VO LU M E 1 1 6 N O . 4 J U LY- AU G 2 0 1 9
COLORADO MEDICINE ADVOCATING EXCELLENCE IN THE PROFESSION OF MEDICINE
MAKE A SYSTEMS CHANGE
PROMOTE AUTONOMY AND SELF-CARE
CULTIVATE COMMUNITY
DEVELOP A PROCESS
ALIGN MEANING AND VALUES
CO LOR AD O M E D I CAL SO CI E T Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 720-859-1001 • 800-654-5653 • fax 720-859-7509 • www.cms.org
OFFICERS, BOARD MEMBERS, AMA DELEGATES and STAFF 2018-2019 OFFICERS Debra J. Parsons, MD, FACP President
David Markenson, MD, MBA President-elect
Patrick Pevoto, MD, RPh, MBA Treasurer
Alfred D. Gilchrist
Chief Executive Officer
M. Robert Yakely, MD
Immediate Past President
BOARD OF DIRECTORS
AMA DELEGATES
Iris Burgard, MS Cory Carroll, MD Curtis Hagedorn, MD Mark B. Johnson, MD Jason L. Kelly, MD Evan Manning, MD Patrick Pevoto, MD, RPh, MBA Leto Quarles, MD Brandi Ring, MD Brad A. Roberts, MD Kim Warner, MD C. Rocky White, MD Hap Young, MD
A. “Lee” Morgan, MD David Downs, MD, FACP Jan Kief, MD Tamaan Osbourne-Roberts, MD Lynn Parry, MSc, MD
AMA ALTERNATE DELEGATES Carolynn Francavilla, MD Rachelle Klammer, MD Katie Lozano, MD, FACR Brigitta J. Robinson, MD Michael Volz, MD
AMA PAST PRESIDENT Jeremy Lazarus, MD
COLORADO MEDICAL SOCIETY STAFF EXECUTIVE OFFICE Alfred Gilchrist, Chief Executive Officer Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer Dean_Holzkamp@cms.org Chet Seward, Chief Strategy Officer Chet_Seward@cms.org Dianna Fetter, Director, Professional Services Dianna_Fetter@cms.org Tom Wilson, Manager, Accounting Tom_Wilson@cms.org DIVISION OF COMMUNICATIONS AND MEMBER BENEFITS Mike Campo, Director, Business Development & Member Benefits Mike_Campo@cms.org Kate Alfano, Coordinator, Communications Kate_Alfano@cms.org
DIVISION OF HEALTH CARE POLICY AND FINANCING Marilyn Rissmiller, Senior Director Marilyn_Rissmiller@cms.org Amy Berenbaum Goodman, JD, MBE, Senior Director, Policy amy_goodman@cms.org Gene Richer, Director, Continuing Medical Education Gene_Richer@cms.org DIVISION OF INFORMATION TECHNOLOGY/MEMBERSHIP
DIVISION OF GOVERNMENT RELATIONS Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Emily Bishop, Program Manager Emily_Bishop@cms.org COLORADO MEDICAL SOCIETY FOUNDATION COLORADO MEDICAL SOCIETY EDUCATION FOUNDATION Mike Campo, Staff Support Mike_Campo@cms.org
Krystle Medford, Director, Membership Krystle_Medford@cms.org Tim Yanetta, Manager, IT/Membership Tim_Yanetta@cms.org Susanna Barnett, Coordinator Susanna_Barnett@cms.org Stephanie Salazar, Coordinator Stephanie_Salazar@cms.org
COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colo., and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance. COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified. Alfred D. Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Kate Alfano, Assistant Editor; Chet Seward, Assistant Editor. Design by Scribner Creative.
C O NTE NT S
Cover story: Physician wellbeing is about you, your workplace, our culture and beyond, and the time to act is now
MAKE A SYSTEMS CHANGE
PROMOTE AUTONOMY AND SELF-CARE
The wellbeing of Colorado physicians is vital to individual physicians personally and professionally, and essential for the wellbeing of patients and the health care system. To move from the idea that wellbeing is solely the responsibility of each individual physician, the conversation has changed toward CULTIVATE identifying drivers of burnout and addressing them at the practice and organizational level and in our COMMUNITY culture. This issue of Colorado Medicine explores physician wellbeing from a variety of angles and with a variety of voices, with content guided by the CMS Committee on Physician Wellbeing. PAGE 5 ⊲ W E LLB E I N G
F E ATU R E S
DEVELOP A PROCESS
7 INFOGRAPHIC Social isolation at work
High workloads
Cultural shift from health values to corporate values
Increased time spent in documentation
?
Workflow inefficiencies
Loss of meaning in work
• Key research findings on physician burnout • Primary drivers of physician burnout • Impact of burnout at your organization
I N D I V I D UA L
9
I NTE RV E NTI O N
CHOOSING TO CHANGE: COLORADO PHYSICIANS ON ACHIEVING HAPPINESS IN MEDICINE
A survey of CMS members showed that 40 percent of doctors who are happy in medicine had to make a change to achieve this state of joy. Open-ended responses describe their actions to find an individual way forward.
11 COLORADO PHYSICIAN HEALTH PROGRAM: A SAFE PLACE FOR HELP
CPHP provides supportive health monitoring to Colorado physicians. Services are free to physicians licensed in the state and are kept strictly confidential from the medical board.
13 BURNOUT: IT’S PERSONAL
Colorado Springs urologist Jeff Moody, MD, shares the moment he snapped (his keyboard), how he implemented personal and systemic changes to reduce and eliminate burnout, and how he continues to take action.
15 WELLBEING SELF-ASSESSMENT FOR RESIDENT PHYSICIANS
Physicians-in-training face a tremendous amount of stress in their residency years. Practicing self-assessment, setting a goal and making a plan for change can lay a foundation for wellness that lasts a career.
17 TO OUR PHYSICIAN COLLEAGUES: WE SHARE YOUR PAIN
Burnout reaches other professions outside of medicine. Our colleagues in law share similar stressors, as explained by COPIC general counsel.
P R AC TI C E
I NTE RV E NTI O N
19 TEAM-BASED CARE AND PROVIDER SATISFACTION
A high-functioning medical team is a key component to reducing burnout and improving engagement as it has the ability to address many of the components of modern medical care that drive burnout.
21 BEYOND BURNOUT: THE PATH TO VITALITY
HealthTeamWorks CMO David Ehrenberger, MD, shares his steps to building vitality in practice, illustrated by insights from three Colorado physician leaders.
25 FOSTERING AND SUPPORTING PHYSICIANS’ WELLBEING: WHAT DOES IT TAKE?
Practices can create healthier work environments for physicians by deploying elements of effective wellbeing programs. Top of any successful effort? Creating a workplace where each physician feels truly known and valued.
O R G A N I Z ATI O N
I NTE RV E NTI O N
27 IS IT THEM OR IS IT ME?
Distinguishing intrinsic stresses from extrinsic stresses in a physician’s professional life can be key to developing and deploying real interventions.
29 COLLECTIVE RESILIENCE
The University of Colorado Behavioral Health and Wellness Program partnered with CMS in 2014 to develop the “DIMENSIONS: Work and Well-Being Toolkit for Physicians.” The toolkit continues to be relevant and useful in their work to assess workplace wellness and coach organizations to change.
31 CHARTING A COURSE TOGETHER: 25 LARGE GROUPS ON WELLNESS
36% 64%
CMS interviewed chief wellness officers across Colorado to provide a baseline on organizational efforts to address physician wellbeing and glean best practices to share statewide.
ALIGN MEANING AND VALUES
C U LTU R E
I NTE RV E NTI O N
35 DO NO HARM: PHYSICIANS GATHER FOR DOCUMENTARY SHOWING AND THOUGHTFUL DISCUSSION The Colorado Permanente Medical Group in collaboration with CMS hosted a screening in May of “DO NO HARM: Exposing the Hippocratic Hoax.” Paired with a panel discussion, it raised awareness of the epidemic of physician suicide and provoked dialogue on individual and system interventions.
37 INHERENT STRESS AND REWARD VERSUS ADDED STRESS AND REWARD, AND HOW TO DEAL WITH EACH? Inherent stresses may be unavoidable in medicine but embracing them in a healthy way can optimize the inherent rewards. On the other hand, added stresses are not connected to added rewards and must be dealt with directly.
39 TECHNO TOXICITY?
Is technology really to blame for burnout? Some tools coming down the pipeline may mitigate workplace frustrations.
OTH E R
F E ATU R E S
41 MCLAUTHLIN FAMILY DONATION PRESERVES STORIED HISTORY OF COLORADO PHYSICIAN LEADERS The Colorado Medical Society is honored to have received family memorabilia from three generations of Denver-area physicians.
42 PHYSICIANS TAKING STEPS TO REVERSE OPIOID EPIDEMIC NATIONALLY AND IN COLORADO
A new report from the American Medical Association shows that Colorado physicians are making real progress in reducing opioid prescriptions and increasing use of the PDMP, but that prescribers are only one part of the solution.
43 AMA ANNUAL MEETING REPORT: COLORADO FORGES AHEAD
The Colorado Delegation to the AMA celebrates a successful AMA Annual Meeting, once again making progress on behalf of the state’s physicians.
45 CANDIDATE STATEMENTS FOR CMS PRESIDENT-ELECT AND AMA DELEGATION
The Colorado Medical Society will hold our leadership election in August. Get to know the candidates by reading their candidate statements before you receive your email ballot.
51 2019 CMS ANNUAL MEETING: PRESIDENTIAL CELEBRATION AND INAUGURAL GALA Registration is open for the 2019 Presidential Celebration and Inaugural Gala, Sept. 14 in Denver. Join us in celebrating the precious role of physicians.
53 AN OVERVIEW OF THE COLORADO CANDOR ACT
Find out what you need to know about the new Colorado Candor Act, which went into effect July 1.
F I N A L
WO R D
67 IT’S ABOUT CHANGING THE CULTURE: FROM INDIVIDUALISM TO COLLEGIALITY
CMS Past President F. Brent Keeler, MD, envisions a new era of medicine where we go beyond the taboo of burnout, recognizing colleagues in trouble, supporting them with friendship and connecting them to the right resources.
E X TR A S
8
THANKS TO THE CMS COMMITTEE ON PHYSICIAN WELLBEING
16 EIGHT DIMENSIONS OF WELLNESS 24 WHERE CAN AN ORGANIZATION START? WITH INVESTED PHYSICIANS 34 COMPONENT SOCIETY WELLBEING ACTIVITIES 40 BOOK RECOMMENDATIONS
I N S I D E
3
C M S
PRESIDENT’S LETTER
12 CMS CORPORATE SUPPORTERS AND ADVANTAGE PARTNERS
D E PA R TM E NT S
56 COPIC COMMENT 57 REFLECTIONS: THE AMAZING NURSE 59 INTROSPECTIONS: THE VACCINE DIVIDE 61 MEDICAL NEWS 66 CLASSIFIEDS
P R E S I D E NT ’ S
LE T TE R
CMS’ progress on physician wellbeing: Three focus points
Debra Parsons, MD, FACP President, Colorado Medical Society
Most of you know CMS as a policy and advocacy organization for Colorado’s physicians – and this year our advocacy work falls under the umbrella of physician wellbeing. CMS set a goal to “highlight, emphasize and promote solutions to enhance both physician wellbeing and joy in the practice of medicine.” We are achieving this goal by specifically focusing on three buckets of solutions to the burnout crisis – organizational interventions, public policy advocacy and individual wellbeing. Burnout has major consequences for physicians, staff, patients and the entire health care system. It affects quality, patient safety, health care system performance and morale of the health care workforce. We join others in the understanding that “burnout and the absence of joy” across all health care disciplines is a brewing public health crisis.
The time to measure and discuss the problem is in the rearview mirror. Concrete steps that are proven to reduce burnout, fatigue and suicidal ideation must be promoted and implemented across our practices regardless of type of ownership or size of practice. The foundation for CMS’ current effort began in 2012, following an illuminating CMS member survey that showed that the majority of physicians felt they were unable to have work-life balance and time for “life outside of work.” It was a big wake-up call and CMS got to work. We established the CMS Committee on Physician Wellbeing, signed onto former Gov. John Hickenlooper’s goal to be the healthiest state in the nation, and began our work on the CMS Board of Directors’ first focus: a wellbeing toolkit aimed at reducing stress and burnout that was co-produced by CMS and COPIC and developed by the University of Colorado Behavioral Health and Wellness Program.
3 C O LO R A D O M E D I C I N E
Recognizing that one size does not fit all, the toolkit contains a variety of evidence-based proactive activities that individual physicians can integrate into a daily routine, not only to prevent burnout but also to create more fulfilling professional and personal lives. The activity on “physician values” is fundamentally important. Values are of the utmost importance to maintaining a fulfilling and satisfying practice; values guide our life priorities and decisions. Not being able to work according to one’s values can be a significant source of dissatisfaction. This mismatch of values and practice can lead to feelings of hopelessness and demoralization, which are directly associated with PAGE 9 burnout. As discussed below, page 9 physicians who reported in this issue highlights physicians who no symptoms of burnout reported feeling happy in their careers, with no symptoms of burnout. It is my belief that these physicians made practice changes that were more aligned with their values rather than discovering a “secret sauce” in another prac-
P R E S I D E N T ’ S LE T T E R
tice setting. Movement to or from employed practice, private practice, academics or administrative roles were sure to reflect their values, resulting in new-found “joy in practice.” Whether one has five minutes or an hour, the wellbeing toolkit offers strategies to improve wellbeing that can easily be integrated into the busiest schedule. It is a wonderful expression of concern for physicians on behalf of CMS. Read more about “DIMENSIONS: Work & Well-Being Toolkit for Physicians” on page 29.
