wozney, MD, Kathy Kerscher, and Christopher Elfner from Bellin Health, for their contributions to the content and review of this manuscript.
Leaders in health care and practicing physicians recognize the need for changes in how health care is delivered.1-3 Despite this awareness, though, barriers to meaningful change persist and the current practice environment wherein physicians must routinely spend 2 hours on electronic health records (EHRs) and desk work for every hour of direct face time with patients4 is driving trainees away from ambulatory specialties and is contributing to physicians’ decisions to reduce their practices to part-time, retire early, or leave medicine altogether.5,6 Those who persevere in this environment with heavy administrative burdens run the increasing risk of burnout.7
Some physicians and practices are responding by taking creative measures to reform the way patient care is delivered. Bellin Health—a 160-provider, multispecialty health system in northeast Wisconsin where one of the authors (JJ) works—introduced an advanced team-based care (aTBC) model between November 2014 and November 2018, starting with our primary care providers. The development and introduction of this new model arose from an iterative, multidisciplinary process driven by the desire to transform the Triple Aim—enhancing patient experience, improving population health, and reducing costs—into a Quadruple Aim8 by additionally focusing on improving the work life of health care providers, which, in turn, will help achieve the first 3 goals. In introducing an aTBC model, Bellin Health focused on 3 elements: office visit redesign, in-basket management redesign, and the use of extended care team members and system and community resources to assist in the care of complex and high-risk patients.
Herein we describe the 3 components of our aTBC model,1,9 identify the barriers that existed in the minds of multiple stakeholders (from patients to clinicians and Bellin executives), and describe the strategies that enabled us to overcome these barriers.
The impetus behind our move to aTBC
Bellin Health considered a move to an aTBC model to be critical in light of factors in the health care environment, in general, and at Bellin, in particular. The factors included
- an industry-wide shift to value-based payments, which requires new models for long-term financial viability.
- recognition that physician and medical staff burnout leads to lower productivity and, in some cases, workforce losses.5,6 Replacing a physician in a practice can be difficult and expensive, with cost estimates of $500,000 to more than $1 million per physician.10,11
- a belief that aTBC could help the Bellin Health leadership team meet its organizational goals of improved patient satisfaction, achieve gains in quality measures, enhance engagement and loyalty among patients and employees, and lower recruitment costs.
A 3-part aTBC initiative
■ Part 1: Redesign the office visit
We redesigned staffing and workflow for office visits to maximize the core skills of physicians, which required distributing ancillary tasks among support staff. We up-trained certified medical assistants (CMAs) and licensed practical nurses (LPNs) to take on the new role of care team coordinator (CTC) and optimized the direct clinical support ratio for busier physicians. For physicians who were seeing 15 to 19 patients a day, a ratio of 3 CTCs to 2 physicians was implemented; for those seeing 20 or more patients a day, we used a support ratio of 2:1.
The role of CTC was designed so that he or she would accompany a patient throughout the entire appointment. Responsibilities were broken out as follows:
Pre-visit. Before the physician enters the room, the CTC would now perform expanded rooming functions including pending orders, refill management, care gap closure using standing orders, agenda setting, and preliminary documentation.12
Visit. The CTC would now hand off the patient to the physician and stay in the room to document details of the visit and record new orders for consults, x-ray films, referrals, or prescriptions.13 This intensive EHR support was established to ensure that the physician could focus directly on the patient without the distraction of the computer.
Continue to: Post-visit
Post-visit. After a physician leaves a room, the CTC was now charged with finishing the pending orders, setting up the patient’s next appointment and pre-visit labs, reviewing details of the after-visit summary, and doing any basic health coaching with the patient. During this time, the physician would use the co-location space to review and edit the documentation, cosign the orders and prescriptions submitted by the CTC, and close the chart before going into the next room with the second CTC. The need to revisit these details after clinic hours was eliminated.
Another change … The role of our phone triage registered nurses (RN) was expanded. Care team RNs began providing diabetes counseling, blood pressure checks, annual wellness visits (AWV), and follow-up through the Centers for Medicare and Medicaid Services (CMS)'s Chronic Care Management and Transitional Care Management programs.
■ Part 2: Redesign between-visit in-basket management
Responding to an increasing number of inbox messages had become overwhelming for our physicians. Bellin Health’s management was aware that strategic delegation of inbox messages could save an hour or more of a physician’s time each day.14 Bellin implemented a procedure whereby inbox test results would be handled by the same CTC who saw the patient, thereby extending continuity. If the results were normal, the CTC would contact the patient. If the results were abnormal, the physician and the CTC would discuss them and develop a plan. Co-location of the RN, the CTC, and the physician would leverage face-to-face communication and make in-basket management more efficient.
■ Part 3: Redesign population health management
We developed an Extended Care Team (ECT), including social workers, clinical pharmacists, RN care coordinators, and diabetes educators, to assist with the care of patients with high-risk disorders or otherwise complex issues. These team members would work closely with the CTC, care team RN, and physician to review patients, develop plans of care, optimize management, and improve outcomes. Patients would be identified as candidates for potential ECT involvement based on the physician’s judgment in consultation with an EHR-based risk score for hospitalization or emergency department visit.
As we developed new processes, such as screening for determinants of health, we engaged additional system and community resources to help meet the needs of our patients.
Continue to: A look at stakeholder concerns and overcoming the barriers
A look at stakeholder concerns and overcoming the barriers
Critical to our success was being attentive to the concerns of our stakeholders and addressing them. Along the way, we gained valuable implementation insights, which we share here along with some specifics about how, exactly, we did things at Bellin.
Patients
Some patients expressed hesitation at having a person other than their physician in the exam room. They worried that the intimacy and privacy with their physician would be lost. In light of this, we gave patients the option not to have the CTC remain in the room. However, patients quickly saw the value of this team-based care approach and seldom asked to be seen without the CTC.
Throughout the process, we surveyed patients for feedback on their experiences. Comments indicated that the presence of the CTC in our team-based model led to positive patient experiences:
My physician is fully attentive. Patients appreciated that physicians were not distracted by the computer in the exam room. “I feel like I’ve got my doctor back” has been a common refrain.
The office staff is more responsive. The CTC, having been present during the appointment, has a deeper understanding of the care plan and can respond to calls or emails between visits, thereby reducing the time patients must wait for answers. One patient commented that, “I love [the doctor’s] team; his nurses are willing to answer every question I have.”
Continue to: I increasingly feel that I'm understood
I increasingly feel that I’m understood. We have seen patients develop meaningful relationships with other team members, confiding in them in ways that they hadn’t always done with physicians and advanced practice clinicians (APCs). Team members, in turn, have added valuable insights that help optimize patients’ care. In particular, the care of patients with multiple needs has been enhanced with the addition of ECT members who work with the core team and use their expertise to optimize the care of these patients.
Certified medical assistants and licensed practical nurses
Bellin’s leadership knew that team documentation could cause stress for the CMA, who, acting as a CTC, wanted to avoid misrepresenting details of the clinical encounter.13 Adding to the stress were other duties that would need to be learned, including agenda setting, refill management, care gap closure, and health coaching. With thorough training and preparation, many—but not all—of our CMAs and LPNs were able to successfully make the transition and flourish.
Implementation strategies
Provide thorough training. Our training process started 8 weeks before it was time to “go live.” There were weekly hour-long training sessions in population health basics, team culture and change management, documentation basics, and new roles and responsibilities. In the final week, the entire aTBC team sat together for 3 days of EHR training. All new teams shadowed existing teams to get a clear picture of the new processes.
Create a community of support. As our CMAs adapted to their new CTC roles, it was critical that they had support from experienced CTCs. Encouragement and patience from physicians were—and are—essential for CTCs to develop confidence in their new roles.
Enable ongoing feedback. We introduced weekly team meetings to enhance team communication and dynamics. Forums for all roles are held periodically to facilitate discussion, share learning, and enable support between teams.
Continue to: Use EHR tools to facilitate this work
Use EHR tools to facilitate this work. Using standard templates and documentation tools helped CTCs develop the confidence needed to thrive in their new role. Knowing these tools were available helped CTCs become effective in helping the team manage the between-visit work.
Monitor workload. As we developed more workflows and processes, we took care to monitor the amount of additional work for those in this role. We offloaded work whenever possible. For example, coordinated refill management at time of service, coupled with a back-up centralized refill system, can significantly decrease the number of refill requests made to CTCs. We continue to adjust staffing, where appropriate, to provide adequate support for those in this valuable role.
Be prepared for turnover. As CTCs became empowered in their new roles, some decided to advance their training into other roles. We developed a plan for replacing and training new staff. Higher pay can also be used to help attract and retain these staff members. Bellin uses LPNs in this role to ensure adequate staffing. Other health systems have developed a tier system for CMAs to improve retention.
Registered nurses
Before our move to an aTBC model, our office RNs primarily managed phone triage. Now the nurses were enlisted to play a more active role in patient care and team leadership. Although it was a dramatic departure from prior responsibilities, the majority of Bellin’s RNs have found increased satisfaction in taking on direct patient care.
Implementation strategies
Define new roles and provide training. In addition to participating in acute patient visits, consider ways that care team RNs can expand responsibilities as they pertain to disease counseling, population health management, and team leadership.15 At Bellin, the expanded role of the RN is evident in diabetes education and Medicare AWVs. Specifically, RNs now provide diabetes education to appropriate patients following a warm handoff from the physician at the time of the visit. RNs now also complete Medicare AWVs, which frees up physicians for other tasks and helps ensure sustainability for the new RN roles. Rates of completed AWVs at Bellin are now more than 70%, compared with reported national rates of less than 30%.16
Continue to: Maximize co-location
Maximize co-location. It is helpful to have the team members whose work is closely related—such as the CTCs and the RN for the team—to be situated near each other, rather than down a hall or in separate offices. Since the RN is co-located with the core teams at Bellin, there is now greater opportunity for verbal interaction, rather than just electronic communications, for matters such as triage calls and results management. RNs also provide a valuable resource for CMAs and LPNs, as well as help oversee team management of the in-basket.
Evaluate sustainability. Additional roles for the RNs required additional RN staffing. We assessed the new workload duties and balanced that against potential revenue from RN visits. This analysis indicated that an optimal ratio was 1 RN to every 3000 patients. This would allow an adequate number of RNs to fulfill additional roles and was financially sustainable with the goal of 4 billable RN visits per day.