PAGE 29 DIMENSIONS: Work & WellBeing Toolkit for Physicians
Moving beyond individual resiliency, CMS’ second focus was to adopt good public policy as CMS policy. We found such policy in the American College of Physicians’ seven policy recommendations on administrative tasks – a call to mitigate or eliminate the administrative burdens resulting in adverse effects on providers, patients and the health care system as a whole. In September 2017, the board adopted all seven as CMS policy and widely distributed them to external stakeholders including payers, governmental oversight organizations and vendors. Our new stance in policy No. 300.992 was staunchly declared with the paraphrased highlights below:
Querying “happy doctors” In our January 2019 all-member survey on PAGE 9 professional review and the liability climate, we “Happy doctors” included the validated “Mini Z Single Question.” in their words This question asked members to use their own definition of burnout and provided five responses ranging from “I feel completely burned out; am at the tipping point where I may need to seek help” to “I enjoy my work; feel no symptoms of burnout.” To those who answered that they feel no symptoms of burnout, we sent a follow-up survey to determine whether these physicians have always enjoyed the practice of medicine throughout their career or if they had to make changes to get to their current state of joy in medicine. Read more about this follow-up survey and eight of the open-ended physician responses on how they achieved joy on page 9. Querying physician practices on efforts around wellbeing and burnout CMS conducted a phone survey of the 25 largest physician groups in the membership database, asking questions to gauge whether these organizations are taking action on physician wellbeing. Read about the phone survey on page 31.
PAGE 31 Survey of the 25 largest physician groups
• CMS calls on external stakeholders who develop or implement administrative tasks to provide financial, time and quality-of-care impact statements. Tasks that are determined to have a negative effect on quality and patient care, unnecessarily question physician and other clinician judgment, or increase costs should be challenged, revised or removed entirely.
Hosting a wellbeing summit The CMS Board approved the recommendation of the CMS Committee on Physician Wellbeing to hold a day-long summit of physicians, chief wellness officers or other administrators in charge of wellness, to share best practices and increase wellbeing efforts on a large scale. Planning will commence during the second half of 2019. Read more on page 32.
• Administrative tasks that cannot be eliminated must be regularly reviewed, revised, aligned and/or streamlined with the goal of minimizing burden.
Special issue of Colorado Medicine And then there is this special issue of Colorado Medicine dedicated to physician wellbeing, which I hope you will take time to fully explore and share with colleagues.
• Stakeholders, including public and private payers, must collaborate with professional societies, frontline clinicians, patients and EHR vendors to aim for performance measures that minimize unnecessary clinician burden, maximize patient and family centeredness, and integrate with quality improvement and care delivery. • CMS calls for rigorous research on the effect of administrative tasks on our health care system in terms of quality, time and cost; the health care workforce; the patient experience; and, most important, patient outcomes.
Despite decades of publications documenting the problem of physician burnout and some of its causes and potential consequences, many questions remain and information on effective interventions is limited. Progress will require methodologically sound studies, better understanding of physician practice culture, adequate funding and collaboration efforts. I urge us all to move forward together.
Contact me anytime by emailing president@cms.org ■
• CMS calls for research on best practices to help reduce administrative burden. We are currently working diligently through our third focus – organizational interventions – which is exciting and promising, and involves a boots-on-the-ground strategy and listening to our members. C O LO R A D O M E D I C I N E 4
C OV E R
S TO RY
DEVELOP A PROCESS
Physician wellbeing is about you, your workplace, our culture and beyond - and the time to act is now Martina Schulte, MD, Chair, CMS Committee on Physician Wellbeing
PROMOTE AUTONOMY AND SELF-CARE
CULTIVATE COMMUNITY
Welcome to a special issue of Colorado Medicine that puts the focus on you – Colorado’s physicians – and your wellbeing. The writers, contributors, CMS staff and members of the CMS Committee on Physician Wellbeing are excited to share stories, ideas and expertise with you on this topic. The wellbeing of our Colorado physicians is vital to each of us personally and professionally, and is essential for the wellbeing of our patients and our health care system. So let’s jump in. Whether you’ve heard the terms burnout, moral distress, satisfaction, wellness or professional joy, or whether you have a different preferred way of talking about the professional situations of yourself and your colleagues, we physicians are hearing a lot these days about it all. Each label or description elicits emotions, associations and, sometimes, reactions in our minds. Many leaders and frontline doctors want to move away from the term burnout because they see it as blaming or shaming the individual for his or her situation. And some organizations have attempted to address burnout simply by encouraging individual resilience. To move from the idea of individual blame and individual responsibility, the conversation has changed to working toward joy in practice, wellness and professional fulfillment. Certainly those are the goals, and this issue will touch on many ideas for moving in ALIGN that direction.
MEANING AND VALUES
Regardless of the vernacular, something serious and concerning is happening to health care professionals in the workplace and we must understand it so we can make meaningful and effective interventions. The work environment is rife with cultural and systems challenges that are leaving many feeling emotionally exhausted, detached from the very patients and colleagues we choose to serve, and wondering if we are accomplishing what we intend or want. These are the symptoms of burnout,1 and medical data suggests that nearly 50 percent of us are experiencing some or all of these.2,3,4 5 C O LO R A D O M E D I C I N E
It is easy to identify issues that impact our workday: productivity requirements, billing and regulatory requirements, hours of electronic health record documentation, diminished say in scheduling, challenges with referrals and medication choices, less time to connect and share with colleagues, systems inefficiencies for which physicians often try to compensate, and so much more. While it is the individual who experiences the symptoms, burnout is caused by the work environment.1 Here is a quick lesson on what we know about drivers of burnout in the workplace.1 From the work of Christina Maslach, an American social psychologist and professor emerita of psychology at the University of California, Berkeley, the six aspects of the work environment that drive burnout are workload, autonomy (or lack of it), values and meaning, fairness, community, and reward. All six of these directly relate to what many of us experience in our clinical practices or other health care workplaces. Addressing these driving concepts underlies many of the interventions currently being tried and recommended. In this issue, you will read stories of reclaiming control and autonomy, building community, and changing practice situations to align with personal values. Nationally, as the focus moves from individual-level interventions to combat burnout to organizational responsibility, the
C OV E R
SIX ASPECTS OF THE WORK ENVIRONMENT THAT DRIVE BURNOUT
WORKLOAD
AUTONOMY (OR LACK OF IT)
VALUES AND MEANING
conversations are about changing the work environment to prevent burnout and to facilitate meaningful engagement.5 The main organizational focuses are on measuring wellness, burnout and satisfaction, and then enhancing workplace culture and addressing workplace inefficiencies. Having had my own experience of burnout in primary care, and now having worked as a coach with many physicians navigating their work and careers to create sustainable experiences, I hear repeatedly how dismissed or unvalued physicians feel in the workplace. We all need and want to feel valued, and when our ideas are ignored and our concerns about systems and safety appear to be disregarded, it is disheartening and devaluing. Addressing workplace culture is vital to reclaiming engagement and fulfillment. Workplace culture includes leadership, voice, authentic and ongoing acknowledgement and appreciation, and building a truly supportive workplace community. When I ask people I work with to tell me of their best work experience, they nearly always credit working with a great team; having time to do some work they truly loved such as teach, write curriculum, try new workplace interventions, etc.; or having a terrific boss. It seldom includes statements like seeing fewer patients, receiving high payment or compensation, or having a sabbatical. In other words, when we reflect on our best work experiences, they are usually great because the workplace environment created a space to do good work, feel that our work is truly noticed and valued, have support from colleagues and boss, and have some freedom and say in our workday and tasks. Culture matters – and so influences the efficiency and effectiveness of workplace. Continually improving workplace systems and workflow are crucial to physicians spending more time doing face-to-face care and less time on administrative care tasks. The section of this issue starting on page 19 contains stories on efforts to enhance care delivery systems. While I have so far stressed workplace interventions including culture and efficiency, we each remain responsible for taking care of ourselves in ways that mean we arrive at work in a state that allows us to be present, contribute and cope well with the challenges inherent in our work. That means our attention to self-care matters. Investing in our own care, our relationships and our growth are essential. Sometimes, caring for ourselves means asking for help or reaching out for professional assistance. Historically, we physicians have not been good about recognizing when we need help or asking for it. We too often hold ourselves to unrealistic expectations and see our humanity
FAIRNESS
COMMUNITY
REWARD
as a weakness. Reaching out for help, in informal or formal ways, is crucial to our wellbeing, and I invite you to read the stories starting on page 9 and explore the resources within, as well. But a word of reality first. There is no clear, easy or simple quick fix to burnout and creating professional fulfillment. Or, as our CMS President Debra Parsons, MD, says, no “secret sauce.” The leading organizations around the country working on this employ multi-pronged approaches, and research is still ongoing to learn best practices for desired results. With that word of caution, this issue aims to share stories and ideas that may give you realistic and doable options as you pivot to creating your own professional fulfillment. You will read some colleagues’ stories of personal journeys, ideas for workplace and individual interventions, and some organizational actions that are already in the works around our state. I extend a special thank you to all our colleagues who have shared their stories and expertise in this issue. Your willingness to share in order to serve us all is essential to making true progress in combating isolation and creating community as we move forward. There are ideas for big groups and for individual practices, ideas for employed physicians, academics, specialists and primary care doctors. I welcome you to read ahead, and I am confident you will find connection in the stories, lots of ideas, and maybe even some new thoughts worth more exploration. Please enjoy and let us know your thoughts and suggestions by emailing enews_editor@cms.org. ■ 1. Maslach, C., & Leiter, M.P.(1997). The truth about burnout: How organizations cause personal stress and what to do about it. SanFrancisco, Calif: Jossey-Bass. 2. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Physician Burnout: A systemic review. JAMA. 2018;320(11):1131-1150. doi:10.1001/jama.2018.12777. 3. Shanafelt TD, Hsan 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(12):1600-1613. 4. Shanafelt TD, West, CP, Sinsky C, et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017. Mayo Clin Proc. n XXX 2019;nn(n):1-14 n https://doi.org/10.1016/j. mayocp.2018.10.023. 5. Noseworthy J, Madara J, Cosgrove D, et al. Physician Burnout is a Public Health Crisis: A message to our fellow healthcare CEOs. Health Affairs Blog. March, 2017: 10.1377/hblog20170328.059397.
MAKE A SYSTEMS CHANGE
C O LO R A D O M E D I C I N E 6
F E ATU R E
Key research findings on physician burnout It costs approximately
More than
HALF
$500K
of U.S. physicians experience burnout
to $2M and
12-14 mos.
Each 1 point increase equates to a
43% GREATER
to replace a physician
Burnout is shown to increase the risk of medical errors by
200%
It is estimated that
80%
of burnout is related to organizational factors
likelihood of clinical reduction within 24 months
Primary drivers of physician burnout
High workloads Increased time spent in documentation
?
Loss of meaning in work
Social isolation at work Cultural shift from health values to corporate values
Workflow inefficiencies
On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7,600 per employed physician each year.
Bottom paragraph: Shasha Han, MS; et al. “Estimating the Attributable Cost of Physician Burnout in the United States,” Annals of Internal Medicine. Vol. 170, No. 11, 4 June 2019
7 C O LO R A D O M E D I C I N E
Impact of burnout at your organization Fill in your own numbers online: edhub.ama-assn.org/steps-forward/interactive/16830405
E X TR A
Thanks to the Committee on Physician Wellbeing, our editorial board for this special issue of Colorado Medicine
YOUR PRACTICE
500
Number of physicians at your center
54%
Burnout
7%
Turnover
$500,000
Cost per physician BURNOUT IMPACT
12.3
Number of physicians turning over due to burnout per year
$6,136,364
Projected cost of physician turnover per year due to burnout INTERVENTION COST
$1,000,000
Cost of intervention per year
20%
Anticipated reduction in burnout INTERVENTION SAVINGS
4.5%
Turnover without burnout
$1,227,273
Savings due to reduced burnout ANNUAL RETURN ON INVESTMENT
22.7%
Return on investment per year Infographic statistics from the American Medical Association presentation “Business Case for Wellbeing”
The CMS Committee on Physician Wellbeing met on April 29 to begin planning the July/August issue of Colorado Medicine. In addition to the April 29 meeting, which some members attended by phone, committee members provided feedback to editorial staff through a file-sharing platform. From left: Mark Fogg, JD; Lucy Loomis, MD; F. Brent Keeler, MD; Michael Victoroff, MD; Oscar Sanchez, MD; Martina Schulte, MD; Elizabeth Yoder, MD; and Debra Parsons, MD, FACP. CMS Committee on Wellbeing Martina Schulte, MD (Chair) Clara Raquel Epstein, MD Mark Fogg, JD Doris Gundersen, MD David Hutchison, MD Andrew Kamel F. Brent Keeler, MD Lucy Loomis, MD Lela Mansoori, MD Dianne McCallister, MD William Neff, MD Debra Parsons, MD, FACP Patrick Pevoto, MD, RPh, MBA Christie Reimer, MD Deborah Saint-Phard, MD Oscar Sanchez, MD Donna Sullivan, MD Judy Toney, DO Michael Victoroff, MD Jennifer Wood, MD Alison Yager, MD Elizabeth Yoder, MD C O LO R A D O M E D I C I N E 8
F E ATU R E
I N D I V I D UA L
I NTE RV E NTI O N
Choosing to change
COLORADO PHYSICIANS SHARE WHAT THEY DID TO BE HAPPY IN MEDICINE AGAIN Kate Alfano, CMS Communications Coordinator
A survey of CMS physician members conducted in early 2019 revealed that 56 percent of those who reported that they are happy in medicine have enjoyed the practice of medicine throughout their career without any symptoms of burnout. But 40 percent of those who reported current joy in practice identified at some point that they were burning out and made a change to achieve their current state. With permission and without identifying the physicians, CMS shares some of the comments of those who took action to increase their wellbeing. A common theme among the responses is that the individual found their individual way forward or, often, a way out of a negative practice setting. Some chose to transition from larger to smaller practice environments, others did the opposite; some went from a private setting to employed and vice versa; others made a change of location. Within this context, readers can approach the accounts below as inspiration for early stages of moving forward, one individual at a time. The stories can serve as examples of the various paths physicians can take to regain joy in medicine, with the acknowledgement that all stakeholders can and must advocate for change in health systems and work environments that will ultimately make life more sustainable for the servants at its heart.