Physicians
Bellin’s leadership recognized that some physicians might perceive team-based care as eroding their primary responsibility for patients’ care. Physicians have historically been trained in a model based on the primacy of the individual physician and that can be a hurdle to embracing team culture as a new paradigm of care. Several strategies helped us and can help others, too.
Implementation strategies
Cultivate trust. Thorough training of CTCs and RNs is critical to helping physicians develop trust and reliance in the team. The physician retains final authority over the team for cosigning orders, editing and finalizing documentation, and overseeing results management. Physicians invested in training and educating their staff will reap the rewards of a highly functioning, more satisfied team.
Encourage leadership. This can be a cultural shift for physicians, yet it is critical that they take a leadership role in this transformation.17 Physicians and their team leaders attended training sessions in team culture and change management. Prior to the go-live date, team leaders also met with the physician individually to explore their concerns and discuss ways to effectively lead and support their teams.
Continue to: Urge acceptance of support
Urge acceptance of support. The complexity of patient care today makes it difficult for a physician to manage all of a patient’s needs single-handedly. Complexity arises from the variety of plan co-pays and deductibles, the number of patients with chronic diseases, and the increased emphasis on improving quality measures.18 Enhanced support during any office visit and the extra support of an ECT for complex patients improves the ability of the physician to more effectively meet the needs of the patient.
Emphasize the benefit of an empowered team. The demands of the EHR on physicians and the resultant frustrations are well chronicled.4,19-22 Strategically delegating much of this work to other team members allows the physician to focus on the patient and perform physician-level work. At Bellin, we observed that our most successful care teams were those in which the physician fully accepted team-based care principles and empowered the staff to work at the top of their skill set.
Advanced practice clinicians
APCs in our system had traditionally practiced in 1 of 3 ways: independently handling defined panels with physician supervision; handling overflow or acute visits; or working collaboratively with a supervising physician to share a larger “team panel.” The third approach has become our preferred model. aTBC provides opportunities for APCs to thrive and collaborate with the physician to provide excellent care for patients.
APCs underwent the same process changes as physicians, including appropriate CTC support. Implementation strategies for APCs were similar to those that were useful for physicians.
Risk management professionals
At Bellin, we found that risk-management professionals had concerns about the scope of practice assigned to various team members, particularly regarding documentation. CMS allows for elements of a patient visit to be documented by CMAs and other members of the care team in real time as authorized by the physician.23,24 CTCs at Bellin also have other clinical duties in patient and EHR management. aTBC practices generally prefer the term team documentation over scribing, since it more accurately reflects the scope of the CTC’s work.
Continue to: Implementation strategies
Implementation strategies
Clarify regulatory issues. Extensive use of standing orders and protocols allowed us to increase involvement of various team members. State laws vary in what functions CMAs and LPNs are allowed to perform, so it is important to check your state guidelines.25 There is a tendency for some risk managers to overinterpret regulations. Challenge them to provide exact documentation from regulatory agencies to support their decisions.
Give assurances of physician oversight and processes. The physician assumes responsibility for standing orders, protocols, and documentation. We made sure that we had clear and consistent processes in place and worked closely with our risk managers as we developed our model. aTBC provides checks and balances to ensure accurate records, since team members are able to contribute and check for accuracy. A recent study suggested that CMAs perform documentation that is of equal or higher quality than that performed by the physician.26
Financial leadership
Like any organization adopting aTBC, Bellin’s leadership was concerned about the expense of adopting this approach. However, the leadership also recognized that the transition to aTBC could increase revenue by more than the increased staffing costs. In addition, we expected that capacity, access, continuity, and financial margins would increase.2,3,27,28 We also anticipated a decrease in downstream services, such as unnecessary tests, emergency department visits, and hospitalizations—a benefit of accountable care payment models.
Our efforts have been successful from a financial point of view. We attribute the financial sustainability that we have experienced to 4 factors:
1. Increased productivity. We knew that the increased efficiency of team-based care enables physicians to see 1 to 2 more patients per half day, and sometimes more.3,28,29 An increase of at least 1 patient visit per half-day was expected of our physicians and APCs on aTBC. In addition, they were expected to support the care team RN in achieving at least 4 billable visits per day. Our current level of RN visits is at 3.5 per nurse per day. There is significant variability in the increase of patients seen by a physician per day, ranging from 1 to 4 additional patients. These increased visits have helped us achieve financial viability, even in a predominantly fee-for-service environment.
2. More thorough service. The ability to keep patients in primary care and to focus on the patient’s full range of needs has led to higher levels of service and, consequently, to appropriately higher levels of billing codes. For example, Bellin’s revenue from billing increased by $724 per patient, related (in part) to higher rates of immunizations, cancer screenings with mammography, and colonoscopies.
Continue to: 3. New billable services
3. New billable services. Billing for RN blood pressure checks, AWVs, and extended care team services have helped make aTBC at Bellin financially feasible. Revenue from RN visits, for example, was $630,000 in 2018.
4. Improved access for patients. Of the 130 primary care providers now on aTBC, 15 (11.5%) had closed their practices to new patients before aTBC. Now, all of their practices are open to new patients, which has improved access to care. In a 2018 patient access survey, 96.6% of patients obtained an appointment as soon as they thought it was needed, compared with 70.7% of patients before the transition to aTBC.
Greater opportunity for financial sustainability. The combination of improved quality measures and decreased cost of care in the Bellin aTBC bodes well for future success in a value-based world. We have realized a significant increase in value-based payments for improved quality, and in our Next Gen Accountable Care Organization (ACO) patients, we have seen a decrease of $29 in per-member-per-month costs, likely due to the use of nonphysicians in expanded roles. In addition, hospital admissions have decreased by 5% due to the ability of ambulatory teams to manage more complex patients in the office setting. This model has also allowed physicians and APCs to increase their panel size, another key value-based metric. From 2016 to 2018, panel size for primary care providers increased by an average of 8%.
Enhanced ability to retain and recruit. Several of Bellin’s primary care recruits indicated that they had interviewed only at practices incorporating team-based care. This trend may increase as residencies transition to team-based models of care.
So how did we do?
Metrics of Bellin’s aTBC success
By the end of 2018, all 130 primary care physicians and APCs at Bellin had made the transition to this model, representing family medicine, internal medicine, and pediatrics. We have now begun the transition of our non-primary care specialties to team-based care.
Continue to: In the aTBC model...
In the aTBC model, the percentage of patients receiving age-appropriate screening is higher than before in every domain we measure (FIGURE 1). There has also been improvement in major quality metrics (FIGURE 2).
In a survey done in Spring 2018 by St. Norbert College Strategic Research Center, provider satisfaction increased, with 83% of physicians having made the transition to an aTBC practice moderately or very satisfied with their Bellin Health experience, compared with 70% in the traditional model. More recent 2019 survey data show a satisfaction rate of 90% for team-based care providers. Finally, in our aTBC model—in CMS’s Next-Gen ACO initiative—the cost per patient per month is significantly less than for those in a non-team-based care model ($796 vs $940).
CORRESPONDENCE
James Jerzak, MD, 1630 Commanche Ave, Green Bay, WI 54313; james.jerzak@bellin.org.
ACKNOWLEDGEMENTS
The authors would like to thank Lindsey E. Carlasare, MBA, from the American Medical Association, and Brad Wozney, MD, Kathy Kerscher, and Christopher Elfner from Bellin Health, for their contributions to the content and review of this manuscript.
1. Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.
2. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
3. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-29.
4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760.
5. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91:422-431.
6. Sinsky CA, Dyrbye LN, West CP, et al. Professional satisfaction and the career plans of US physicians. Mayo Clin Proc. 2017;92:1625-1635.
7. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.
8. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
9. Sinsky CA, Sinsky TA, Althaus D, et al. Practice profile. ‘Core teams’: nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood). 2010;29:966-968.
10. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
11. Association for Advancing Physician and Provider Recruitment. Schutte L. What you don’t know can cost you: building a business case for recruitment and retention best practices. 2012. https://member.aappr.org/general/custom.asp?page=696. Accessed June 20, 2019.
12. American Medical Association. AMA STEPS Forward. Expanded rooming and discharge protocols. https://edhub.ama-assn.org/steps-forward/module/2702600. Accessed June 20, 2019.
13. American Medical Association. AMA STEPS Forward. Team documentation. https://edhub.ama-assn.org/steps-forward/module/2702598?resultClick=3&bypassSolrId=J_2702598. Accessed June 20, 2019.
14. American Medical Association. AMA STEPS Forward. EHR in-basket restructuring for improved efficiency. https://edhub.ama-assn.org/steps-forward/module/2702694?resultClick=3&bypassSolrId=J_2702694. Accessed June 20, 2019.
15. California Health Care Foundation. Bodenheimer T, Bauer L, Olayiwola JN. RN role reimagined: how empowering registered nurses can improve primary care. https://www.chcf.org/publication/rn-role-reimagined-how-empowering-registered-nurses-can-improve-primary-care/. Accessed June 20, 2019.
16. Chung S, Lesser LI, Lauderdale DS, et al. Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate. Health Aff (Millwood). 2015;34:11-20.
17. American Medical Association. AMA Policy H-160.912. The structure and function of interprofessional health care teams. https://policysearch.ama-assn.org/policyfinder/detail/The%20Structure%20and%20Function%20of%20Interprofessional%20Health%20Care%20Teams?uri=%2FAMADoc%2FHOD.xml-0-727.xml. Accessed June 20, 2019.
18. Milani RV, Lavie CJ. Health care 2020: reengineering health care delivery to combat chronic disease. Am J Med. 2015;128:337-343.
19. Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31:1591-1594.
20. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21:e100-e106.
21. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848.
22. RAND Corporation. Friedberg MW, Chen PG, Ban Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. https://www.rand.org/pubs/research_reports/RR439.html. Accessed June 20, 2019.
23. Evaluation and Management (E/M) visit frequently asked questions (FAQs): physician fee schedule (PPS). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf. Accessed August 27, 2019.
24. Centers for Medicare & Medicaid Services. Scribe services signature requirements. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals-Items/R713PI.html. Accessed June 20, 2019.
25. American Association of Medical Assistants. State scope of practice laws. http://www.aama-ntl.org/employers/state-scope-of-practice-laws. Accessed June 20, 2019.
26. Misra-Hebert AD, Amah L, Rabovsky A, et al. Medical scribes: how do their notes stack up? J Fam Pract. 2016;65:155-159.
27. Arya R, Salovich DM, Ohman-Strickland P, et al. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17:490-494.
28. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.
29. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15:35-40.
1. Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.
2. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
3. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-29.
4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760.
5. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91:422-431.