It is also crucial to acknowledge and support our colleagues suffering from mental health issues that can accompany burnout: depression, anxiety, increased suicide risk, and others.
HELP IS AVAILABLE. Chiefly, the Colorado Physician Health Program provides peer assistance services – aid for any problems that would affect one’s health such as emotional, psychological or medical problems – for licensed physicians and physician assistants of Colorado. They provide diagnostic evaluation, treatment referral and monitoring, and support services. Visit www.cphp.org for more. Other sources for resources, screening tools and help are Mental Health Colorado (visit mentalhealthcolorado.org/help) or Colorado Crisis Services (call 1-844 - 493-8255 or text “TALK” to 38255).
9 C O LO R A D O M E D I C I N E
F E AT U R E S
IN THEIR WORDS I was working five days per week with two and a half hours of paperwork and calls each night, barely having time to eat with my family or interact with my children, and topping this with call every third night and my worries about pay and employee tensions. Patient satisfaction and consumerism made me feel like I just couldn’t win. Many patients were happy but being a perfectionist, I let the unhappy 3 percent monopolize my thoughts. I was having nightmares. I felt like I could not keep my head above water and that I I reduced my schedule to three days a week instead of four, initially to spend more time with my teenage daughter and attend more of her school and sports events. I started taking Pilates classes the two days I was “off” and this morphed into starting yoga classes and then diving deep into yoga philosophy and meditation. I also became involved with the foundation board of the district library
system. A huge change that has contributed to a more enjoyable and relaxed lifestyle for me is that our practice uses a hospitalist service for our hospitalized patients. Our call nights are much quieter since we take office calls only and thus we get more sleep. Another advantage is that we are not spending full weekend days at the hospital so overall I feel more rested.
I worked in different settings before finding the right setting for me. I was initially employed in a multispecialty group, then joined a solo practitioner and finally worked in a single specialty group. I found abiding by other practitioners’ demands and expectations led to friction and gradual I was working at an FQHC and was completely burned out. I was seeing 26 to 30 patients a day and then had two to three hours of work at home. Administrators were no help as they just continued to force us to see more patients. I literally was constantly one to two hours behind, never took breaks and rarely took a lunch. It was too much. Over the
attention as well. When I dealt with a crisis in my extended family, I used this experience to join a group that allowed me to share my heart in a transparent way as well as to hear others share their experience, strength and hope. I needed meaningful connections, as well as prioritizing family relationships, physical and spiritual health.
the hospital adopted a hospitalist program and I bowed out of inpatient care. I now practice exclusively outpatient primary care with 1:5 call and am confident I will make it another 10 years or so to retirement. I also began vigorous cycling and triathlon hobbies and thrive in those activities.
During the first 15 years that I was in practice I was always able to set aside some time to do volunteer work. I felt that the reward of caring for people without access to health care made the time and financial sacrifices on my part seem miniscule. Now that I am in my mid 50s and my kids are off to college I have even more time to invest in patient care for those in need. I have narrowed down my commitment to two non-governmental organizations (NGOs) that I was in private solo practice, making less money and working harder each passing year but left to become
resentment of work and burnout. When I finally gained the autonomy of my own solo practice I was able to do things like I wanted, specifically focusing on patient care and staff happiness, and it’s the best thing I’ve done.
course of a year I built a direct primary care (DPC) practice and quit my employed job. I have been loving medicine again ever since. I completely removed myself from the model of insurance and managed care and transitioned to a model of a true patient-physician relationship. I couldn’t be happier.
After a painful period, I pursued a master’s of public health degree and focused more on population health. While I continued to see patients, I began to change my frame around what other factors were impacting health care. I think as a frontline primary care physician we can feel that it is impossible to get above the fray. I was able to see that the community was another “patient” that needed I was doing full-service rural primary care, including OB (non-operative, though on call to help operative colleagues), inpatient care and 1:4 call. I was heavily involved in my church and was snapping at folks. I knew a change was needed and I was told I needed to change. I dropped OB,
was really short-changing my marriage and family. It was unsustainable. I got very sick. Fast forward: Now I am in academics and teaching medical students. I love what I do and leave each day feeling energized, appreciated, and feel that I have really made a difference. My work is diverse, my colleagues are great and it is a non-competitive but interesting environment. I am still involved in organized medicine and really feel that my career was worth it.
do phenomenal work in Africa. The time that I spend here in my practice getting paid to work as a physician feels as if it is what I do in order to stay on top of my game as a clinician and have some residual income to spend working with people in need. The people that I meet and the places that I work in make these medical missions some of the most rewarding work of my career. The joy of medicine is in my heart nearly every day now.
an employed physician with an enormous multispecialty group and am enjoying medicine again. ■ C O LO R A D O M E D I C I N E 1 0
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The Colorado Physician Health Program: HERE FOR COLORADO PHYSICIANS, CONFIDENTIALLY Doris C. Gundersen, MD, CPHP Medical Director
Efforts to address issues pertaining to physician illness and impairment began as far back as 1958. Historically, medical boards considered addiction among physicians as a disciplinary problem rather than a health problem, consistent with the belief that addiction was a moral failure, rather than the disease we know it is today. U l t imatel y, s t ate phy sician heal t h programs were developed to assist physicians through rehabilitation and protect the public by monitoring the health of the recovering physicians in a confidential and supportive manner. Having this therapeutic alternative to discipline resulted in more physicians willing to come forward when needing assistance. Over time, physician health programs expanded in scope to include other potentially impairing illnesses such as mood and anxiety disorders, burnout and neurological disorders, to name a few. The Colorado Physician Health Program (CPHP) was developed in 1986. Since our inception, we have assisted over 5,300 physicians. At any one time, we provide supportive health monitoring to approximately 500 physicians. We see about 300 new physicians each year. Our ser vices are free to physicians licensed in the state of Colorado. We provide comprehensive health assessments, make timely referrals to needed treatment and monitor the progress of our participants as they recover from illness. CPHP also provides support and critical incident debriefing for physicians who are involved in lawsuits or who have experi-
enced bad outcomes. When necessary, CPHP advocates for our participants needing time off from work, modified duty or accommodations. CPHP provides education to the medical community on a regular basis. The topics include stress management, wellness, education about addiction and other occupational hazards physicians face. CPHP is devoted to conducting physician health research and has produced several publications accepted by peer-reviewed journals. Unlike the majority of physician health programs across the country, physicians in Colorado are afforded strict confidentiality from the medical board. With this confidentiality in place, the number of voluntar y participants has grown exponentially. With this model, CPHP is able to intervene early, before impairment develops and before the public is in jeopardy. With this confidentiality, CPHP assists more physicians each year compared to otherstates lacking confidentiality. Finally, a joint research project between CPHP and COPIC revealed that physicians who participate in our program – for any health problem – have a lower malpractice risk compared to physicians in the general community. We believe this is because physicians learn better selfcare skills in the process. Re m e m b e r, h e a l t h y d o c to r s g i ve better care! Please visit our website at www.CPHP.org for additional information on our services. ■
85%
of physicians who received services said that their coping mechanisms improved after interaction with CPHP
After involvement with CPHP, participants noted
improvement in
professional, personal and interpersonal
outcomes.
5,300 CPHP has assisted over
physicians since
1986
CPHP provides supportive
health
monitoring to
500 physicians
CPHP sees
300
new
physicians each year
free services
CPHP provides
to physicians licensed in Colorado
CPHP upholds
strict
confidentiality 1 1 C O LO R A D O M E D I C I N E
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IT’S PERSONAL Jeff Moody, MD
I was surprised at how easily it broke in two. I had finally reached the end of my rope with my EMR. Now what I had to show was the cracked halves of my keyboard in my hands, neatly divided in the middle, with stray, homeless keys strewn across my desk. The death-of-athousand-cuts interaction that I have with my EMR usually involves endless clicking, freezes and crashes. I had been pushed past my breaking point. Before I knew it, my keyboard was in pieces on my desk. I thought, “Is this what my work life has become?” I personally know of at least two other physicians who have smashed computers or screens while expressing their “frustrations” with an EMR. The endless loop; the failed integration; the helpless, hopeless time sink that had become the documentation of my patient visits had finally gotten the better of me. And, to date, no randomized study has proven the utility of electronic medical records in improving health care or reducing costs. I have to say that I was definitely feeling burned out. I still loved practicing medicine, but my work/life balance was out of balance. My keyboard was beyond repair. Hopefully, my life and my career were not. Since the “keyboard event,” as we call it in my practice, I undertook a comprehensive approach to personal and systemic changes on a number of fronts to reduce and eliminate burnout. Research shows that both personal and systemic changes must occur to produce long-lasting, significant change. It is helpful to think of your current situation as a box of your construction (no blaming, just naming), with a floor, walls and a ceiling. The floor is your cumulative learning, experience and education. The walls consist of work environment, mental, physical, financial, spiritual and social elements. The ceiling is any limiting beliefs you may hold. To effect change, assessment and action are critical. It is a simple process that when repeated is like peeling an onion. Start with the outer layers, then progress to the next, once you have success with the first. To assess burnout, pick first the one aspect of any “wall” of your box, or current situation, that seems to be the major driver of your burnout. In other words: What makes your blood boil on a regular basis? Write that down. Next, think of one action or planned intention you can take to improve, change or reduce the problem. Write that down. Let money or cost for the solution be no object in this thought experiment, for now. It will expand your creativity for possible solutions. 1 3 C O LO R A D O M E D I C I N E
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Next, put a deadline on your action plan. Behavioral science research shows that planned intentions with actions and deadlines triple the likelihood of completion of the task. Finally, take action on your plan! You have successfully attacked your first burnout driver. Now, repeat with whatever is next on your list of problems. Systemic changes are addressed in the same way, but simply require interaction with your group, employer or hospital system. Engage with your system, let them know how you are doing, what is good and not so good, and what you need to care for yourself. That should start a very productive conversation. Then, repeat the problem solution process detailed above. Problem. Intention. Deadline. Action. 1. 2. 3. 4. No more burnout anymore. Sorry, couldn’t resist. Let me give you examples of how this process worked for me personally and systemically. Personally, I had some real issues with insomnia, waking up at 2 and 3 a.m. thinking and stressing about my practice and any other problems going on, and then being completely unable to return to sleep, making the next day a draining, fatigued fog. This was something affecting the physical wall of my box. So I wrote down “insomnia.”
was teaching my medical assistant how to open the notes prior to me seeing the patients. I gave myself a one-day deadline. Teaching her how to open new notes took 15 minutes and permanently saved me more than 30 minutes per day. Voila! I magically had 10 hours per month and 120 hours per year of my life back!
changes over time yield large results. Even a 1 percent per day improvement, if compounded over a year, will yield a 3,700 percent improvement. I’ll take that. And, my new keyboard and I are doing just fine! ■
You may think this plan seems too simplistic or straightforward. But the real issue is lack of action once a problem is identified. Doctor, diagnose and treat this problem! We all do this all day, every day for our patients. Turn your energy, initiative and integrity towards yourself. This is what I have done for the past two years, and continue to do every day. The wonderful aspect of taking action is that you are taking back your control. The peace, sense of calm and new hope for my future practice of medicine, while taking action, have empowered me. I am no longer a helpless bystander, but an active change agent in my practice and my life. Small
Next, I educated myself about strategies for treating insomnia. I gave myself a week deadline to learn and start implementing new strategies. I wrote down four of the strategies I thought I could apply. I stopped using devices 30-60 minutes before bed. I “scheduled” time to attack my insomnia-creating practice problems during the day. I had a bedside journal for writing down any of these thoughts when they occurred at night to get them out of my head. Finally, I used meditative breathing while drifting off to sleep, counting the breaths. I rarely make it past six or seven before I am asleep. If I wake up in the middle of the night, I repeat the breathing process with very good results. Systemically, our EMR was very inefficient (I know, surprise!) at generating new or return notes, taking me about 30 minutes per day just to get them to open. So I wrote down “EMR note opening.” My strategy C O LO R A D O M E D I C I N E 1 4
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Wellbeing self-assessment for resident physicians Debra Parsons, MD, FACP
The years of residency training may be some of the most difficult of a doctor’s life as long hours are spent honing clinical and technical skills, facing difficult patient situations and decisions, and navigating the business side of medicine that can sometimes be in direct conflict to your mission as a physician. Add personal challenges – like balancing educational debt; buying a new home or car; making time for loved ones, for exercise, for your faith – and juggling daily life almost seems a Sisyphean task! I want to offer my perspective based on my experiences interacting with residents during COPIC’s educational sessions. Frequently, residents are surprised by their lack of wellbeing in various measured dimensions of wellness. I first ask, “why should we focus on physician health and wellbeing at the resident and student level?” They invariably answer that “healthy doctors live longer, lead more satisfying lives and are safer practitioners.” We discuss the literature that tells us that physician wellbeing and joy in the practice of medicine are associated with fewer medical errors, enhanced patient satisfaction and a positive environment in the workplace. And links between burnout and low professionalism are larger in residents and early-career physicians (<5 years post-residency) compared with mid- and late-career physicians. Yet inherent barriers may prevent physicians from seeking and receiving assistance when in need. Utilizing tools like the “DIMENSIONS: Work & Well-Being Toolkit for Physicians” can provide vital insight and self-awareness. The toolkit was produced by CMS and COPIC in partnership with the University of Colorado Behavioral Health and Wellness Program, and includes 10 evidence-based assessment activities. Self-assessment is imperative to the overall wellbeing of physicians in that it directs one’s focus and one’s actions towards a safer, more efficient and rewarding practice. During my COPIC presentations, residents complete self-assessment exercises and openly share their stories and perspectives. Many are amazed that their self-reflections reveal lower ratings in areas of emotional, social, spiritual, intellectual and even occupational wellbeing than the assumed financial or physical dimensions (although residents fall here as well). Most are committed to making a specific change to enhance their future wellbeing.