6. Sinsky CA, Dyrbye LN, West CP, et al. Professional satisfaction and the career plans of US physicians. Mayo Clin Proc. 2017;92:1625-1635.
7. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.
8. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
9. Sinsky CA, Sinsky TA, Althaus D, et al. Practice profile. ‘Core teams’: nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood). 2010;29:966-968.
10. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.
11. Association for Advancing Physician and Provider Recruitment. Schutte L. What you don’t know can cost you: building a business case for recruitment and retention best practices. 2012. https://member.aappr.org/general/custom.asp?page=696. Accessed June 20, 2019.
12. American Medical Association. AMA STEPS Forward. Expanded rooming and discharge protocols. https://edhub.ama-assn.org/steps-forward/module/2702600. Accessed June 20, 2019.
13. American Medical Association. AMA STEPS Forward. Team documentation. https://edhub.ama-assn.org/steps-forward/module/2702598?resultClick=3&bypassSolrId=J_2702598. Accessed June 20, 2019.
14. American Medical Association. AMA STEPS Forward. EHR in-basket restructuring for improved efficiency. https://edhub.ama-assn.org/steps-forward/module/2702694?resultClick=3&bypassSolrId=J_2702694. Accessed June 20, 2019.
15. California Health Care Foundation. Bodenheimer T, Bauer L, Olayiwola JN. RN role reimagined: how empowering registered nurses can improve primary care. https://www.chcf.org/publication/rn-role-reimagined-how-empowering-registered-nurses-can-improve-primary-care/. Accessed June 20, 2019.
16. Chung S, Lesser LI, Lauderdale DS, et al. Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate. Health Aff (Millwood). 2015;34:11-20.
17. American Medical Association. AMA Policy H-160.912. The structure and function of interprofessional health care teams. https://policysearch.ama-assn.org/policyfinder/detail/The%20Structure%20and%20Function%20of%20Interprofessional%20Health%20Care%20Teams?uri=%2FAMADoc%2FHOD.xml-0-727.xml. Accessed June 20, 2019.
18. Milani RV, Lavie CJ. Health care 2020: reengineering health care delivery to combat chronic disease. Am J Med. 2015;128:337-343.
19. Hill RG Jr, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31:1591-1594.
20. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21:e100-e106.
21. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848.
22. RAND Corporation. Friedberg MW, Chen PG, Ban Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. https://www.rand.org/pubs/research_reports/RR439.html. Accessed June 20, 2019.
23. Evaluation and Management (E/M) visit frequently asked questions (FAQs): physician fee schedule (PPS). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf. Accessed August 27, 2019.
24. Centers for Medicare & Medicaid Services. Scribe services signature requirements. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals-Items/R713PI.html. Accessed June 20, 2019.
25. American Association of Medical Assistants. State scope of practice laws. http://www.aama-ntl.org/employers/state-scope-of-practice-laws. Accessed June 20, 2019.
26. Misra-Hebert AD, Amah L, Rabovsky A, et al. Medical scribes: how do their notes stack up? J Fam Pract. 2016;65:155-159.
27. Arya R, Salovich DM, Ohman-Strickland P, et al. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17:490-494.
28. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.
29. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15:35-40.
PRACTICE RECOMMENDATIONS
› Up-train staff to provide enhanced support for physicians during the office visit, such as handling most electronic health record work, including documentation. C
› Take a team approach to between-visit work, leveraging principles of team-based care (such as co-location) to optimize efficiency. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
It’s board recertification time!
Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
Yes, I’m studying for my 10-year boards.
It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.
Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.
But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.
A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.
Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.
Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
Yes, I’m studying for my 10-year boards.
It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.
Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.
But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.
A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.
Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.
Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
Yes, I’m studying for my 10-year boards.
It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.
Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.
But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.
A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.
Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.
Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Michigan becomes first state to ban flavored e-cigarettes
The state health agency is expected to issue rules outlining the ban within the next 30 days. The emergency ban will be in effect for 6 months, with the possibility of a 6-month extension while state health regulators craft rules to set in place a permanent ban.
The ban will also prohibit “misleading marketing of vaping products, including the use of terms like ‘clean,’ ‘safe,’ and ‘healthy,’ that perpetuate beliefs that these products are harmless,” according to a statement issued by Gov. Whitmer.
Companies selling vaping products “are using candy flavors to hook children on nicotine and misleading claims to promote the belief that these products are safe,” she said in a statement. “That ends today. Our kids deserve leaders who are going to fight to protect them. These bold steps will finally put an end to these irresponsible and deceptive practices and protect Michiganders’ public health.”
The ban also will cover mint- and menthol-flavors in addition to sweet flavors but will not ban tobacco-flavored e-cigarette products.
The American Academy of Pediatrics, American Heart Association, American Lung Association, American Cancer Society Cancer Action Network and other organizations praised the action taken by the state, calling the steps “necessary and appropriate.”
“The need for action is even more urgent in light of the recent outbreak of severe lung illness associated with e-cigarette use and the failure of the U.S. Food and Drug Administration to take strong regulatory action such as prohibiting the sale of the flavored products nationwide that have attracted shocking numbers of our nation’s youth,” the organizations said in a statement.
The groups noted that “health authorities are investigating reports of severe respiratory illness associated with e-cigarette use in at least 215 people ... in 25 states,” adding that many are youth and young adults.
The U.S. Department of Health & Human Services Secretary Alex Azar said in an Aug. 30 statement that the federal government is “using every tool we have to get to the bottom of this deeply concerning outbreak of illness in Americans who use e-cigarettes. More broadly, we will continue using every regulatory and enforcement power we have to stop the epidemic of youth e-cigarette use.”
HHS noted that no single substance or e-cigarette product has been consistently associated with the reports of illness. The agency called upon clinicians to report any new cases as appropriate to their state and local health departments.
Gov. Whitmer earlier this year signed bills that clarify that it is illegal to sell nontraditional nicotine products to minors, but the governor’s statement notes her criticism that the bills did not go far enough to protect the state’s youth, necessitating this further action.
The state health agency is expected to issue rules outlining the ban within the next 30 days. The emergency ban will be in effect for 6 months, with the possibility of a 6-month extension while state health regulators craft rules to set in place a permanent ban.
The ban will also prohibit “misleading marketing of vaping products, including the use of terms like ‘clean,’ ‘safe,’ and ‘healthy,’ that perpetuate beliefs that these products are harmless,” according to a statement issued by Gov. Whitmer.
Companies selling vaping products “are using candy flavors to hook children on nicotine and misleading claims to promote the belief that these products are safe,” she said in a statement. “That ends today. Our kids deserve leaders who are going to fight to protect them. These bold steps will finally put an end to these irresponsible and deceptive practices and protect Michiganders’ public health.”
The ban also will cover mint- and menthol-flavors in addition to sweet flavors but will not ban tobacco-flavored e-cigarette products.
The American Academy of Pediatrics, American Heart Association, American Lung Association, American Cancer Society Cancer Action Network and other organizations praised the action taken by the state, calling the steps “necessary and appropriate.”
“The need for action is even more urgent in light of the recent outbreak of severe lung illness associated with e-cigarette use and the failure of the U.S. Food and Drug Administration to take strong regulatory action such as prohibiting the sale of the flavored products nationwide that have attracted shocking numbers of our nation’s youth,” the organizations said in a statement.
The groups noted that “health authorities are investigating reports of severe respiratory illness associated with e-cigarette use in at least 215 people ... in 25 states,” adding that many are youth and young adults.
The U.S. Department of Health & Human Services Secretary Alex Azar said in an Aug. 30 statement that the federal government is “using every tool we have to get to the bottom of this deeply concerning outbreak of illness in Americans who use e-cigarettes. More broadly, we will continue using every regulatory and enforcement power we have to stop the epidemic of youth e-cigarette use.”
HHS noted that no single substance or e-cigarette product has been consistently associated with the reports of illness. The agency called upon clinicians to report any new cases as appropriate to their state and local health departments.
Gov. Whitmer earlier this year signed bills that clarify that it is illegal to sell nontraditional nicotine products to minors, but the governor’s statement notes her criticism that the bills did not go far enough to protect the state’s youth, necessitating this further action.
The state health agency is expected to issue rules outlining the ban within the next 30 days. The emergency ban will be in effect for 6 months, with the possibility of a 6-month extension while state health regulators craft rules to set in place a permanent ban.
The ban will also prohibit “misleading marketing of vaping products, including the use of terms like ‘clean,’ ‘safe,’ and ‘healthy,’ that perpetuate beliefs that these products are harmless,” according to a statement issued by Gov. Whitmer.
Companies selling vaping products “are using candy flavors to hook children on nicotine and misleading claims to promote the belief that these products are safe,” she said in a statement. “That ends today. Our kids deserve leaders who are going to fight to protect them. These bold steps will finally put an end to these irresponsible and deceptive practices and protect Michiganders’ public health.”
The ban also will cover mint- and menthol-flavors in addition to sweet flavors but will not ban tobacco-flavored e-cigarette products.
The American Academy of Pediatrics, American Heart Association, American Lung Association, American Cancer Society Cancer Action Network and other organizations praised the action taken by the state, calling the steps “necessary and appropriate.”
“The need for action is even more urgent in light of the recent outbreak of severe lung illness associated with e-cigarette use and the failure of the U.S. Food and Drug Administration to take strong regulatory action such as prohibiting the sale of the flavored products nationwide that have attracted shocking numbers of our nation’s youth,” the organizations said in a statement.
The groups noted that “health authorities are investigating reports of severe respiratory illness associated with e-cigarette use in at least 215 people ... in 25 states,” adding that many are youth and young adults.
The U.S. Department of Health & Human Services Secretary Alex Azar said in an Aug. 30 statement that the federal government is “using every tool we have to get to the bottom of this deeply concerning outbreak of illness in Americans who use e-cigarettes. More broadly, we will continue using every regulatory and enforcement power we have to stop the epidemic of youth e-cigarette use.”
HHS noted that no single substance or e-cigarette product has been consistently associated with the reports of illness. The agency called upon clinicians to report any new cases as appropriate to their state and local health departments.
Gov. Whitmer earlier this year signed bills that clarify that it is illegal to sell nontraditional nicotine products to minors, but the governor’s statement notes her criticism that the bills did not go far enough to protect the state’s youth, necessitating this further action.
Addressing the Shortage of Physician Assistants in Medicine Clerkship Sites
The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.1 This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.2 Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.3
This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.4
Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.5 The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.9 As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.
The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.
Clinical Clerkship Program
VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.
The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.