1 5 C O LO R A D O M E D I C I N E
5 minute
self assessment As a quick assignment, take five minutes to assess your own wellbeing across the eight dimensions described in the “DIMENSIONS” toolkit and listed on the opposite page. The idea is to develop insight as you reflect on where you are most well and where you have work to do. Rate yourself on a scale of 1 (low) to 10 (high) for each dimension. Circle one “low;” use it to set a specific goal and a plan for change. Accomplishing this goal will enhance your wellbeing and all of the benefits that come with being a well physician. Set the goal using the “S.M.A.R.T.” format:
SPECIFIC
Target a specific area for improvement
MEASURABLE
Identify indicators for progress
ATTAINABLE
Challenging but perceived as possible
REALISTIC
Achievable through available resources
TIMELY
Timeline in which goals will be achieved Reflect on your self-assessment and repeat it from time to time, aiming for another goal. It is not easy, but it is critical for your wellbeing. I believe that using this and similar tools will help you be safer and more efficient and have a more rewarding practice. And don’t forget: everyone needs support. Please make time to connect with a loved one, reach out to a colleague or ask for help if needed. ■
E X TR A
Eight dimensions of wellness See full descriptions of each dimension in the DIMENSIONS: Work & Well-Being Toolkit for Physicians at www.cms.org/articles/category/physician-wellness
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Environmental Wellness
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Financial Wellness
Social Wellness
Intellectual Wellness
Spiritual Wellness
Occupational Wellness
Emotional Wellness
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To our physician colleagues: WE SHARE YOUR PAIN
Mark A. Fogg, General Counsel, COPIC
I’ve spent a lot of time working on attorney wellbeing issues. Quite naturally, when CMS asked me to write an article on some of the common struggles shared by physicians and lawyers, I jumped in. So, here I sit at 1 a.m. writing on wellbeing. Hmm…does the term “oxymoron” come to mind? “Take the fear out of the legal system for physicians.”
I’ve represented hundreds of physicians in medical liability cases, many involving trials. I view doctors as kindred spirits: tough decisions, big impact on others, not enough time, and most went into their profession for the right reasons – service and a desire to help others. “I couldn’t stand your adversarial process,” many physicians have said to me. My adversarial process pales in comparison to yours in the struggle with sickness and death. I admit, a great deal of stress on physicians is imposed by my profession. My clients were on a spectrum between being so upset they were sued that they could not see straight to being unable to cope with a patient suffering an adverse event even though the care was pristine. Some clients called me daily and others were in such denial they had not opened the last 20 letters I sent. A high-ranking physician regulator once asked me if I could make one transformative change in the medical-legal system, what would that be? Without hesitation, I responded, 1 7 C O LO R A D O M E D I C I N E
Despite best efforts, physicians face a high likelihood of dealing with a claim or lawsuit during their career. The stress, frustration and anger that arises is understandable. In my role, I’ve always tried to be an advocate to help address these feelings, and this has allowed me to see the common afflictions that plague both our professions, which far outweigh any differences between us. Attorneys, like doctors, are suffering from chronic stress along with record rates of depression and substance abuse. Early exit from our professions is more common than others. There is no question that we need to assist those suffering with supportive programs and build professional cultures to encourage seeking help. But we also need to recognize that there are core values of our professions that are being undermined: grit, adaptability, resilience and flexibility. We need to retain these core values to maximize the positive traits of healthy professionals. We are discussing this robustly in the legal profession. The American Bar Association Task Force on Lawyer Well-Being issued an extensive report recognizing that lawyer wellbeing is “a continuous process in which lawyers strive for thriving in each dimension of their lives.” This includes emotional, occupational, intellectual, social, physical and spiritual dimensions.1 In an interesting study published in The George Washington Law Review, the factors of autonomy (being able to be authentic), relatedness (interaction with others), and competence far outweighed
the often-lauded factors of income, partnership, total billable hours and other seemingly objective benchmarks in achieving lawyer wellbeing.2 I believe these ideas relate to physicians as well. The high demands placed upon them can cause them to neglect their own personal wellbeing. Addressing this is not just about focusing on the individual. It also requires an examination of system changes and how healthy professionals make economic sense. In a task force under the leadership of Colorado Supreme Court Justice Monica Márquez, we formed a “making the business case for wellbeing” committee, which is creating an attorney wellbeing recognition program for law leadership to follow best practices in areas such as mentoring, alternative fee arrangements, and minimizing old hierarchical, vertical structures. All participants in the health care system must understand that it makes societal and economic sense to promote healthy physicians. We need to identify and instill those practices in our systems that strengthen our core values as professionals. ■ 1. American Bar Association, The Path to Lawyer Well-Being: Practical Recommendations for Positive Change (2017). 2. Lawrence S. Krieger and Kennon M. Sheldon, What Makes Lawyers Happy? A Data-Driven Prescription to Redefine Professional Success, 83 Geo. Wash. L. Rev 554 (2015).
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Team-based care and provider satisfaction Lucy Loomis, MD, MSPH, family physician, Denver Health
In the past five years, there has been increasing recognition of the importance of an engaged medical team for the delivery of high-quality medical care. The concept of the “Triple Aim,” conceptualized by Don Berwick, MD, of the Institute for Healthcare Improvement, encourages focus on simultaneously improving population health and patient experience, while also reducing costs. It was updated in 2014 by Thomas Bodenheimer, MD, and Christine Sinsky, MD,1 to the “quadruple aim,” including joy in practice. This concept recognized that if the workforce develops burnout while striving to achieve the triple aim, progress will be difficult to sustain. A high-functioning medical team is a key component to reducing burnout and improving engagement. Team-based care addresses many of the components of modern medical care that drive burnout including reducing administrative burden and workplace chaos, and increasing autonomy and camaraderie. There have been multiple studies of the impact of team care on improving joy in practice. In their review of 23 practices, Sinsky and Bodenheimer2 also recognized that “team-based care is shown to make primary care more feasible and enjoyable.” The IHI3 has also described “joy in practice” as a “fundamental redesign of the medical encounter to restore the health relationship of patients with a physician and health care systems.” In the primary care setting, there are numerous examples2 of key components of practice redesign that can improve physician satisfaction. The majority of the innovations are built on enhancement of the practice team, both through expanded team member roles, and efforts to build camaraderie, communication and teamwork. Improved communication and team cohesiveness through co-location, pre-clinic huddles, regular meetings, and real-time communication in the visit support team function and reduce rework. Enhanced team roles such as scribing, or medical assistants (MAs) assisting with order entry or inbox management, reduce documentation time. MAs can also assist with coaching and agenda setting, allowing for better focused visits. A lot of the routine work of prevention and chronic disease management is easily delegated to non-provider staff, freeing up physician time for patient interaction and relationship. For example, with additional rooming time, MAs can review medica-
BURNOUT RATES DROP after increasing the ratio of MAs to providers to 2.5:1 1 9 C O LO R A D O M E D I C I N E
tions, help set agendas, close gaps in care or complete forms, preserving time in the encounter for the provider to focus on the patient and his or her health concerns. These changes can also help improve satisfaction of other team members, and increase their sense of engagement with the patients. Here in Colorado, the University of Colorado Department of Family Medicine set out to test the effects of expanding the MA role.4,5 Starting in 2015 they increased their ratio of MAs to providers to 2.5:1, based on the University of Utah’s “Care by Design” model. MAs went through rigorous training and used structured protocols to function semi-independently. Each MA stayed with a single patient throughout the visit, and had more time to assist in documentation, as well as provide pre- and post-visit assistance. The additional MA assisted with in-basket management. Within six months after implementation, the burnout rates among providers dropped significantly, from 53 percent to 13 percent. Staff satisfaction also improved, demonstrating the benefits of the team-based model for all members of the team. Practice performance metrics for preventive and chronic disease care indicators also improved. With the gains in efficiency and performance, the practice was able to increase visits enough to offset the costs of the additional staff, without affecting provider satisfaction. Since 2016, the model has been adopted by many other sites in the UCH system. ■ 1. Thomas Bodenheimer, MD and Christine Sinsky, MD, From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, Ann Fam Med November/December 2014 vol. 12 no. 6 573-576. 2. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3): 272–278. 3. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at ihi.org.) 4. Wright A, Katz I, Beyond Burnout – Redesigning Care to Restore Meaning and Sanity for Physicians. NEJM 378:4 Jan 25, 2018. 5. Lyon C, English AF, Chabot Smith P, A Team-Based Care Model That Improves Job Satisfaction, Fam Pract Manag. 2018 Mar/ Apr;25(2):6-11.
53%
13%
BURNOUT RATE BEFORE MA INCREASE
BURNOUT RATE AFTER MA INCREASE
SAVE
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Beyond burnout: The path to vitality David Ehrenberger, MD, Chief Medical Officer, HealthTeamWorks www.healthteamworks.org
“Houston, we’ve got a system problem” A paraphrase of the
profoundly understated quote from astronaut Jack Swigert of Apollo 13
It is an alarming paradox that as our health care system evolves and achieves higher quality, patient-centered care, there is a growing epidemic of physician and care team burnout. To many, this disconnect represents a “systems problem,” most notably at the frontlines of health care delivery: the community-based delivery of care. Scott Hammond, MD, a family physician leader and president of Westminster Medical Clinic, shares this insight: “Burnout is not [fundamentally] a ‘workload problem.’ It is a work distribution problem exacerbated by workflow inefficiencies, non-value-added work, and loss of autonomy and purpose.” This article will explore a systems approach to understanding and addressing burnout, one that is designed to promote vitality in practice, helping physicians (and their care teams) improve the care they give and the lives they live. These practical tips, based on our experience working with practices across Colorado and nationally, are further illustrated by insights from a webinar panel discussion on burnout conducted in March 20191 that included three Colorado physician leaders: Debra Parsons, MD, an internist and president of the Colorado Medical Society; Corey Lyon, MD, a family physician, associate professor at the University of Colorado School of Medicine and associate program director for the family medicine residency; and Hammond.
CRITICAL STEPS TO BUILDING VITALITY IN PRACTICE 1
ORGANIZATIONAL COMMITMENT
THE NEW LEADERSHIP COMMITMENT:
Creating and formalizing organizational commitment to promoting physician (and team) wellbeing is the first step. This can begin modestly with a small group – or one or two physicians in a small practice – studying and sharing the national data on burnout (prevalence, etiology, impacts on engagement, productivity, suicide, etc.). To ensure a commitment to addressing burnout, however, requires sponsorship and championship by senior leadership and formalizing this commitment in the form of a policy or charter establishing, for instance, a “practice vitality committee.”
2
MAKE THE DIAGNOSIS
Select and use a screening tool, such as the Mini-Z Burnout Survey2 and the Maslach Burnout Inventory HSS (MP), to quickly and easily assess the prevalence and severity of physician burnout at the practice or institution. This critical step can also be done across all staff and repeated periodically to monitor progress and to maintain focus and commitment to improvement. Hammond and Lyon stress the importance of proactive engagement of staff and providers and recommend surveying attitudes, the experience of work, and burnout on a regular basis. Lyon uses the Mini Z survey to assess staff burnout, includes both providers and medical assistants, and notes that a meaningful interval for these surveys is approximately every six months. 2 1 C O LO R A D O M E D I C I N E
Hammond stresses that multiple levels of leadership across a practice are essential to address burnout, especially when practices are neck-deep in the work of practice transformation. As an example, the leadership model at his Westminster Medical Clinic is a dyad structure where the practice administrator, Caitlin Barba, plays a critical role in developing and growing a culture of change (“a learning lab”) and a “patient-centered healing environment.”
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DEFINE THE LOCAL “PATHOPHYSIOLOGY”
What are the major drivers of stress and burnout specific to your practice? Simple tools, such as staff surveys or focus groups, can be used to understand what is most stressful or frustrating in the experience of work and care delivery. From this, prioritize a short list focusing on the big impact – and the impactable – pain points. Examples may include non-clinical workload, staffing ratios, EHR workflow inefficiencies, panel mix, clinical workflow issues, or lack of voice.
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CREATE AN ONGOING BURNOUT TREATMENT AND PREVENTION PLAN
With a clear idea of the degree of burnout and its drivers, develop your practice plan to address and test evidence-based “system changes” that promote provider and team engagement, top-of-license care, and workflow efficiencies. Here, it is useful to begin by studying Lencioni’s “5 dysfunctions of a team” to better understand the strengths and weaknesses of your team(s) and the profound roles high-functioning teams play in the healthy workplace. 3 Common best-practice system changes include: A Invest in and grow non-traditional skillsets across your staff. Examples include training physicians in leadership and management, MAs in population health management, and/or RNs in care management. B Explore innovations in care team design and staffing including Bodenheimer’s Teamlet model,4 improved staffing ratios, the addition of new team members (e.g., care manager, behaviorist, clinical pharmacist) and the use of scribes. At CU’s AF Williams Family Medicine Center, the work, training and workflow of MAs is critical to the encounter. Lyon notes that their team-based care model, with an optimal MA:Provider ratio of ~2.5:1, has increased visit volume and patient access, improved clinical quality and decreased provider burnout by 50 percent.5 C Enlist the care team in improving the health IT experience. This could include exploring HIT workflows, looking for efficiencies and opportunities for team-based documentation, or investing in tools to mine and leverage clinical data used to excel in value-based care. D Study and practice wellbeing skills and strategies. Parsons points to the “Work & Well-Being Toolkit for Physicians” as an excellent online resource from the Colorado Medical Society and the Colorado University Department of Behavioral Health.6 Christine Sinsky, MD, Tait Shanafelt, MD, and Mark Linzer, MD, all national experts in physician burnout, have built the Steps Forward Professional Well-Being website, a free seven-module resource out of the American Medical Association.7,8
5 LEVERAGE HUMAN-CENTERED DESIGN OF THE MODERN CLINICAL OFFICE SPACE The traditional physical design of the office practice is based on a physician-centered workflow. Modern “human-centered design” can dramatically improve “top-of-license” care efficiency through principles of team member co-location and line-of-sight space workflows.9
“I CAN DO THAT!” Lyon provides this perspective on empowering your team: “For years, MAs’ training and guidance focused on a very narrow definition of their scope of practice – what they were not permitted to do.” His recommendation for top-of-license MA training and roles? Change the predominant attitude from “can I do that?” to “of course I can do that!” 5 The impact at AF Williams Family Medicine Center: • Rooming typically takes 20 minutes and includes exploring the patient’s agenda, updating the medical record to capture changes in the patient’s history and medications, and documenting basic complaint-based HPIs using care protocols to address a variety of patient diagnostic and preventive needs. • MAs then stay with the patient during the visit and capture the clinical encounter data in the EHR as “documentation assistants.” • Post-visit, MAs review the care plan, execute orders (e.g., labs) and schedule/ coordinate next visits and referrals.
THE OFFICE SPACE INSIDE OUT Hammond shared that over the past year, Westminster Medical Clinic invested in changing its clinical office space to emphasize “what works” to support efficiency of both “advanced teamwork” and patient-centered care. • Key changes focused on co-location of seven providers and their supporting staff. • Benefits include line-of-sight efficiencies, promotion of horizontal hierarchy, and the sense and culture of effective teamwork. • These changes power the work of the advanced care team – as Hammond exclaimed, this human-centered redesign of his practice is a “great burnout buster”! PAGE 21 ⊲ C O LO R A D O M E D I C I N E 2 2
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BECOME A LEARNING ORGANIZATION
Improving and sustaining vitality is an ongoing and collaborative learning process to promote meaning and purpose in the work of clinical care. This means baking the performance improvement and change management sciences into the practice’s routine: A Create venues for sharing, studying and learning from performance data. B Build and maintain safe venues to engage and give voice to staff in the improvement process. C Embrace ongoing, proactive change as key to learning and staff engagement. D Leverage the coaching resources of your local IPA or practice transformation organization.
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HAPPY BUSINESS IS A HAPPY PRACTICE
There is ample – though anecdotal – evidence that advanced primary care practices (e.g. PCMH) that translate their performance in patient-centered, team-based care into value-based remuneration are more fun, more engaging and better places to work. These practices tend to pursue every opportunity for non-fee-for-service payment. What are their secrets? These practices invest in, improve and transform their systems of team-based care, often with the support of a practice transformation coach, and demonstrate progressive improvement in market-relevant outcomes – quality, experience of care and cost efficiencies. They understand and make the connection between business vitality and physician (and team!) vitality. ■
STAFF ENGAGEMENT — UNDERSTAND THEIR STORY Hammond emphasizes that staff engagement in the change process around high-value, patient-centered care is critical and offers this advice: • Work to develop an effective learning organization where staff contribute at all levels of the clinic’s vision and operations. • Ensure staff understanding of and buy-in to the organization’s mission, vision and goals by also understanding their story, values and purpose. • Establish clear role definition and accountability.
WELLBEING WIDGET • Define the “wellbeing widget” for each team member: what each role does best and finds fulfilling; e.g., for physicians and providers, the clinical evaluation/diagnosis/treatment and the relationship with their patients. • Use performance improvement and change management methodologies for ef fective and sustainable changes that optimize the “wellbeing widget.”
HealthTeamWorks® helps medical practices, physician organizations and integrated delivery networks improve their performance in delivering value-based services. Our subject matter experts and solutions help providers improve clinical quality outcomes, patient experience, and provider vitality, while reducing the escalation in per capita cost of medical care.
1. Burnout and Vitality in Practice: Expert Panel. HealthTeamWorks Webinar (March 13, 2019). https://www.healthteamworks.org/event/expert-panel-burnout-and-vitality-practice 2. Mini Z Burnout Survey. Preventing Physician Burnout: Step 3 https://edhub.ama-assn.org/steps-forward/module/2702509 3. Lencioni, P. (2005). Overcoming the Five Dysfunctions of a Team. San Francisco, CA: Jossey-Bass 4. Bodenheimer T, Willard-Grace R. Teamlets in Primary Care: Enhancing the Patient and Clinician Experience. J Am Board Fam Med 2016;29: 135-138 5. Lyon C, English A, Smith PA. Team-Based Care Model Than Improves Job Satisfaction. Family Practice Management; March/April 2018;6-11 6. Work & Well-Being Toolkit for Physicians (Colorado Medical Society). https://www.bhwellness.org/toolkits/Work-and-Well-Being-Toolkit-for-Physicians.pdf 7. “Professional Well-Being”- AMA Steps Forward Learning Module 8. https://edhub.ama-assn.org/steps-forward/pages/professional-well-being 9. “Creating the Organizational Foundation for Joy in Medicine” – AMA Steps Forward Learning Module https://edhub.ama-assn.org/steps-forward/module/2702510 10. McGough P, Jaffy M, et al. Redesigning Your Work Space to Support Team-Based Care. Fam Pract Manag. 2013 Mar-Apr;20(2):20-24
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Where can an organization start? WITH INVESTED PHYSICIANS
The Colorado Permanente Medical Group (CPMG) is known for innovation in health care delivery, using a team approach to care for 645,000 Kaiser Permanente Colorado members each year. With nearly 1,200 physicians, CPMG is one of the state’s largest multispecialty groups and a physician-led practice. So it comes as no surprise that they are on the forefront of physician wellness or, their preferred terminology, joy in work. It began with a small group of CPMG physicians realizing that CPMG’s wellness challenges and needs were unique. Together, they created the CPMG Wellness Committee in 2013. In 2017, CPMG created a dedicated role for a wellness director. Lise Barbour, MD, assumed this role; she is accountable for wellness activities and integrating wellness with human resources programming. Concurrently the CPMG Board of Directors committed to filtering all decisions through the “quadruple aim:” improving the health of populations, enhancing the experience of care for individuals, reducing the per capita cost of health care, and improving the work-life balance of health care providers.
On the organizational level, CPMG’s focus is on supporting adequate staffing and administrative resources that allow physicians to provide high-quality care to patients. Stephen Haley, MD, CPMG’s vice president and chief medical informatics officer, has set a team goal of creating physician time in the work day for “what matters most.” His Department of Medical Informatics coordinates Clinical IT Efficiency (CITE) workshops to help doctors become more efficient at Electronic
Medical Record (EMR) technology. And CPMG continues to measure physician joy in work with a twice-yearly engagement survey. Though CPMG is unique in many ways, other organizations looking to implement a wellness program may consider the broad blueprint of their experience to enhance physician joy in work. ■
Most of CPMG’s wellness work is a combination of encouraging individual wellbeing and seeking to create a culture of wellness with systemwide programs, keeping joy in work as a primary focus. In 2019, CPMG’s wellness work includes recognizing physicians for excellent work, engaging physicians at community events, celebrating Kaiser Permanente Colorado’s 50th anniversary, and investing in leadership development. Peer recognition has been streamlined with the invention of “ColoRADograms” – a virtual thank-you note that any physician can send to their colleagues, which also is shared with each colleague’s supervisor. These are especially important internal initiatives in a time that Kaiser Permanente Colorado is working to better meet patients’ demands for accessible and affordable care. C O LO R A D O M E D I C I N E 2 4
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Fostering and supporting physicians’ wellbeing WHAT DOES IT TAKE? Martina Schulte, MD
Leading national health care organizations have put forth frameworks for creating healthier work environments for physicians through developing engagement and fostering joy.1,2,3 I summarize the common and recurring elements for wellbeing programs below, but I want to start with what some might call a “soft ingredient,” one I see as vital to any successful effort:
creating a workplace where each physician feels truly known and valued. I draw from my professional experience as a coach specializing in burnout in physicians, nurses, advanced practice practitioners and others. Most of those who reach out to work with me are at or near the end of their rope. Some are ready to leave their physician job the day I first meet with them. Others want to figure out how to make their work and personal life sustainable because neither feels that way to them in their current form. One of the first things I do with physicians is ask them to spend time thinking, talking and defining their values. To do that, I ask them to recall peak or positively important work or personal experiences. Experiences are often “peak” because they are times of fully living our values and are also times when we feel a sense of mastery. In talking through these times, people define their own values, in their own words, connected to lived experiences. There is one desire that surfaces for everyone – to be valued. Sometimes people relay stories of a particular period at a job. In talking about the peak time and what made it so, they often describe the people they worked with, feeling supported and respected by their boss, working on initiatives or projects that excited them, and express being truly seen and feeling valued for what they did.
Conversely, when people first seek me out to discuss making a change in their work, the most common issue is not being valued in their job. I relay these coaching moments to drive home the point that any wellbeing program has to begin with understanding the fundamental need to be valued that even, and perhaps especially, physicians have. As more of us work in employed situations, it is even more important to pay attention to this need and driver of disconnection. My belief and zealous opinion that real physician wellbeing has to authentically begin with a healthy work environment was recently boosted by a short piece in JAMA Internal Medicine.5 The authors found physicians in an academic medical center who felt valued for their work were more satisfied. It seems an obvious conclusion, but the fact that it has to be studied and proven is interesting. Investing in social capital and demonstrating value and respect for employee staff, be they physicians or all our other health care colleagues, need to form the foundation for a physician wellbeing program. While not explicitly stated in the engagement or wellbeing frameworks currently available in the medical literature, creating a healthy workplace where physicians are engaged, listened to, respected and supported are implicit parts of each of them.
1. 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. 2. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. 3. AMA Steps Forward: https://edhub.ama-assn.org/steps-forward/pages/professional-well-being 4. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432-440. 5. Simpkin AL, Chang Y, Yu L, Campbell EG, Armstrong K, Walensky RP. Assessment of job satisfaction and feeling valued in academic medicine [published online May 6, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed.2019.0377. 2 5 C O LO R A D O M E D I C I N E
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Studying three frameworks for physician wellbeing in the workplace – from the Mayo Clinic, the Institute for Healthcare Improvement, and AMA Steps Forward – common themes emerge. Creating environments where physicians are well and can thrive include these key elements.
ACKNOWLEDGE AND ASSESS THE PROBLEM The AMA recommends an annual wellness survey. Other organizations have a physician wellness indicator. The IHI says start with the question, “What matters to you?”
DEVELOP AND USE AN EFFECTIVE PROCESS FOR MAKING TARGET WORKPLACE INTERVENTIONS This component is specifically directed at workplace processes and inefficiencies: identifying the impediments to joy in work in the local context. This includes, but is not limited to, workflow redesign, staffing, workplace chaos and electronic health record use.
COMMIT TO SYSTEMS WORK TO MAKING CHANGE Addressing local issues (above) is essential, but so is organizational commitment to addressing real workplace change.
CULTIVATE COMMUNITY Invest in social capital to create truly supportive and safe working environments.
ALIGN MEANING AND VALUES Having a work environment where one can regularly live one’s values and connect with one’s meaning greatly enhance satisfaction and wellbeing.
FOSTER LEADERSHIP! Develop it and leverage it to improve the work experience. Industries outside of health care, and now even in health care, recognize that leadership matters in workplace culture; in fact, leaders often dictate workplace culture. Leadership impacts satisfaction, burnout, turnover, and the general sense of being valued and heard.
PROMOTE WORKPLACE FLEXIBILITY AND AUTONOMY To build sustainable physician lives, the ability to make decisions over one’s work experience and responsibilities is essential.
PROMOTE HEALTHY SELF-CARE While this should not be the only component of workplace wellbeing programs, it has a place as part of them. Making self-care easier and normal are ways organizations can support self-care.