The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.
Program Description
The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.
In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.
The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.
Program Evaluation
At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.
Results
The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).
Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).
There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.
Discussion
Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.12 The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.5 Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.
The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”
Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.
The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.
Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.
Limitations
The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.
Conclusion
PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.
Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.
1. US Department of Labor, Bureau of Labor Statistics. Occupational outlook handbook: physician assistants. https://www.bls.gov/ooh/healthcare/physician-assistants.htm. Updated June 18, 2019. Accessed August 13, 2019.
2. Association of American Medical Colleges. 2019 update: the complexities of physician supply and demand: projections from 2017 to 2032. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. Published April 2019. Accessed August 15, 2019.
3. Glicken AD, Miller AA. Physician assistants: from pipeline to practice. Acad Med. 2013;88(12):1883-1889.
4. Erikson C, Hamann R, Levitan T, Pankow S, Stanley J, Whatley M. Recruiting and maintaining US clinical training sites: joint report of the 2013 multi-discipline clerkship/clinical training site survey. https://paeaonline.org/wp-content/uploads/2015/10/Recruiting-and-Maintaining-U.S.-Clinical-Training-Sites.pdf. Accessed August 13, 2019.
5. Physician Assistant Education Association. By the numbers: 30th annual report on physician assistant educational programs. 2015. http://paeaonline.org/wp-content/uploads/2016/12/2015-by-the-numbers-program-report-30.pdf. Published 2015. Accessed August 15, 2019.
6. Morgan P, Himmerick KA, Leach B, Dieter P, Everett C. Scarcity of primary care positions may divert physician assistants into specialty practice. Med Care Res Rev. 2017;74(1):109-122.
7. Coplan B, Cawley J, Stoehr J. Physician assistants in primary care: trends and characteristics. Ann Fam Med. 2013;11(1):75-79.
8. Morgan P, Leach B, Himmerick K, Everett C. Job openings for PAs by specialty. JAAPA. 2018;31(1):45-47.
9. American Academy of Physician Assistants. 2017 AAPA Salary Report. Alexandria, VA; 2017.
10. Barnett ML, Grabowski DC, Mehrotra A. Home-to-home time—measuring what matters to patients and payers. N Engl J Med. 2017;377(1):4-6.
11. Werner RM, Konetzka RT. Trends in post-acute care use among Medicare beneficiaries: 2000 to 2015. JAMA. 2018;319(15):1616-1617.
12. Accreditation Review Commission on Education for the Physician Assistant. http://www.arc-pa.org/accreditation/accredited-programs. Accessed May 10, 2019.
The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.1 This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.2 Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.3
This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.4
Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.5 The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.9 As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.
The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.
Clinical Clerkship Program
VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.
The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.
The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.
Program Description
The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.
In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.
The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.
Program Evaluation
At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.
Results
The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).
Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).
There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.
Discussion
Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.12 The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.5 Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.
The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”
Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.
The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.
Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.
Limitations
The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.
Conclusion
PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.
Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.
The Federal Bureau of Labor Statistics projects 37% job growth for physician assistants (PAs) from 2016 to 2026, much greater than the average for all other occupations as well as for other medical professions.1 This growth has been accompanied by increased enrollment in medical (doctor of medicine [MD], doctor of osteopathic medicine) and nurse practitioner (NP) schools.2 Clinical teaching sites serve a crucial function in the training of all clinical disciplines. These sites provide hands-on and experiential learning in medical settings, necessary components for learners practicing to become clinicians. Significant PA program expansion has led to increased demand for clinical training, creating competition for sites and a shortage of willing and well-trained preceptors.3
This challenge has been recognized by PA program directors. In the Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, PA program directors expressed concern about the adequacy of clinical opportunities for students, increased difficulty developing new core sites, and preserving existing core sites. In addition, they noted that a shortage of clinical sites was one of the greatest barriers to the PA programs’ sustained growth and success.4
Program directors also indicated difficulty securing clinical training sites in internal medicine (IM) and high rates of attrition of medicine clinical preceptors for their students.5 The reasons are multifold: increasing clinical demands, time, teaching competence, lack of experience, academic affiliation, lack of reimbursement, or compensation. Moreover, there is a declining number of PAs who work in primary care compared with specialty and subspecialty care, limiting the availability of clinical training preceptors in medicine and primary care.6-8 According to the American Academy of PAs (AAPA) census and salary survey data, the percentage of PAs working in the primary care specialties (ie, family medicine, IM, and general pediatrics) has decreased from > 47% in 1995 to 24% in 2017.9 As such, there is a need to broaden the educational landscape to provide more high-quality training sites in IM.
The postacute health care setting may address this training need. It offers a unique clinical opportunity to expose learners to a broad range of disease complexity and clinical acuity, as the percentage of patients discharged from hospitals to postacute care (PAC) has increased and care shifts from the hospital to the PAC setting.10,11 The longer PAC length of stay also enables learners to follow patients longitudinally over several weeks and experience interprofessional team-based care. In addition, the PAC setting offers learners the ability to acquire the necessary skills for smooth and effective transitions of care. This setting has been extensively used for trainees of nursing, pharmacy, physical therapy (PT) and occupational therapy (OT), speech-language pathology, psychology, and social work (SW), but few programs have used the PAC setting as clerkship sites for IM rotations for PA students. To address this need for IM sites, the VA Boston Healthcare System (VABHS), in conjunction with the Boston University School of Medicine Physician Assistant Program, developed a novel medicine clinical clerkship site for physician assistants in the PAC unit of the community living center (CLC) at VABHS. This report describes the program structure, curriculum, and participant evaluation results.
Clinical Clerkship Program
VABHS CLC is a 110-bed facility comprising 3 units: a 65-bed PAC unit, a 15-bed closed hospice/palliative care unit, and a 30-bed long-term care unit. The service is staffed continuously with physicians, PAs, and NPs. A majority of patients are admitted from the acute care hospital of VABHS (West Roxbury campus) and other regional VA facilities. The CLC offers dynamic services, including phlebotomy, general radiology, IV diuretics and antibiotics, wound care, and subacute PT, OT, and speech-language pathology rehabilitation. The CLC serves as a venue for transitioning patients from acute inpatient care to home. The patient population is often elderly, with multiple active comorbidities and variable medical literacy, adherence, and follow-up.
The CLC provides a diverse interprofessional learning environment, offering core IM rotations for first-year psychiatry residents, oral and maxillofacial surgery residents, and PA students. The CLC also has expanded as a clinical site both for transitions-in-care IM resident curricula and electives as well as a geriatrics fellowship. In addition, the site offers rotations for NPs, nursing, pharmacy, physical and occupational therapies, speech-language pathology, psychology, and SW.
The Boston University School of Medicine Physician Assistant Program was founded in 2015 as a master’s degree program completed over 28 months. The first 12 months are didactic, and the following 16 months are clinical training with 14 months of rotations (2 IM, family medicine, pediatrics, emergency medicine, general surgery, obstetrics and gynecology, psychiatry, neurology, and 5 elective rotations), and 2 months for a thesis. The program has about 30 students per year and 4 clerkship sites for IM.
Program Description
The VABHS medicine clerkship hosts 1 to 2 PA students for 4-week blocks in the PAC unit of the CLC. Each student rotates on both PA and MD teams. Students follow 3 to 4 patients and participate fully in their care from admission to discharge; they prepare daily presentations and participate in medical management, family meetings, chart documentation, and care coordination with the interprofessional team. Students are provided a physical examination checklist and feedback form, and they are expected to track findings and record feedback and goals with their supervising preceptor weekly. They also make formal case presentations and participate in monthly medicine didactic rounds available to all VABHS IM students and trainees via videoconference.
In addition, beginning in July 2017, all PA students in the CLC began to participate in a 4-week Interprofessional Curriculum in Transitional Care. The curriculum includes 14 didactic lectures taught by 16 interprofessional faculty, including medicine, geriatric, and palliative care physicians; PAs; social workers; physical and occupational therapists; pharmacists; and a geriatric psychologist. The didactics include topics on the interprofessional team, the care continuum, teams and teamwork, interdisciplinary coordination of care, components of effective transitions in care, medication reconciliation, approaching difficult conversations, advance care planning, and quality improvement. The goal of the curriculum is to provide learners the knowledge, skills, and dispositions necessary for high-quality transitional care and interprofessional practice as well as specific training for effective and safe transfers of care between clinical settings. Although PA students are the main participants in this curriculum, all other learners in the PAC unit are also invited to attend the lectures.
The unique attributes of this training site include direct interaction with supervising PAs and physicians, rather than experiencing the traditional teaching hierarchy (with interns, residents, fellows); observation of the natural progression of disease of both acute care and primary care issues due to the longer length of stay (2 to 6 weeks, where the typical student will see the same patient 7 to 10 times during their rotation); exposure to a host of medically complex patients offering a multitude of clinical scenarios and abnormal physical exam findings; exposure to a hospice/palliative care ward and end-of-life care; and interaction within an interprofessional training environment of nursing, pharmacy, PT, OT, speech-language pathology, psychology, and SW trainees.
Program Evaluation
At the end of rotations continuously through the year, PA students electronically complete a site evaluation from the Boston University School of Medicine Physician Assistant Program. The evaluation consists of 14 questions: 6 about site quality and 8 about instruction quality. The questions are answered on a 5-point Likert scale. Also included are 2 open-ended response questions that ask what they liked about the rotation and what they felt could be improved. Results are anonymous, de-identified and blinded both to the program as well as the clerkship site. Results are aggregated and provided to program sites annually. Responses are converted to a dichotomous variable, where any good or excellent response (4 or 5) is considered positive and any neutral or below (3, 2, 1) is considered a nonpositive response.
Results
The clerkship site has been operational since June 22, 2015. There have been 59 students who participated in the rotation. A different scale in these evaluations was used between June 22, 2015, and September 13, 2015. Therefore, 7 responses were excluded from the analysis, leaving 52 usable evaluations. The responses were analyzed both in total (for the CLC as well as other IM rotation sites) and by individual clerkship year to look for any trends over time: September 14, 2015, through April 24, 2016; April 25, 2016, through April 28, 2017; and May 1, 2017, through March 1, 2018 (Table).
Site evaluations showed high satisfaction regarding the quality of the physical environment as well as the learning environment. Students endorsed the PAC unit having resources and physical space for them, such as a desk and computer, opportunity for participation in patient care, and parking (100%; n = 52). Site evaluations revealed high satisfaction with the quality of teaching and faculty encouragement and support of their learning (100%; n = 52). The evaluations revealed that bedside teaching was strong (94%; n = 49). The students reported high satisfaction with the volume of patients provided (92%; n = 48) as well as the diversity of diagnoses (92%; n = 48).