While these ideas come from national organizations addressing burnout, here in Colorado, practices and organizations are developing their own physician wellbeing programs. As Jeff Moody, MD, notes in his article on page 13, you must start somewhere and do something. Few programs start in a comprehensive way. Most begin with one or two steps and build over time. Every well-done effort provides help and adds to the scaffolding for the next step or two. Beginning with understanding the issue and making first steps is vital! ■
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Is it them or is it me? M. Victoroff, MD
Occupations expose their practitioners to intrinsic and extrinsic stresses. For health care, some intrinsic stresses are taking call, emergencies, night shifts, interruptions, coping with fatigue, sorrow, people in distress, errors and falling short of your own expectations. You knew these when you signed up.
Extrinsic stresses are things you didn’t necessarily foresee and aren’t inherent to the job. These are things like difficult bosses, colleagues or subordinates, unrealistic schedules, administrative burdens, balky technology, nonsensical regulations and dysfunctional organizations. They can also be political or social conditions completely extraneous to medical practice.
interaction problems without group interactions. And, these may need to be externally facilitated to avoid making things worse.
Distinguishing between “it’s me” and “it’s them” means overcoming guilt, resentment and doubt. This is where peers are vital, when given a chance. Mythology stereotypes doctors as “loners” and “fixers.” If you are a self-sufficient type, you will There is a well-intentioned trend to address stress from both often be exposed to trolling in today’s hypercritical culture, but sources with programs for individual “wellness” or “resilience.” less often offered help. Objectively working the me/them probThis can be a mistake. For intrinsic demands of the profession, lem on your own is pretty much impossible. You need a trusted network for reality testing. But, networks individual measures like lifestyle hygiene, demand care and feeding. Not everybody has pacing and self-care are valid. But, organizathem. Medical professionals are more isolated tional problems usually need organizational “They” could be sure these days than ever before, and bona fide solutions. Yet, despite more of us spending the problem is you. social networks – in contrast to synthetic more time in more organizations, we are not counterfeits – are a threatened species. as well served by them as we should be. You could wonder Being offered self-improvement remedies for if “they” are right. It’s unavoidable to reflect on your own temperextrinsic stresses can feel condescending or ament, unless you are a narcissist or sociopath. victim-blaming. A lot of times, it turns out the problem comes “They” could be sure the problem is you. You could wonder from interactions between the environment and your personal if “they” are right. Your defense could be to disengage (“I just constitution. Don’t necessarily accept the broad whitewash, mind my own business and go home”) or to enroll in the bubble “you see, it’s all of us!” That’s a lazy analysis. All of us don’t of a protection-group. Both tactics are counterproductive in have equal roles in creating working conditions. But, the fact organizational terms. The evidence-based solution is elevating that a lot of stress is from external causes doesn’t mean they are awareness of group process to the same level of attention other necessarily malicious. That’s paranoid (usually). A constructive important business matters receive. Of course, this is annoying, starting point is to assume, “all of us are trying imperfectly to intrusive and time consuming. But, it’s hard to see solving group do our best.” 2 7 C O LO R A D O M E D I C I N E
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One tactic is to name the stress and treat it as if it were a person in the room. Not an enemy to be destroyed but a colleague to be invited in, worked with, listened to empathically and coached. Might the stress be open to change? Many of us reach a point when we think, “why do I always have to be the mature professional? Why can’t I be the cranky person once in a while?” But, unconstructive behavior creates a negative spiral. The solution to exasperation is not to hit your boiling point and ventilate. It’s to take turns being the adult in the room so that no one gets imprisoned in that role. Role shifting is an indispensable skill in effective groups. One is a helper; another asks for help; one calls attention to a problem; another is attached to the problem. If you’re depleted from patient care, you’ll have a hard time summoning energy to help a peer. But, you could still recognize the need. Professionalism is not the ability to eliminate conflicts of interest. Professionalism is the ability – and the obligation – to manage conflicts of interest. Healthy organizations monitor the energy needed for group hygiene and make sure it’s well spent. It’s possible to find yourself in a fix that isn’t fixable. That’s when you pull the ripcord and get out. Doubt is one of the stages. “Am I a quitter?” “Should I just try harder?” Again, answering this calls for help from your network. Well-functioning organizations understand the importance of professional networking. If the doctors’ lounge is empty at lunchtime, chances are the organization is under stress. Human networks are the root and the remedy for a lot of stress. Research shows the best groups are diverse and inclusive. They tolerate disagreement, conflict and discomfort. They push through these to create solutions that a homogeneous group could never achieve. “Comfort groups,” where everybody is compatible, are objectively less creative, productive and successful than groups where sincere disagreements are constructively resolved. If you are in a setting where you are content and happy all the time, you can be sure someone else isn’t.
High performance teams are populated by imperfect people who manage boundaries well and compensate for each other’s blind spots. Members rapidly identify needed changes and adjust to them. This kind of organization is the most rewarding to work in, and the sort we want to cultivate for health care. ■
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Collective Resilience Chad D. Morris and Cindy W. Morris
The World Health Organization recently updated the definition of burnout. Now considered a syndrome tied to chronic workplace stress, burnout has increasing legitimacy as a global issue, an issue which clearly affects too many physicians. At the University of Colorado Behavioral Health and Wellness Program (BHWP), we are committed to promoting wellness and preventing burnout. We believe that work and wellbeing demand individual commitment as well as institutional transformation, simultaneously focusing on resiliency for individuals, agencies and health systems. Wellness is a multifaceted approach to living and our team utilizes a parallel process to support health care providers’ whole health goals while facilitating the systems change necessary to support individuals’ wellbeing.
To support Colorado’s physicians, BHWP partnered with CMS to create the DIMENSIONS: Work and Well-Being Toolkit for Physicians, available online at www.cms.org/articles/category/ physician-wellness. This toolkit acknowledges the many competing demands physicians face and provides brief strategies for assessing values, building awareness of personal wellness, and implementing realistic life goals. Toolkit users are guided through a sequence of short learning activities to support healthy lifestyle change. Since this toolkit’s release five years ago, we have utilized the information, activities and resources contained within our toolkit to educate and support practicing physicians as well as physicians in training. Whether at the beginning, middle or end of a career in medicine, there is a consensus that in order to truly provide health care, it is essential to refocus on creating sustainable and supportive workplace practices. To this end, BHWP has partnered with health care organizations to collect and integrate data from our Workplace Wellness Assessment, which includes a workplace wellness survey, site
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visits, focus groups and key informant interviews. We examine organizational workflows, employee benefits, applicable policies and programs, and salient community linkages to identify ways in which organizations can create an environment that facilitates wellness. Synthesizing these data, we are able to offer comprehensive recommendations that assist agencies to “start where they are” and work towards wellness solutions aligned with agency missions and strategic goals. Based on assessment of organizational readiness for change, BHWP also utilizes tools such as communities of practice (CoP) to promote system improvement. CoPs are rooted in social learning theory under the assumption that the best teachers are those with similar professional and life experiences. CoPs use distance learning platforms, which offer structured, peer-learning environments that combine didactic experiences and companion facilitated peer-learning sessions. Through the participation of interdisciplinary wellness champions in CoPs, we have found that health systems change is not only possible but probable. Once an organization takes even a single, incremental, time-limited step toward a wellness goal, there is
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a ratcheting effect that make subsequent changes more easily realized. Developing a pipeline of physician wellness leaders is key to such initiatives, once again reinforcing the complementary growth of individuals and systems. These health care professionals who are activated to attend to their own wellness are the best positioned to advocate for health care systems transformation. Indeed, many providers believe that acting as a wellness champion for colleagues is a core component of their own wellness regimen. With an increased personal awareness, these physicians are more apt to lead organizational change focused on critical issues such as a sense of job control, workload balance, and team-based care associated with job satisfaction. We look forward to continuing our partnership with CMS and other interdisciplinary provider groups to further promote individual wellbeing, develop physician wellness leaders, and together bolster our collective resilience. For more information on our programs please visit www.bhwellness.org or contact us at BH.Wellness@ucdenver.edu. ■ Further reading Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., ... & Esmail, A. (2017). Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA internal medicine, 177(2), 195-205. Swensen, S., Kabcenell, A., & Shanafelt, T. (2016). Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience. Journal of Healthcare Management, 61(2), 105-127. West, C. P., & Hauer, K. E. (2015). Reducing burnout in primary care: a step toward solutions. Journal of General Internal Medicine, 30(8), 1056-1057. World Health Organization (2019). Burn-out an “occupational phenomenon”: International Classification of Diseases. Retrieved from: https://www.who.int/mental_health/ evidence/burn-out/en/
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Charting a course together
A SURVEY OF THE 25 LARGEST GROUPS IN THE CMS MEMBERSHIP Dean Holzkamp, CMS Chief Operating Officer
The Colorado Medical Society reached out to 25 of the largest organizations in the CMS database – 50 percent of which represented specialists, 28 percent multi-specialty groups and 27 percent primary care – to find out what different groups are doing to enhance physician wellbeing and address burnout. Interviews were conducted by phone and included a short battery of questions. Interviewers asked to speak to the group’s top wellness officer, if they had one, or the chief medical officer.
structure of the programs, many of which seemed to evolve to meet the distinct needs of each practice. A near-unanimous supermajority of 96 percent of the groups interviewed reported interest in a wellness summit. Those who elaborated on their answer wanted to learn from other organizations and share ways to improve.
The interviews revealed significant awareness of physician wellbeing as a priority, with 88 percent reporting some sort of individual practice program in place or in development to be in place in the next year. There was significant variability in the
Several specifically praised CMS for suggesting the idea, including one that said, “I commend CMS for taking the bull by the horns. The more we explore together, the better course we can set.”
Some questions received fewer than 25 responses; some received more than 25.
1
Has the board of directors of your practice made physician wellbeing a priority?
48% TWELVE - 48% of the practices answered a definite yes and have a program.
20% FIVE - 20% answered a definite no.
20%
FIVE - 20% reported a version of “sort of” and reported having partial programs.
12% THREE - 12% reported not now but they have plans to start a program in the next year. 3 1 C O LO R A D O M E D I C I N E
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Does your program include
PERSONAL WELLNESS:
SIXTEEN - 64% report that their practice does have some sort of personal wellness program. This number includes both practice-sponsored wellness programs and individual employee-sponsored activities.
36% 64%
NINE - 36% report that their practice does not have a personal wellness program.
ORGANIZATIONAL MEASURES TO REDUCE BURNOUT (LISTENING TO PHYSICIANS AND ADDRESSING THEIR CONCERNS, SUCH AS WITH WORKFLOW OR CLINICAL SUPPORT):
NINETEEN - 83% report that their practice does have some sort of organizational wellness program. Most center around administrative simplification, help with technology and systems flow. Some answered this question interchangeably with the question on third-party interference.
17%
83%
FOUR - 17% report that their practice does not have an organizational wellness program.
THIRD-PARTY INTERFERENCE, SUCH AS DEALING WITH HEALTH PLAN PRIOR AUTHORIZATION PROGRAMS OR OTHER THIRD-PARTY INTERFERENCE, WHETHER FROM THE COMMERCIAL OR GOVERNMENTAL SIDE:
52%
48%
TEN - 48% report that their practice does have some sort of wellness program that addresses third-party interference. ELEVEN - 52% report that their practice does not have a wellness program that addresses third-party interference.
CMS board approves “uniquely Colorado” physician wellbeing project At their May 17 meeting, the CMS board of directors approved a project recommended by the Committee on Physician Wellbeing that will include: • A day-long convening for physicians from different systems and practices who are responsible within their system or practice for assessing burnout and enhancing physician wellbeing and professional satisfaction; • Keeping the convening participants connected virtually for a 12-month period for the purpose of an ongoing learning and sharing collaborative; • Contracting with a qualified expert in the field of wellbeing to monitor and moderate the virtual platform; • Conducting a thorough evaluation at the end of the period detailing lessons learned, impacts, spread, value to CMS and other partners, and opportunities for the future; and • Pursuing funding and grants from other sponsors in addition to general CMS support. The convening will likely take place in 2020. Look for more details as they are available. C O LO R A D O M E D I C I N E 3 2
F E AT U R E S C H A R T I N G A C O U R S E T O G E T H E R : C O N T
CMS is having discussions about holding a one-day summit on physician wellbeing. The summit would primarily include individuals who are responsible for addressing physician burnout and promoting wellbeing at the practice or system level. If CMS held this summit:
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GENERAL: SIX
PERSONAL WELLNESS: EIGHT
21%
28%
WHAT TOPICS AND ISSUES WOULD BE HELPFUL TO YOU AND YOUR GROUP?
THIRD-PARTY ISSUES: FOUR
14%
PHYSICAL BURNOUT: FOUR
14%
ORGANIZATION WELLNESS: SEVEN
24% MAYBE: ONE
4%
NO: ONE
4%
WOULD YOU FIND IT HELPFUL TO LEARN WHAT OTHER PRACTICES ARE DOING TO ADDRESS PHYSICIAN BURNOUT AND TO ENHANCE PROFESSIONAL SATISFACTION?
YES: TWENTY-TWO
92%
NO: ZERO
PROBABLY OR MAYBE: EIGHT
33%
0%
WOULD IT BE HELPFUL TO YOU TO BE CONNECTED TO A NETWORK OF PHYSICIANS IN COLORADO WHO ARE RESPONSIBLE WITHIN THEIR SYSTEM OR PRACTICE FOR ASSESSING BURNOUT AND PUTTING MEASURES IN PLACE TO INCREASE PHYSICIAN WELLBEING?
YES: SIXTEEN
The notable subtext behind most of “probably or maybe” answers centered around the quality of the content and the amount of time it would take.
67%
IS THERE ANYTHING ELSE YOU WOULD LIKE TO TELL US, EITHER ABOUT THE IDEA OF A WELLBEING SUMMIT OR ADVICE TO THE CMS COMMITTEE ON WELLBEING?
Those who answered this open-ended question shared the distinction of not providing one duplicate answer. Additional ideas given include inviting rank-and-file physicians; addressing culture change; reducing governmental administrative burden; providing usable tools for small practice; addressing documentation overload; sharing real stories; suicide prevention; addressing dysfunctional behavior; addressing distrust between facilities and physicians; including a job description for a wellness officer; including the Colorado Hospital Association and being able to use A/V tools.
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What is the likelihood that you would attend a wellbeing summit for physicians in Colorado who are responsible for wellness in their group? 4%
YES: TWENTY-THREE - 96% reported they or someone from their practice would attend. NO: ONE - 4% reported that nobody from their practice would attend. ■ 96%
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Component society wellbeing activities
BCMS: Supporting physicians through social and educational events Connecting with peers in social settings benefits physicians in multiple ways. Certainly it can help build referral networks but it can also bring back the proverbial water cooler – providing a place where physicians can check in with each other
about positive or negative outcomes, the latest medical knowledge or personal interests. The Boulder County Medical Society sees our bimonthly educational soirees and other no-agenda social events throughout the year as crucial to support-
ing the community of local physicians and encouraging physician wellbeing. Contact BCMS Executive Director Judy Ladd at bcmedsoc@aol.com for more information on upcoming events. ■
A PCMS event: Your work or your life? PHYSICIAN BURNOUT IN 2019 “Your career? Yourself? Your Life?” These were just three of the provocative questions 13 attendees considered at a physician wellness event hosted by the Pueblo County Medical Society on May 23, 2019. The small group setting lent itself to a warm and friendly learning experience as presenter Jeff Moody, MD, shared his personal and professional experience with burnout and the results of a survey on physician burnout he conducted with local physicians.
“Although we’ve been addressing the issue of physician burnout and wellness in our online newsletter and hosted the 2018 Heal the Healer symposium and the 2019 Physician Burnout event, our work is only starting; the need to address the issue of physician wellness in Pueblo is growing,” Law said. “We hope that we can count on our members for their continued support of our cause.”
Law encourages all Pueblo physicians to attend an upcoming PCMS event to connec t with peers in the local medical community. Watch for the next monthly enewsletter or contact her at 719-281-6073 or cheryl.law@pueblocms.org. ■
The survey found: • Nearly 40 percent of PCMS members sought treatment for burnout but 60 percent have not due to concern over privacy issues, • EMR documentation was the clinical activity contributing the most to burnout among members, and • Seeing patients caused little to no burnout among members. Subsequently, due to the size of the group, deeper discussions took place and relationships between colleagues were established. Hope and confidence were also inspired, said Cheryl Law, PCMS CEO.
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Do No Harm
PHYSICIANS GATHER FOR DOCUMENTARY SHOWING AND THOUGHTFUL DISCUSSION Kate Alfano, CMS Communications Coordinator The Colorado Permanente Medical Group in collaboration with the Colorado Medical Society hosted a screening in May of “DO NO HARM: Exposing the Hippocratic Hoax,” a documentary about the recent epidemic of suicides affecting the medical profession, at the Sie FilmCenter in Denver. Director Robyn Symon said in promotional materials that the film allowed those touched by suicide to “come out of the shadows to expose this silent epidemic and the truth about a sick health care system that not only drives our brilliant young doctors to take their own lives but puts patients’ lives at risk too.” A guided panel discussion followed the movie.
Doctors have the highest suicide rate among all professions – almost twice the rate of the general population – and more than 50 percent of physicians report feeling burned out. A July 2018 study by researchers at the Stanford University School of Medicine showed that physician burnout influences quality of care, patient safety, turnover rates and patient satisfaction, and that medical errors and burnout can double the risk of suicidal thoughts among physicians. The film focused mainly on systems issues in medical t raining and hospi t al medicine. Two panelists mentioned their aversion to the parallel focus on medical errors for raising questions about safet y without providing context. Panelist Martina Schulte, MD, an internist and chair of the CMS Committee on Physician Wellbeing, said physicians and administrators need to move away from thinking about burnout as an individual issue and approach it as an organizational issue. “Don’t tell us to be more resilient,” she said she has heard from her colleagues. “ When we think about systems issues, part of it is the culture we work in,” Schulte said. “Par t of systems change is not the efficiency piece; physicians want to be valued, they want to have control over their schedule, they want to be heard and when bad things happen they want a peer there to listen. Those are big parts of systems change.”
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Fellow panelist Abraham Nussbaum, MD, a psychiatrist and chief education officer for Denver Health, agreed. “The real key is to treat people like real human beings,” he said. He sits down with each person on his staff to identify their needs, asking: “I’d like to keep working with you; what will it take to do that?” Some mention higher pay, he said, but most mention other goals such as pursuing a research project, having a flexible schedule to have and raise a child, and others. An audience member posed a question about the nature of suicide and whether it is predictable and preventable: “The water is getting hotter and some of the molecules are going to pop off. Is it something you can identify in the doctor or is it in the temperature of the water? Is it avoidable?” Panelists agreed that physician suicide is preventable, but said that organizations need to find better ways to study it, build better data and identify those most at risk. Oscar Sanchez, MD, of CPMG, said the culture must change to make it more acceptable to show weakness, to move away from the façade of perfection. Another audience member shared her experience of burnout, expressing appreciation for comments by U.S. Surgeon General Vivek Murthy, MD, on the epidemic of loneliness affecting the population as a whole, including clinicians. “Nights like this where we come together are very important,” she said. “The medical school [UC Denver] is dropping some of the science and clinical requirements and creating a new pillar for community and health that includes wellness and resilience. We must support reaching out and connecting.” ■
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Physicians pack the theater for the screening and discussion
2-3 Attendees enjoy socializing and refreshments before the documentary begins. 4
CPMG’s Oscar Sanchez, MD, gives context to the film before its screening.
5 Panel members answer questions from the audience. From left to right: Doris Gundersen, MD, CPHP medical director; Samuel Clinch, MD, CPMG psychiatrist; Ami Khatri, MD, family physician and chair of the CPMG wellness committee; Abraham Nussbaum, MD, Denver Health psychiatrist and chief education officer; and Martina Schulte, MD, internist and chair of the CMS Committee on Wellbeing. C O LO R A D O M E D I C I N E 3 6
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Inherent stress and reward versus added stress and reward, and how to deal with each Martina Schulte, MD
Somewhere in the decision to become a doctor is a conscious or subconscious understanding of signing on for hard things. Dealing with complexity, challenges, painful conversations, and life-and-death issues are “knowns” about becoming a doctor. On some level, we accept these as inherent with the calling, and many of us even find great meaning and connection doing these hard parts of the job. These are inherent stresses that come with caring for patients, and inherent rewards are often tied to them. Beyond the inherent stresses are added ones. Examples of added stresses include productivity, EMR requirements, workflow and staffing issues, poor management or leadership, and subtle examples of not being valued. Added rewards include income, benefits, prestige, privileges, teamwork and recognition. Thomas Lee, MD, and Deirdre E. Mylod, PhD, provide a succinct and helpful description of these stresses and rewards in an article published in March 2019.1
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INHERENT STRESSES/INHERENT REWARDS Interestingly, trying to decrease the impact of inherent stresses by avoiding these hard parts of our work can decrease the inherent rewards we feel from connecting and assisting during challenging times. The inherent rewards of physician work include meaning, ability to help and heal, appreciation from patients, and sometimes practice improvement and leadership in clinical care. The overall goal is not to decrease the inherent stresses and thereby decrease some of the inherent rewards, but to maximize them. Instead of shying away from inherent stress, creating a space to experience it and share it with peers helps to raise one’s awareness of the experience and can add to pride in one’s work, or add to one’s sense of meaning.2 Health care organizations and medical societies are recognizing the importance of promoting time for collegial support gatherings and socialization. Additionally, the inherent stress of physician work that involves witnessing suffering and trauma dictates that more be done to assist physicians in processing and expressing the pain and challenges of these times. Increasingly, organizations are adopting peer-to-peer support programs to formalize this collegial support for each other at times of heightened stress from trauma and loss. Prototypes exist for these programs including the peer support program by Jo Shapiro, MD, at Harvard and Johns Hopkins’ “RISE: Resilience in Stressful Events.” The bottom line is that inherent stress is part of our work as physicians and embracing it in a healthy way needs to involve regular, supportive and collegial relationships where sharing the experiences and caring with each other in difficult times is the expected norm. Connecting with and supporting each other help optimize the meaning and inherent reward that comes with doing our life’s work.
ADDED STRESSES/ADDED REWARDS On top of inherent stresses are the added ones that we know well in our daily work. And there are added rewards, such as income, prestige, privileges, recognition and teamwork. But, unlike the connection between inherent stresses and rewards, added stresses are not connected to added rewards. For example, more of the added reward of income does not take away the challenges and, dare I say, frustration, anger or irritation of the time drain that often is the EMR. To mitigate added stress, individuals, practices and organizations need to commit focused attention on reducing work demands that are not connected to improving patient care. Interventions by practices and organizations are now happening, centered on improving efficiency and decreasing burdensome documenting and paperwork. Organizational approaches to addressing these stresses are many3 and some are discussed more in this issue. IN SUMMARY Though inherent stress of our physician work is often tied to the inherent reward, this does not mean nothing can be done to assist physicians in processing and managing these stresses more effectively. Much of this involves enhancing relationships and community. And, as added reward is not tied to added stress, added stress should be dealt with directly by initiating ways to lessen the work demands that comprise it. ■
1. Lee TH & Mylod DE. Deconstructing burnout to define a positive path forward. JAMA Intern Med. 2019;179(3):429-430. doi:10.1001/jamainternmed.2018.8247. 2. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533. doi:10.1001/jamainternmed.2013.14387. 3. 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. C O LO R A D O M E D I C I N E 3 8
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Techno toxicity? M. Victoroff, MD
“A system that promised to increase physicians’ mastery over their work has, instead, increased their work’s mastery over them.” Atul Gawande
There is a view that technology can be toxic, and health information technology (HIT), specifically electronic health records (EHRs), can harm users. Literature on provider burnout names EHRs as a substantial factor in stress and unhappiness. Proving whether this is true needs more study. But, hypothesizing how it might be true is a matter of observation. Given the implications if it were true, the precautionary principle suggests it would be prudent to consider mitigation early. This investigation is confounded by the fact that HIT is a moving target inseparable from health care organizational management, which itself is a stress. Let’s start by stipulating there is no reasonable case for returning to paper, just as there is no case for bringing back horse-drawn transportation. But, although internal combustion engines have wrought wonders, exhaust fumes still kill you. No matter how thrilled we are about emerging benefits of HIT, it is incumbent to do hazard appraisals on what we currently have. And, the preliminary data are worrisome. Safety for patients has long been a focus of clinical informatics. Safety for professionals lags. There are at least six mechanisms by which HIT/EHR exposure may plausibly injure users. Each of these are side effects of functions that are well-intended.
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ATTENTION IMPAIRMENT. Interacting with information on devices is impossible to do concurrently with other tasks, like texting and driving. Screen displays are compelling; they can misdirect and alter user attention detrimentally, induce bias and error, and interfere with human interactions. MOTIVATIONAL IMPAIRMENT. Performance and quality metrics – even legitimate ones – introduce conflicts of interest and goal distortion. Much of the heavy demand from EHRs for structured data is driven by managerial obsession with measurement and a distrust of workforce integrity. COGNITIVE IMPAIRMENT. Electronic devices deliver a volume of input that is frankly impossible to assimilate; this cannot currently be alleviated by automation. User interfaces are often incompatible with individual patterns for information management. Interrupt-driven design is discordant with human thought processes. Even the way screens display data may interfere with cognitive operations. MOOD IMPAIRMENT. Awareness of continuous surveillance, hyper alertness for errors, production pressure and the moral hazard of distorted priorities can produce anxiety, depression, irritability, fatigue, and difficulty transitioning between settings and roles. NEUROLOGICAL IMPAIRMENT. Screen exposure itself may remodel brain circuitry, interfere with sleep and possibly alter neural reward, reinforcement and learning pathways. METABOLIC AND MUSCULOSKELETAL IMPAIRMENT. At a mundane – but non-trivial – level, it has long been recognized that fixed visual focus, repetitive motion, postural strain and prolonged sedentary activity are health hazards.
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The promises of HIT were only wireframes 40 years ago, but early adopters instinctively knew better information tools would make us better doctors. Our exhilaration was like it must have been in the heyday of the printing press. No one noticed that linotypes gave off lead vapor. Some early informaticians foresaw, but were powerless to prevent, the transformation of computers into antagonists. The mutagen was provider hesitance to invest in HIT. Filling the financial shortfall with a giant federal subsidy was the only way to catalyze adoption that would meet the desperate need to automate claims processing – and utilization review – at the payer level. Evangelists touted clinical benefits but the financial model was entirely grounded in accounting. Inside the DNA of every EHR today sits a cash register. This repurposed the design and configuration of health information technology away from the needs of providers and patients to secondary benefi-
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ciaries (payers and regulators). Developers simply followed the money. Preoccupation with revenue was just an abscess in the body of medicine in the days of paper claims. It became full-on gangrene with electronic submission. The return on investment for HIT has become capturing charges, tracking production and mitigating fraud. Perhaps adverse reactions to EHRs are risks that only impact the older generation. Maybe it’s just cognitive stiffness. Or, maybe practitioners who have lived the transition from paper to cyber are canaries for threats that impact everyone. Recall the fate of the women who painted radium on watch dials in the 1920s. Or Google it…. ■
EHRs risks
Fuel for the journey: Book recommendations for wellbeing OFFERED BY THE CMS COMMITTEE ON PHYSICIAN WELLBEING
Self-Compassion: The True Power of Being Kind to Yourself
Kristin Neff Read expert advice on how to limit selfcriticism and offset its negative effects, enabling you to achieve your highest potential and a more contented, fulfilled life.