There were fewer positive responses in the first 2 years of the rotation with regard to formal lectures (50% and 67%; 7/14 and 16/24, respectively). In the third year of the rotation, students had a much higher satisfaction rate (93%; 13/14). This increased satisfaction was associated with the development and incorporation of the Interprofessional Curriculum in Transitional Care in 2017.
Discussion
Access to high-quality PA student clerkship sites has become a pressing issue in recent years because of increased competition for sites and a shortage of willing and well-trained preceptors. There has been marked growth in schools and enrollment across all medical professions. The Accreditation Review Commission on Education for the PA (ARC-PA) reported that the total number of accredited entry-level PA programs in 2018 was 246, with 58 new accredited programs projected by 2022.12 The Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey reported a 66% increase in first-year enrollment in PA programs from 2002 to 2012.5 Programs must implement alternative strategies to attract clinical sites (eg, academic appointments, increased clinical resources to training sites) or face continued challenges with recruiting training sites for their students. Postacute care may be a natural extension to expand the footprint for clinical sites for these programs, augmenting acute inpatient and outpatient rotations. This implementation would increase the pool of clinical training sites and preceptors.
The experience with this novel training site, based on PA student feedback and evaluations, has been positive, and the postacute setting can provide students with high-quality IM clinical experiences. Students report adequate patient volume and diversity. In addition, evaluations are comparable with that of other IM site rotations the students experience. Qualitative feedback has emphasized the value of following patients over longer periods; eg, weeks vs days (as in acute care) enabling students to build relationships with patients as well as observe a richer clinical spectrum of disease over a less compressed period. “Patients have complex issues, so from a medical standpoint it challenges you to think of new ways to manage their care,” commented a representative student. “It is really beneficial that you can follow them over time.”
Furthermore, in response to student feedback on didactics, an interprofessional curriculum was developed to add formal structure as well as to create a curriculum in care transitions. This curriculum provided a unique opportunity for PA students to receive formal instruction on areas of particular relevance for transitional care (eg, care continuum, end of life issues, and care transitions). The curriculum also allows the interprofessional faculty a unique and enjoyable opportunity for interprofessional collaboration.
The 1 month PAC rotation is augmented with inpatient IM and outpatient family medicine rotations, consequently giving exposure to the full continuum of care. The PAC setting provides learners multifaceted benefits: the opportunity to strengthen and develop the knowledge, attitudes, and skills necessary for IM; increased understanding of other professions by observing and interacting as a team caring for a patient over a longer period as opposed to the acute care setting; the ability to perform effective, efficient, and safe transfer between clinical settings; and broad exposure to transitional care. As a result, the PAC rotation enhances but does not replace the necessary and essential rotations of inpatient and outpatient medicine.
Moreover, this rotation provides unique and core IM training for PA students. Our site focuses on interprofessional collaboration, emphasizing the importance of team-based care, an essential concept in modern day medicine. Formal exposure to other care specialties, such as PT and OT, SW, and mental health, is essential for students to appreciate clinical medicine and a patient’s physical and mental experience over the course of a disease and clinical state. In addition, the physical exam checklist ensures that students are exposed to the full spectrum of IM examination findings during their rotation. Finally, weekly feedback forms require students to ask and receive concrete feedback from their supervising providers.
Limitations
The generalizability of this model requires careful consideration. VABHS is a tertiary care integrated health care system, enabling students to learn from patients moving through multiple care transitions in a single health care system. In addition, other settings may not have the staffing or clinical volume to sustain such a model. All PAC clinical faculty teach voluntarily, and local leadership has set expectations for all clinicians to participate in teaching of trainees and PA students. Evaluations also note less diversity in the patient population, a challenge that some VA facilities face. This issue could be addressed by ensuring that students also have IM rotations at other inpatient medical facilities. A more balanced experience, where students reap the positive benefits of PAC but do not lose exposure to a diverse patient pool, could result. Furthermore, some of the perceived positive impacts also may be related to professional and personal attributes of the teaching clinicians rather than to the PAC setting.
Conclusion
PAC settings can be effective training sites for medicine clerkships for PA students and can provide high-quality training in IM as PA programs continue to expand. This setting offers students exposure to interprofessional, team-based care and the opportunity to care for patients with a broad range of disease complexity. Learning is further enhanced by the ability to follow patients longitudinally over their disease course as well as to work directly with teaching faculty and other interprofessional health care professionals. Evaluations of this novel clerkship experience have shown high levels of student satisfaction in knowledge growth, clinical skills, bedside teaching, and mentorship.
Acknowledgments
We thank Juman Hijab for her critical role in establishing and maintaining the clerkship. We thank Steven Simon, Matt Russell, and Thomas Parrino for their leadership and guidance in establishing and maintaining the clerkship. We thank the Boston University School of Medicine Physician Assistant Program Director Mary Warner for her support and guidance in creating and supporting the clerkship. In addition, we thank the interprofessional education faculty for their dedicated involvement in teaching, including Stephanie Saunders, Lindsay Lefers, Jessica Rawlins, Lindsay Brennan, Angela Viani, Eric Charette, Nicole O’Neil, Susan Nathan, Jordana Meyerson, Shivani Jindal, Wei Shen, Amy Hanson, Gilda Cain, and Kate Hinrichs.
1. US Department of Labor, Bureau of Labor Statistics. Occupational outlook handbook: physician assistants. https://www.bls.gov/ooh/healthcare/physician-assistants.htm. Updated June 18, 2019. Accessed August 13, 2019.
2. Association of American Medical Colleges. 2019 update: the complexities of physician supply and demand: projections from 2017 to 2032. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. Published April 2019. Accessed August 15, 2019.
3. Glicken AD, Miller AA. Physician assistants: from pipeline to practice. Acad Med. 2013;88(12):1883-1889.
4. Erikson C, Hamann R, Levitan T, Pankow S, Stanley J, Whatley M. Recruiting and maintaining US clinical training sites: joint report of the 2013 multi-discipline clerkship/clinical training site survey. https://paeaonline.org/wp-content/uploads/2015/10/Recruiting-and-Maintaining-U.S.-Clinical-Training-Sites.pdf. Accessed August 13, 2019.
5. Physician Assistant Education Association. By the numbers: 30th annual report on physician assistant educational programs. 2015. http://paeaonline.org/wp-content/uploads/2016/12/2015-by-the-numbers-program-report-30.pdf. Published 2015. Accessed August 15, 2019.
6. Morgan P, Himmerick KA, Leach B, Dieter P, Everett C. Scarcity of primary care positions may divert physician assistants into specialty practice. Med Care Res Rev. 2017;74(1):109-122.
7. Coplan B, Cawley J, Stoehr J. Physician assistants in primary care: trends and characteristics. Ann Fam Med. 2013;11(1):75-79.
8. Morgan P, Leach B, Himmerick K, Everett C. Job openings for PAs by specialty. JAAPA. 2018;31(1):45-47.
9. American Academy of Physician Assistants. 2017 AAPA Salary Report. Alexandria, VA; 2017.
10. Barnett ML, Grabowski DC, Mehrotra A. Home-to-home time—measuring what matters to patients and payers. N Engl J Med. 2017;377(1):4-6.
11. Werner RM, Konetzka RT. Trends in post-acute care use among Medicare beneficiaries: 2000 to 2015. JAMA. 2018;319(15):1616-1617.
12. Accreditation Review Commission on Education for the Physician Assistant. http://www.arc-pa.org/accreditation/accredited-programs. Accessed May 10, 2019.
1. US Department of Labor, Bureau of Labor Statistics. Occupational outlook handbook: physician assistants. https://www.bls.gov/ooh/healthcare/physician-assistants.htm. Updated June 18, 2019. Accessed August 13, 2019.
2. Association of American Medical Colleges. 2019 update: the complexities of physician supply and demand: projections from 2017 to 2032. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. Published April 2019. Accessed August 15, 2019.
3. Glicken AD, Miller AA. Physician assistants: from pipeline to practice. Acad Med. 2013;88(12):1883-1889.
4. Erikson C, Hamann R, Levitan T, Pankow S, Stanley J, Whatley M. Recruiting and maintaining US clinical training sites: joint report of the 2013 multi-discipline clerkship/clinical training site survey. https://paeaonline.org/wp-content/uploads/2015/10/Recruiting-and-Maintaining-U.S.-Clinical-Training-Sites.pdf. Accessed August 13, 2019.
5. Physician Assistant Education Association. By the numbers: 30th annual report on physician assistant educational programs. 2015. http://paeaonline.org/wp-content/uploads/2016/12/2015-by-the-numbers-program-report-30.pdf. Published 2015. Accessed August 15, 2019.
6. Morgan P, Himmerick KA, Leach B, Dieter P, Everett C. Scarcity of primary care positions may divert physician assistants into specialty practice. Med Care Res Rev. 2017;74(1):109-122.
7. Coplan B, Cawley J, Stoehr J. Physician assistants in primary care: trends and characteristics. Ann Fam Med. 2013;11(1):75-79.
8. Morgan P, Leach B, Himmerick K, Everett C. Job openings for PAs by specialty. JAAPA. 2018;31(1):45-47.
9. American Academy of Physician Assistants. 2017 AAPA Salary Report. Alexandria, VA; 2017.
10. Barnett ML, Grabowski DC, Mehrotra A. Home-to-home time—measuring what matters to patients and payers. N Engl J Med. 2017;377(1):4-6.
11. Werner RM, Konetzka RT. Trends in post-acute care use among Medicare beneficiaries: 2000 to 2015. JAMA. 2018;319(15):1616-1617.
12. Accreditation Review Commission on Education for the Physician Assistant. http://www.arc-pa.org/accreditation/accredited-programs. Accessed May 10, 2019.
Reframing Clinician Distress: Moral Injury Not Burnout
*This version has been corrected. In the original version the first sentence incorrectly referred to moral injury instead of burnout.
For more than a decade, the term burnout has been used to describe clinician distress.1,2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population.3 Massive information technology investments, which promised efficiency for health care providers,4 have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers,5 diverted the time and attention of those already engaged in patient care,6 and done little to improve patient outcomes.7 Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day.8 As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise.9 It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.
Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace.10 The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.
In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care.11 The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation.12 On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.
The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient. It implies that the individual lacks the resources or resilience to withstand the work environment. Since the problem is in the individual, the solutions to burnout must be in the individual, too, and therefore, it is the individual’s responsibility to find and implement them. Many of the solutions to physician distress posited to date revolve around this conception; hence, the focus on yoga, mindfulness, wellness retreats, and meditation.13 While there is nothing inherently wrong with any of those practices, it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy, having no time to discuss a complex diagnosis, or relying on a computer system that places metrics ahead of communication. These problems are not the result of some failing on the part of the individual clinician.
Moral injury, on the other hand, describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control. Moral injury is the consequence of the ever-present double binds in health care: Do we take care of our patient, the hospital, the insurer, the EMR, the health care system, or our productivity metrics first? There should be only 1 answer to that question, but the current business framework of medicine pressures us to serve all these masters at once. Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. And in the end, addressing the drivers of moral injury on a large scale may be the most effective preventive treatment for its cumulative effects among health care providers.
The long-term solutions to moral injury demand changes in the business framework of health care. The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship. The long-term solutions to moral injury include a health care system that prioritizes healing over profit and that trusts its clinicians to always put their patients’ best interests first.
Treating moral injury will not be simple. It cannot happen quickly, and it will not happen without widespread clinician engagement. Change can begin when clinicians identify the double binds they face every day and convey those challenges to their administrators. If administrators and clinicians are willing to work together to resolve these double binds, health care will improve for everyone.
The following are our recommendations for how you can bring change both locally and on a broader scale.
Bring together the 2 sides of the health care house: administrators and clinicians. Invite administrators to join you on rounds, in clinic, or in the operating room. Ask them to follow you during a night of call or to spend an overnight shift with you in the emergency department. The majority of people, including health care administrators, have had only glancing encounters with the medical system. They see their primary care doctor, have regular screening procedures, and maybe get treated for a routine illness or injury. None of those encounters expose them to the depth of challenge in the system.
It takes exposure over a longer duration, or with greater intensity, to appreciate the tensions and double binds that patients and clinicians face regularly.14,15 Whether or not the administrators accept your invitation, you must also ask to see the challenges from their side. Block out an afternoon, a day, or a week to follow them and learn where they struggle in their work. Only when we understand the other party’s perspective can we truly begin to empathize and communicate meaningfully. That profound understanding is the place where commonality and compromises are found.
Make clinician satisfaction a financial priority. Although care team well-being is now part of the quadruple aim (patient experience, population health, reducing costs, and provider experience), organizations must be held accountable to ensure it is a priority. If we choose to link patient satisfaction with clinician compensation, why not link clinician satisfaction with executive compensation?
Make sure every physician leader has and uses the cell phone number of his or her legislators. Hospitals and big pharma have nearly bottomless lobbying budgets, which makes competing with them for lawmakers’ attention a formidable prospect. Despite this, physician leaders (ie, chief wellness officer, department chairperson, medical society president, etc) have a responsibility to communicate with legislators about the needs of patients (their constituents) and what role our legislators can play in fulfilling those needs. We must understand how policy, regulation, and legislation work, and we need to find seats at every table where the decisions that impact clinical care are made. The first step is opening lines of communication with those who have the power to enact large-scale change.
Reestablish a sense of community among clinicians. Too often clinicians are pitted against one another as resources shrink. Doctors compete with each other for referrals, advanced practitioners and nurses compete with doctors, and everyone feels overstressed. What we tend to forget is that we are all working toward the same goal: To give patients the best care possible. It’s time to view each other with the presumption of charity and to have each other’s backs. Uniting for support, camaraderie, mentorship, and activism is a necessary step in making change.
1 . West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321.
2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
3. Institute of Medicine (US) National Cancer Policy Forum. Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary. Washington, DC: National Academies Press; 2009.
4. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55.
5. Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect. 2016;6(5):32643.
6. Zeng X. The impacts of electronic health record implementation on the health care workforce. N C Med J. 2016;77(2):112-114.
7. Squires D. U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective. Published October 8, 2015. Accessed August 19, 2019.
8. Fifer R. Health care economics: the real source of reimbursement problems. https://www.asha.org/Articles/Health-Care-Economics-The-Real-Source-of-Reimbursement-Problems/. Published July 2016. Accessed August 19, 2019.
9. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YR. A crisis in health care: a call to action on physician burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/. Published March 28, 2019. Accessed August 19, 2019.
10. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
11. Dean W, Talbot S. Physicians aren’t “burning out.” They’re suffering from moral injury. STAT . July 26, 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed August 19, 2019.
12. Shay J. Moral injury. Psychoanal Psych. 2014;31(2):182-191.
13. Sinsky C, Shanafelt TD, Murphy ML, et al. Creating the organizational foundation for joy in medicine: organizational changes lead to physician satisfaction. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed August 19, 2019.
14. Golshan Ma. When a cancer surgeon becomes a cancer patient. https://elemental.medium.com/when-a-cancer-surgeon-becomes-a-cancer-patient-3b9d984066da. Published June 25, 2019. Accessed August 19, 2019.
15. Joseph S, Japa S. We were inspired to become primary care physicians. Now we’re reconsidering a field in crisis. STAT . June 20, 2019. https://www.statnews.com/2019/06/20/primary-care-field-crisis/. Accessed August 19, 2019.
*This version has been corrected. In the original version the first sentence incorrectly referred to moral injury instead of burnout.
For more than a decade, the term burnout has been used to describe clinician distress.1,2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population.3 Massive information technology investments, which promised efficiency for health care providers,4 have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers,5 diverted the time and attention of those already engaged in patient care,6 and done little to improve patient outcomes.7 Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day.8 As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise.9 It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.
Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace.10 The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.
In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care.11 The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation.12 On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.
The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient. It implies that the individual lacks the resources or resilience to withstand the work environment. Since the problem is in the individual, the solutions to burnout must be in the individual, too, and therefore, it is the individual’s responsibility to find and implement them. Many of the solutions to physician distress posited to date revolve around this conception; hence, the focus on yoga, mindfulness, wellness retreats, and meditation.13 While there is nothing inherently wrong with any of those practices, it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy, having no time to discuss a complex diagnosis, or relying on a computer system that places metrics ahead of communication. These problems are not the result of some failing on the part of the individual clinician.
Moral injury, on the other hand, describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control. Moral injury is the consequence of the ever-present double binds in health care: Do we take care of our patient, the hospital, the insurer, the EMR, the health care system, or our productivity metrics first? There should be only 1 answer to that question, but the current business framework of medicine pressures us to serve all these masters at once. Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. And in the end, addressing the drivers of moral injury on a large scale may be the most effective preventive treatment for its cumulative effects among health care providers.
The long-term solutions to moral injury demand changes in the business framework of health care. The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship. The long-term solutions to moral injury include a health care system that prioritizes healing over profit and that trusts its clinicians to always put their patients’ best interests first.
Treating moral injury will not be simple. It cannot happen quickly, and it will not happen without widespread clinician engagement. Change can begin when clinicians identify the double binds they face every day and convey those challenges to their administrators. If administrators and clinicians are willing to work together to resolve these double binds, health care will improve for everyone.
The following are our recommendations for how you can bring change both locally and on a broader scale.
Bring together the 2 sides of the health care house: administrators and clinicians. Invite administrators to join you on rounds, in clinic, or in the operating room. Ask them to follow you during a night of call or to spend an overnight shift with you in the emergency department. The majority of people, including health care administrators, have had only glancing encounters with the medical system. They see their primary care doctor, have regular screening procedures, and maybe get treated for a routine illness or injury. None of those encounters expose them to the depth of challenge in the system.
It takes exposure over a longer duration, or with greater intensity, to appreciate the tensions and double binds that patients and clinicians face regularly.14,15 Whether or not the administrators accept your invitation, you must also ask to see the challenges from their side. Block out an afternoon, a day, or a week to follow them and learn where they struggle in their work. Only when we understand the other party’s perspective can we truly begin to empathize and communicate meaningfully. That profound understanding is the place where commonality and compromises are found.
Make clinician satisfaction a financial priority. Although care team well-being is now part of the quadruple aim (patient experience, population health, reducing costs, and provider experience), organizations must be held accountable to ensure it is a priority. If we choose to link patient satisfaction with clinician compensation, why not link clinician satisfaction with executive compensation?
Make sure every physician leader has and uses the cell phone number of his or her legislators. Hospitals and big pharma have nearly bottomless lobbying budgets, which makes competing with them for lawmakers’ attention a formidable prospect. Despite this, physician leaders (ie, chief wellness officer, department chairperson, medical society president, etc) have a responsibility to communicate with legislators about the needs of patients (their constituents) and what role our legislators can play in fulfilling those needs. We must understand how policy, regulation, and legislation work, and we need to find seats at every table where the decisions that impact clinical care are made. The first step is opening lines of communication with those who have the power to enact large-scale change.
Reestablish a sense of community among clinicians. Too often clinicians are pitted against one another as resources shrink. Doctors compete with each other for referrals, advanced practitioners and nurses compete with doctors, and everyone feels overstressed. What we tend to forget is that we are all working toward the same goal: To give patients the best care possible. It’s time to view each other with the presumption of charity and to have each other’s backs. Uniting for support, camaraderie, mentorship, and activism is a necessary step in making change.
*This version has been corrected. In the original version the first sentence incorrectly referred to moral injury instead of burnout.
For more than a decade, the term burnout has been used to describe clinician distress.1,2 Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population.3 Massive information technology investments, which promised efficiency for health care providers,4 have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers,5 diverted the time and attention of those already engaged in patient care,6 and done little to improve patient outcomes.7 Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day.8 As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise.9 It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.
Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace.10 The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.
In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care.11 The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation.12 On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.
The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient. It implies that the individual lacks the resources or resilience to withstand the work environment. Since the problem is in the individual, the solutions to burnout must be in the individual, too, and therefore, it is the individual’s responsibility to find and implement them. Many of the solutions to physician distress posited to date revolve around this conception; hence, the focus on yoga, mindfulness, wellness retreats, and meditation.13 While there is nothing inherently wrong with any of those practices, it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy, having no time to discuss a complex diagnosis, or relying on a computer system that places metrics ahead of communication. These problems are not the result of some failing on the part of the individual clinician.
Moral injury, on the other hand, describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control. Moral injury is the consequence of the ever-present double binds in health care: Do we take care of our patient, the hospital, the insurer, the EMR, the health care system, or our productivity metrics first? There should be only 1 answer to that question, but the current business framework of medicine pressures us to serve all these masters at once. Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress. And in the end, addressing the drivers of moral injury on a large scale may be the most effective preventive treatment for its cumulative effects among health care providers.
The long-term solutions to moral injury demand changes in the business framework of health care. The solutions reside not in promoting mindfulness or resilience among individual physicians, but in creating a health care environment that finally acknowledges the value of the time clinicians and patients spend together developing the trust, understanding, and compassion that accompany a true relationship. The long-term solutions to moral injury include a health care system that prioritizes healing over profit and that trusts its clinicians to always put their patients’ best interests first.
Treating moral injury will not be simple. It cannot happen quickly, and it will not happen without widespread clinician engagement. Change can begin when clinicians identify the double binds they face every day and convey those challenges to their administrators. If administrators and clinicians are willing to work together to resolve these double binds, health care will improve for everyone.
The following are our recommendations for how you can bring change both locally and on a broader scale.
Bring together the 2 sides of the health care house: administrators and clinicians. Invite administrators to join you on rounds, in clinic, or in the operating room. Ask them to follow you during a night of call or to spend an overnight shift with you in the emergency department. The majority of people, including health care administrators, have had only glancing encounters with the medical system. They see their primary care doctor, have regular screening procedures, and maybe get treated for a routine illness or injury. None of those encounters expose them to the depth of challenge in the system.
It takes exposure over a longer duration, or with greater intensity, to appreciate the tensions and double binds that patients and clinicians face regularly.14,15 Whether or not the administrators accept your invitation, you must also ask to see the challenges from their side. Block out an afternoon, a day, or a week to follow them and learn where they struggle in their work. Only when we understand the other party’s perspective can we truly begin to empathize and communicate meaningfully. That profound understanding is the place where commonality and compromises are found.
Make clinician satisfaction a financial priority. Although care team well-being is now part of the quadruple aim (patient experience, population health, reducing costs, and provider experience), organizations must be held accountable to ensure it is a priority. If we choose to link patient satisfaction with clinician compensation, why not link clinician satisfaction with executive compensation?
Make sure every physician leader has and uses the cell phone number of his or her legislators. Hospitals and big pharma have nearly bottomless lobbying budgets, which makes competing with them for lawmakers’ attention a formidable prospect. Despite this, physician leaders (ie, chief wellness officer, department chairperson, medical society president, etc) have a responsibility to communicate with legislators about the needs of patients (their constituents) and what role our legislators can play in fulfilling those needs. We must understand how policy, regulation, and legislation work, and we need to find seats at every table where the decisions that impact clinical care are made. The first step is opening lines of communication with those who have the power to enact large-scale change.
Reestablish a sense of community among clinicians. Too often clinicians are pitted against one another as resources shrink. Doctors compete with each other for referrals, advanced practitioners and nurses compete with doctors, and everyone feels overstressed. What we tend to forget is that we are all working toward the same goal: To give patients the best care possible. It’s time to view each other with the presumption of charity and to have each other’s backs. Uniting for support, camaraderie, mentorship, and activism is a necessary step in making change.
1 . West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321.
2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
3. Institute of Medicine (US) National Cancer Policy Forum. Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary. Washington, DC: National Academies Press; 2009.
4. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55.
5. Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect. 2016;6(5):32643.
6. Zeng X. The impacts of electronic health record implementation on the health care workforce. N C Med J. 2016;77(2):112-114.
7. Squires D. U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective. Published October 8, 2015. Accessed August 19, 2019.
8. Fifer R. Health care economics: the real source of reimbursement problems. https://www.asha.org/Articles/Health-Care-Economics-The-Real-Source-of-Reimbursement-Problems/. Published July 2016. Accessed August 19, 2019.
9. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YR. A crisis in health care: a call to action on physician burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/. Published March 28, 2019. Accessed August 19, 2019.
10. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
11. Dean W, Talbot S. Physicians aren’t “burning out.” They’re suffering from moral injury. STAT . July 26, 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed August 19, 2019.
12. Shay J. Moral injury. Psychoanal Psych. 2014;31(2):182-191.
13. Sinsky C, Shanafelt TD, Murphy ML, et al. Creating the organizational foundation for joy in medicine: organizational changes lead to physician satisfaction. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed August 19, 2019.
14. Golshan Ma. When a cancer surgeon becomes a cancer patient. https://elemental.medium.com/when-a-cancer-surgeon-becomes-a-cancer-patient-3b9d984066da. Published June 25, 2019. Accessed August 19, 2019.
15. Joseph S, Japa S. We were inspired to become primary care physicians. Now we’re reconsidering a field in crisis. STAT . June 20, 2019. https://www.statnews.com/2019/06/20/primary-care-field-crisis/. Accessed August 19, 2019.
1 . West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321.
2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
3. Institute of Medicine (US) National Cancer Policy Forum. Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary. Washington, DC: National Academies Press; 2009.
4. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55.
5. Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect. 2016;6(5):32643.
6. Zeng X. The impacts of electronic health record implementation on the health care workforce. N C Med J. 2016;77(2):112-114.
7. Squires D. U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective. Published October 8, 2015. Accessed August 19, 2019.
8. Fifer R. Health care economics: the real source of reimbursement problems. https://www.asha.org/Articles/Health-Care-Economics-The-Real-Source-of-Reimbursement-Problems/. Published July 2016. Accessed August 19, 2019.
9. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YR. A crisis in health care: a call to action on physician burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/. Published March 28, 2019. Accessed August 19, 2019.
10. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73-82.
11. Dean W, Talbot S. Physicians aren’t “burning out.” They’re suffering from moral injury. STAT . July 26, 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed August 19, 2019.
12. Shay J. Moral injury. Psychoanal Psych. 2014;31(2):182-191.
13. Sinsky C, Shanafelt TD, Murphy ML, et al. Creating the organizational foundation for joy in medicine: organizational changes lead to physician satisfaction. https://edhub.ama-assn.org/steps-forward/module/2702510. Published September 7, 2017. Accessed August 19, 2019.
14. Golshan Ma. When a cancer surgeon becomes a cancer patient. https://elemental.medium.com/when-a-cancer-surgeon-becomes-a-cancer-patient-3b9d984066da. Published June 25, 2019. Accessed August 19, 2019.
15. Joseph S, Japa S. We were inspired to become primary care physicians. Now we’re reconsidering a field in crisis. STAT . June 20, 2019. https://www.statnews.com/2019/06/20/primary-care-field-crisis/. Accessed August 19, 2019.
Our EHRs have a drug problem
The “opioid epidemic” has become, perhaps, the most talked-about health crisis of the 21st century. It is a pervasive topic of discussion in the health literature and beyond, written about on the front pages of national newspapers and even mentioned in presidential state-of-the-union addresses.
As practicing physicians, we are all too familiar with the ills of chronic opioid use and have dealt with the implications of the crisis long before the issue attracted the public’s attention. In many ways, we have felt alone in bearing the burdens of caring for patients on chronic controlled substances. Until this point it has been our sacred duty to determine which patients are truly in need of those medications, and which are merely dependent on or – even worse – abusing them.
Health care providers have been largely blamed for the creation of this crisis, but we are not alone. Responsibility must also be shared by the pharmaceutical industry, health insurers, and even the government. Marketing practices, inadequate coverage of pain-relieving procedures and rehabilitation, and poorly-conceived drug policies have created an environment where it has been far too difficult to provide appropriate care for patients with chronic pain. As a result, patients who may have had an alternative to opioids were still started on these medications, and we – their physicians – have been left alone to manage the outcome.
Recently, however, health policy and public awareness have signaled a dramatic shift in the management of long-term pain medication. Significant legislation has been enacted on national, state, and local levels, and parties who are perceived to be responsible for the crisis are being held to task. For example, in August a landmark legal case was decided in an Oklahoma district court. Johnson & Johnson Pharmaceuticals was found guilty of promoting drug addiction through false and misleading marketing and was thus ordered to pay $572 million to the state to fund drug rehabilitation programs. This is likely a harbinger of many more such decisions to come, and the industry as a whole is bracing for the worst.
Physician prescribing practices are also being carefully scrutinized by the DEA, and a significant number of new “checks and balances” have been put in place to address dependence and addiction concerns. Unfortunately, as with all sweeping reform programs, there are good – and not-so-good – aspects to these changes. In many ways, the new tools at our disposal are a powerful way of mitigating drug dependence and diversion while protecting the sanctity of our “prescription pads.” Yet, as with so many other government mandates, we are burdened with the onus of complying with the new mandates for each and every opioid prescription, while our EHRs provide little help. This means more “clicks” for us, which can feel quite burdensome. It doesn’t need to be this way. Below are two straightforward things that can and should occur in order for providers to feel unburdened and to fully embrace the changes.
PDMP integration
One of the major ways of controlling prescription opioid abuse is through effective monitoring. Forty-nine of the 50 U.S. states have developed Prescription Drug Monitoring Programs (PDMPs), with Missouri being the only holdout (due to the politics of individual privacy concerns and conflation with gun control legislation). Most – though not all – of the states with a PDMP also mandate that physicians query a database prior to prescribing controlled substances. While noble and helpful in principle, querying a PDMP can be cumbersome, and the process is rarely integrated into the EHR workflow. Instead, physicians typically need to login to a separate website and manually transpose patient data to search the database. While most states have offered to subsidize PDMP integration with electronic records, EHR vendors have been very slow to develop the capability, leaving most physicians with no choice but to continue the aforementioned workflow. That is, if they comply at all; many well-meaning physicians have told us that they find themselves too harried to use the PDMP consistently. This reduces the value of these databases and places the physicians at significant risk. In some states, failure to query the database can lead to loss of a doctor’s medical license. It is high time that EHR vendors step up and integrate with every state’s prescription drug database.
Electronic prescribing of controlled substances
The other major milestone in prescription opioid management is the electronic prescribing of controlled substances (EPCS). This received national priority when the SUPPORT for Patients and Communities Act was signed into federal law in October of 2018. Included in this act is a requirement that, by January of 2021, all controlled substance prescriptions covered under Medicare Part D be sent electronically. Taking this as inspiration, many states and private companies have adopted more aggressive policies, choosing to implement electronic prescription requirements prior to the 2021 deadline. In Pennsylvania, where we practice, an EPCS requirement goes into effect in October of this year (2019). National pharmacy chains have also taken a more proactive approach. Walmart, for example, has decided that it will require EPCS nationwide in all of its stores beginning in January of 2020.
Essentially physicians have no choice – if they plan to continue to prescribe controlled substances, they will need to begin doing so electronically. Unfortunately, this may not be a straightforward process. While most EHRs offer some sort of EPCS solution, it is typically far from user friendly. Setting up EPCS can be costly and incredibly time consuming, and the procedure of actually submitting controlled prescriptions can be onerous and add many extra clicks. If vendors are serious about assisting in solving the opioid crisis, they need to make streamlining the steps of EPCS a high priority.
A prescription for success
As with so many other topics we’ve written about, we face an ever-increasing burden to provide quality patient care while complying with cumbersome and often unfunded external mandates. In the case of the opioid crisis, we believe we can do better. Our prescription for success? Streamlined workflow, smarter EHRs, and fewer clicks. There is no question that physicians and patients will benefit from effective implementation of the new tools at our disposal, but we need EHR vendors to step up and help carry the load.
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
The “opioid epidemic” has become, perhaps, the most talked-about health crisis of the 21st century. It is a pervasive topic of discussion in the health literature and beyond, written about on the front pages of national newspapers and even mentioned in presidential state-of-the-union addresses.
As practicing physicians, we are all too familiar with the ills of chronic opioid use and have dealt with the implications of the crisis long before the issue attracted the public’s attention. In many ways, we have felt alone in bearing the burdens of caring for patients on chronic controlled substances. Until this point it has been our sacred duty to determine which patients are truly in need of those medications, and which are merely dependent on or – even worse – abusing them.
Health care providers have been largely blamed for the creation of this crisis, but we are not alone. Responsibility must also be shared by the pharmaceutical industry, health insurers, and even the government. Marketing practices, inadequate coverage of pain-relieving procedures and rehabilitation, and poorly-conceived drug policies have created an environment where it has been far too difficult to provide appropriate care for patients with chronic pain. As a result, patients who may have had an alternative to opioids were still started on these medications, and we – their physicians – have been left alone to manage the outcome.
Recently, however, health policy and public awareness have signaled a dramatic shift in the management of long-term pain medication. Significant legislation has been enacted on national, state, and local levels, and parties who are perceived to be responsible for the crisis are being held to task. For example, in August a landmark legal case was decided in an Oklahoma district court. Johnson & Johnson Pharmaceuticals was found guilty of promoting drug addiction through false and misleading marketing and was thus ordered to pay $572 million to the state to fund drug rehabilitation programs. This is likely a harbinger of many more such decisions to come, and the industry as a whole is bracing for the worst.
Physician prescribing practices are also being carefully scrutinized by the DEA, and a significant number of new “checks and balances” have been put in place to address dependence and addiction concerns. Unfortunately, as with all sweeping reform programs, there are good – and not-so-good – aspects to these changes. In many ways, the new tools at our disposal are a powerful way of mitigating drug dependence and diversion while protecting the sanctity of our “prescription pads.” Yet, as with so many other government mandates, we are burdened with the onus of complying with the new mandates for each and every opioid prescription, while our EHRs provide little help. This means more “clicks” for us, which can feel quite burdensome. It doesn’t need to be this way. Below are two straightforward things that can and should occur in order for providers to feel unburdened and to fully embrace the changes.
PDMP integration
One of the major ways of controlling prescription opioid abuse is through effective monitoring. Forty-nine of the 50 U.S. states have developed Prescription Drug Monitoring Programs (PDMPs), with Missouri being the only holdout (due to the politics of individual privacy concerns and conflation with gun control legislation). Most – though not all – of the states with a PDMP also mandate that physicians query a database prior to prescribing controlled substances. While noble and helpful in principle, querying a PDMP can be cumbersome, and the process is rarely integrated into the EHR workflow. Instead, physicians typically need to login to a separate website and manually transpose patient data to search the database. While most states have offered to subsidize PDMP integration with electronic records, EHR vendors have been very slow to develop the capability, leaving most physicians with no choice but to continue the aforementioned workflow. That is, if they comply at all; many well-meaning physicians have told us that they find themselves too harried to use the PDMP consistently. This reduces the value of these databases and places the physicians at significant risk. In some states, failure to query the database can lead to loss of a doctor’s medical license. It is high time that EHR vendors step up and integrate with every state’s prescription drug database.
Electronic prescribing of controlled substances
The other major milestone in prescription opioid management is the electronic prescribing of controlled substances (EPCS). This received national priority when the SUPPORT for Patients and Communities Act was signed into federal law in October of 2018. Included in this act is a requirement that, by January of 2021, all controlled substance prescriptions covered under Medicare Part D be sent electronically. Taking this as inspiration, many states and private companies have adopted more aggressive policies, choosing to implement electronic prescription requirements prior to the 2021 deadline. In Pennsylvania, where we practice, an EPCS requirement goes into effect in October of this year (2019). National pharmacy chains have also taken a more proactive approach. Walmart, for example, has decided that it will require EPCS nationwide in all of its stores beginning in January of 2020.
Essentially physicians have no choice – if they plan to continue to prescribe controlled substances, they will need to begin doing so electronically. Unfortunately, this may not be a straightforward process. While most EHRs offer some sort of EPCS solution, it is typically far from user friendly. Setting up EPCS can be costly and incredibly time consuming, and the procedure of actually submitting controlled prescriptions can be onerous and add many extra clicks. If vendors are serious about assisting in solving the opioid crisis, they need to make streamlining the steps of EPCS a high priority.
A prescription for success
As with so many other topics we’ve written about, we face an ever-increasing burden to provide quality patient care while complying with cumbersome and often unfunded external mandates. In the case of the opioid crisis, we believe we can do better. Our prescription for success? Streamlined workflow, smarter EHRs, and fewer clicks. There is no question that physicians and patients will benefit from effective implementation of the new tools at our disposal, but we need EHR vendors to step up and help carry the load.
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
The “opioid epidemic” has become, perhaps, the most talked-about health crisis of the 21st century. It is a pervasive topic of discussion in the health literature and beyond, written about on the front pages of national newspapers and even mentioned in presidential state-of-the-union addresses.
As practicing physicians, we are all too familiar with the ills of chronic opioid use and have dealt with the implications of the crisis long before the issue attracted the public’s attention. In many ways, we have felt alone in bearing the burdens of caring for patients on chronic controlled substances. Until this point it has been our sacred duty to determine which patients are truly in need of those medications, and which are merely dependent on or – even worse – abusing them.
Health care providers have been largely blamed for the creation of this crisis, but we are not alone. Responsibility must also be shared by the pharmaceutical industry, health insurers, and even the government. Marketing practices, inadequate coverage of pain-relieving procedures and rehabilitation, and poorly-conceived drug policies have created an environment where it has been far too difficult to provide appropriate care for patients with chronic pain. As a result, patients who may have had an alternative to opioids were still started on these medications, and we – their physicians – have been left alone to manage the outcome.
Recently, however, health policy and public awareness have signaled a dramatic shift in the management of long-term pain medication. Significant legislation has been enacted on national, state, and local levels, and parties who are perceived to be responsible for the crisis are being held to task. For example, in August a landmark legal case was decided in an Oklahoma district court. Johnson & Johnson Pharmaceuticals was found guilty of promoting drug addiction through false and misleading marketing and was thus ordered to pay $572 million to the state to fund drug rehabilitation programs. This is likely a harbinger of many more such decisions to come, and the industry as a whole is bracing for the worst.
Physician prescribing practices are also being carefully scrutinized by the DEA, and a significant number of new “checks and balances” have been put in place to address dependence and addiction concerns. Unfortunately, as with all sweeping reform programs, there are good – and not-so-good – aspects to these changes. In many ways, the new tools at our disposal are a powerful way of mitigating drug dependence and diversion while protecting the sanctity of our “prescription pads.” Yet, as with so many other government mandates, we are burdened with the onus of complying with the new mandates for each and every opioid prescription, while our EHRs provide little help. This means more “clicks” for us, which can feel quite burdensome. It doesn’t need to be this way. Below are two straightforward things that can and should occur in order for providers to feel unburdened and to fully embrace the changes.
PDMP integration
One of the major ways of controlling prescription opioid abuse is through effective monitoring. Forty-nine of the 50 U.S. states have developed Prescription Drug Monitoring Programs (PDMPs), with Missouri being the only holdout (due to the politics of individual privacy concerns and conflation with gun control legislation). Most – though not all – of the states with a PDMP also mandate that physicians query a database prior to prescribing controlled substances. While noble and helpful in principle, querying a PDMP can be cumbersome, and the process is rarely integrated into the EHR workflow. Instead, physicians typically need to login to a separate website and manually transpose patient data to search the database. While most states have offered to subsidize PDMP integration with electronic records, EHR vendors have been very slow to develop the capability, leaving most physicians with no choice but to continue the aforementioned workflow. That is, if they comply at all; many well-meaning physicians have told us that they find themselves too harried to use the PDMP consistently. This reduces the value of these databases and places the physicians at significant risk. In some states, failure to query the database can lead to loss of a doctor’s medical license. It is high time that EHR vendors step up and integrate with every state’s prescription drug database.
Electronic prescribing of controlled substances
The other major milestone in prescription opioid management is the electronic prescribing of controlled substances (EPCS). This received national priority when the SUPPORT for Patients and Communities Act was signed into federal law in October of 2018. Included in this act is a requirement that, by January of 2021, all controlled substance prescriptions covered under Medicare Part D be sent electronically. Taking this as inspiration, many states and private companies have adopted more aggressive policies, choosing to implement electronic prescription requirements prior to the 2021 deadline. In Pennsylvania, where we practice, an EPCS requirement goes into effect in October of this year (2019). National pharmacy chains have also taken a more proactive approach. Walmart, for example, has decided that it will require EPCS nationwide in all of its stores beginning in January of 2020.
Essentially physicians have no choice – if they plan to continue to prescribe controlled substances, they will need to begin doing so electronically. Unfortunately, this may not be a straightforward process. While most EHRs offer some sort of EPCS solution, it is typically far from user friendly. Setting up EPCS can be costly and incredibly time consuming, and the procedure of actually submitting controlled prescriptions can be onerous and add many extra clicks. If vendors are serious about assisting in solving the opioid crisis, they need to make streamlining the steps of EPCS a high priority.
A prescription for success
As with so many other topics we’ve written about, we face an ever-increasing burden to provide quality patient care while complying with cumbersome and often unfunded external mandates. In the case of the opioid crisis, we believe we can do better. Our prescription for success? Streamlined workflow, smarter EHRs, and fewer clicks. There is no question that physicians and patients will benefit from effective implementation of the new tools at our disposal, but we need EHR vendors to step up and help carry the load.
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.