LifeForward: Charting the Journey Ahead
Pamela McLean Explore the concept of a LifeLaunch (the beginning of a new chapter) and how to design your own path regardless of age or situation.
When Things Fall Apart
Pema Chödrön Drawing from traditional Buddhist wisdom, find tools for transforming suffering and negative patterns into habitual ease and boundless joy.
The Book of Joy: Lasting Happiness in a Changing World
Desmond Tutu and the Dalai Lama How do we find joy in the face of life’s inevitable suffering? Two spiritual giants reflect on their lives filled with turmoil and how they have been able to discover peace, courage and joy.
Love for Imperfect Things: How to Accept Yourself in a World Striving for Perfection
Haemin Sunim Glean spiritual wisdom about learning to love ourselves with all our imperfections.
Boundaries
Henry Cloud and John Townsend Boundaries are essential to a healthy, balanced lifestyle; they define who we are and who we are not. Consider biblically based answers to tough questions, showing how to set healthy boundaries with parents, spouses, children, friends, co-workers and even ourselves.
Radical Acceptance
Tara Brach, PhD Understanding that our lives have become ensnared in the trance of unworthiness and feeling deficient, consider advice on taking the first step toward reconnecting with who we really are and what it means to live fully.
Transforming the Heart of Practice: An Organizational and Personal Approach to Physician Wellbeing
Dianne McCallister and Ted Hamilton This step-by-step guide offers a comprehensive exploration of burnout and physician wellbeing. More than 20 chapter authors contribute to the multidimensional volume, edited by Dianne McCallister, MD, member of the CMS Committee on Physician Wellbeing.
The Tyranny of Metrics
Jerry Z. Muller The “tyranny of metrics” that rules organizations threatens the quality of our lives and most important institutions. Explore the damage our obsession with metrics is causing and how we can begin to fix the problem. ■
Finding the Space to Lead: A Practical Guide to Mindful Leadership Janice Marturano Mindful Leadership training integrates the practice of mindfulness with the practical tools of management, enabling leaders to bring a wider range of their capacities to the challenges at hand.
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McLauthlin family donation preserves storied history of Colorado physician leaders Kate Alfano, CMS Communications Coordinator Susan McLauthlin, on behalf of her family, presented the Colorado Medical Society with a collection of medical memorabilia over three generations that includes numerous photos; the personal journal of her great-grandfather, Herbert Weston McLauthlin, MD; articles and letters illustrating the connection between her grandfather, Carl Addison McLauthlin, MD, and President Dwight Eisenhower; and other articles from her father, Carl Herbert McLauthlin, MD.
Herbert Weston McLauthlin, MD
Carl Addison McLauthlin, MD
A Massachusetts native, Herbert Weston (b. 1854) graduated from Harvard Medical School in 1882 and immediately moved to Denver to practice and for the benefit of his wife, Emma, who had contracted tuberculosis. She died in 1901. Herbert joined the faculty of the University of Colorado in 1884, first serving as a professor of pathology and histology; then professor of obstetrics and the diseases of women and children (1885); then professor of materia medica, therapeutics and clinical medicine (1893); and finally as chair of principles and practice of medicine (1894). In 1897 he became a professor of materia medica and therapeutics for the Colorado College of Dental Surgery at the University of Denver. Herbert served as health commissioner of the city of Denver (1885-1887); county physician of Arapahoe County (1886-1891); county health officer (1893-1900); a member of the Colorado State Board of Health (1898); and is credited with organizing the Denver County Hospital. He served as secretary of the Colorado Medical Society, as president of the Denver Medical Society (which was then called the Medical Society of the City and County of Denver) (1892), and as a member of the American Medical Association.
Carl Addison (b. 1888) was the youngest of Herbert and Emma’s three children. He graduated from the University of Colorado School of Medicine in 1913 and practiced in Pueblo for a period before returning to Denver to practice with F. H. McNaught, MD. Carl was a member of the staff of St. Luke’s Hospital, the Denver County Hospital and an attendant physician of St. Joseph’s Hospital. He also maintained memberships with DMS, CMS and AMA. He cared for many prominent Denver families including that of Mamie Doud Eisenhower. Carl remained “on call” to President Dwight D. Eisenhower when he visited his in-laws in Colorado and was later gifted a print of one of the president’s paintings for his years of service. With his wife, Vera, Carl had three children, Carl Herbert, Dorothy Jane and Robert Bradford.
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Carl Herbert McLauthlin, MD Carl Herbert (b. 1915) graduated from the University of Colorado with a pre-med degree in 1937 and from Harvard Medical School in 1941. He served as a captain in the army during World War II. He married Bonnie Ann Paterson in 1955 and the couple had two children, Carl Douglas (b. 1956) and Susan Kay (b. 1958). When Carl Herbert returned to Denver, he joined his father’s practice until his father’s death. He then went into partnership with Robert Macilhanney. Carl Herbert served as CMS president (1976) and passed away in 1977 from a brain tumor. Susan says, “He was a very skilled general surgeon, and a brilliant diagnostician, many of his colleagues coming to him when they had difficulties diagnosing a patient.” ■
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Physicians taking steps to reverse opioid epidemic nationally and in Colorado Kate Alfano, CMS Communications Coordinator A new report on opioids from the American Medical Association highlights the progress physicians are making to stem an epidemic that accounts for the deaths of roughly 130 people every day. The 2019 Opioid Progress Report found that physicians and other health care professionals are taking significant actions in the face of the epidemic, and some reports suggest that prescription opioid-related mortality may be leveling off. Yet, death from heroin and illicitly manufactured fentanyl and fentanyl analogs are at historic levels. OF NOTE IN COLORADO: Opioid prescriptions decreased. The rate of retail-filled opioid prescriptions has decreased to the lowest level in five years, cumulatively dropping almost 30 percent from 20132018. Almost 14 percent of that decrease happened between 2017-2018, putting Colorado efforts to decrease the rate of all retail opioid prescriptions above the national average for this time period.
2013-2018
30%
Opioid prescriptions dropped 30%
PDMP use increased. Physicians and other prescribers using the Colorado Prescription Drug Monitoring Program (PDMP) has exponentially increased since 2014 by about 650 percent. Since 2017 alone that increase has almost tripled; part of this utilization can be attributed to a law mandating PDMP registration for prescribers.
Physicians using PDMP increased 650%
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100%
100%
100%
100%
100%
50%
“The opioid epidemic is at a crossroads,” said AMA President Patrice A. Harris, MD, MA, who chairs the AMA Opioid Task Force. “While physicians must continue to demonstrate leadership by taking action, it is clear that these significant reductions in opioid prescribing, increases in prescription drug monitoring program (PDMP) use and taking more education – by themselves – will not stop people from dying.” The AMA Opioid Task Force is calling on policymakers and other stakeholders to eliminate all barriers to evidence-based treatment and to take specific steps such as removing prior authorization for medication-assisted treatment (MAT) for the treatment of opioid use disorder, enforcing state and federal laws that require insurance parity for mental health and substance use disorders, and ending health insurance company barriers to comprehensive multimodal, multidisciplinary pain care, including non-opioid alternatives. “The report shows that to save many more lives, policymakers, payers, PBMs [pharmacy benefit managers] and pharmacy chains must remove all barriers to evidence-based care,” Harris said. A separate dataset recently compiled by the Consortium for Prescription Drug Abuse Prevention also illustrates Colorado’s progress in decreasing certain targets set by the Centers for Disease Control and Prevention’s opioid guidelines, such as physicians writing fewer opioid prescriptions, improving prescribing practices and aiding in the reduction of patient doctor shopping. Consortium Executive Director Robert Valuck, PhD, RPh, noted that Colorado stakeholders have done a good job decreasing all of the CDC’s indicators over the past several years: “Taken together, these data points are very compelling in showing that Colorado doctors are taking the epidemic seriously and are changing their behaviors for the better in alignment with best practice goals and guidelines.” ■
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AMA Annual Meeting report: Colorado forges ahead Colorado Delegation to the American Medical Association
Your Colorado Delegation has returned from an engaged, productive and exciting AMA Annual Meeting, held June 8-12 in Chicago. Depicted by the Reference Committee as “the most important resolution of this meeting,” the House of Delegates passed a transformational policy that definitively states that health and health care are basic human rights clarifies the medical profession’s commitment to patients and their communities.
HEALTH, IN ALL ITS DIMENSIONS, IS A BASIC HUMAN RIGHT. RESOLVED that our American Medical Association acknowledge that enjoyment of the highest attainable standard of health, in all its dimensions, including health care is a basic human right (new AMA House of Delegates (HOD) policy); and be it further RESOLVED that the provision of health care services as well as optimizing the social determinants of health is an ethical obligation of a civil society. (New HOD policy).
The policy is a value statement and does not endorse any system or approach for delivering health care, but definitively places the AMA as the champion of patients. As health and health care consume more of the societal debate, the AMA having a true “north star” will allow physicians to have a constructive voice in the discussion. The AMA has also taken the bold step of suing HHS on the “gag rule” in Title X (AMA v. Azar Case 6:19-cv-00318-MC). While the AMA has been active in providing assistance to states and on federal issues with persuasive amicus briefs, the AMA took a firm stand against the recent federal rule that prohibited physicians from counseling or referring their patients according to their best medical judgment. The detailed presentation in federal court resulted in a national injunction while the rule travels through the courts. Your delegates continue to advocate for you and your patients, forging relationships and policy and providing Colorado’s experience as a guide for the rest the country.
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COLORADO DELEGATES ELECTED TO NATIONAL POSITIONS: • Tamaan Osbourne-Roberts, MD, was elected to the Council on Science and Public Health. • Jan Kief, MD, was appointed to the Council on Long Range Planning and Development. • Medical student Adam Panzer was elected as medical student section delegate and Halea Meese was elected medical student regional delegation chair. Panzer, Meese and Iris Burgard (MSS Region 1 alternate delegate) served as a bridge between the state delegation physician and medical student members. All of these positions provide opportunities to meet with the leaders, movers and shakers at the AMA.
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1 Lynn Parry, MD, testifies on the policy “Health Care is a Right. 2 Colorado medical students participate in the MSS Assembly. 3 The Colorado Delegation hosts the annual PacWest wine reception featuring Balistreri Vineyards of Denver. From left: CMS President Debra Parsons, MD; Tamaan Osbourne-Roberts, MD; David Downs, MD, FACP; and Rachelle Klammer, MD.
DELEGATES’ ACCOMPLISHMENTS IN POLICY: • The prior example of Carolynn Francavilla, MD, of “patientfirst language” for patients with obesity was followed by new policy on “patient-first language” for people who have medical conditions or disabilities. • Katie Lozano, MD, FACR, spoke in strong support of this new policy as it reflects how we should talk and think about patients and colleagues as people rather than as demonstrators of disease states. She continues to serve in her elected leadership position on the executive committee of the Radiology Section Council. • Lee Morgan, MD, and Brigitta Robinson, MD, continued to carry the voice of Colorado to our 14-state coalition of PacWest, providing leadership in the Council on Campaigns for the coalition. • Morgan also maintains her gracious and conscientious mentorship as chair of both the Colorado Delegation and as a section leader of five states in PacWest.
• David Downs, MD, FACP, testified persuasively on the need to remove barriers in the system to integrate mental health with primary care. • Michael Volz, MD, was involved in representing Colorado and PacWest in addressing various administrative issues facing medicine while also broadening his participation with the Chest-Allergy Caucus as well as the Internal Medicine Caucus. • Rachelle Klammer, MD, an unsung hero of the election process for Osbourne-Roberts, continued to liaise for the Young Physician Section as well as her emergency department colleagues. • Lynn Parry, MD, met with the Neuroscience Caucus and the Neurology Section as well as provided compelling testimony in strong support of the resolution that Health Care is a Right. • Deb Parsons, MD, CMS President, attended and shone in the inaugural ceremony for AMA President Patrice Harris, MD, a psychiatrist from Atlanta, who became the 174th president of the AMA and the organization’s first African-American woman to hold this position.
The AMA HOD continues to increase in diversity in many ways resulting in many resolutions and efforts to optimize patient access and care while improving the ability of physicians to provide care as trained. These topics covered broad territory from further supporting efforts on improving the opioid crisis to reducing the many administrative burdens for health care providers. ■
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VIEW ALL CANDIDATES’ STATEMENTS,
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Candidate statements
CVs and profiles on the election webpage of the CMS website, www.cms.org/articles/2019-cms-elections. The 2019 CMS election will be held Aug. 1-31, with all ballots cast electronically. Do you receive CMS enewsletters? If not, CMS may not have your email address. Contact membership@cms.org to update your contact information so you’ll be sure to get your ballot.
CANDIDATE FOR PRESIDENT-ELECT Sami Diab, MD
It is an honor to be considered for the position of president-elect of the Colorado Medical Society. As the landscape of health care continues to pose new challenges, CMS plays a critical role in addressing issues in public policy, physician wellbeing, and communication. I would like your support to work tirelessly with CMS to make a difference in the professional lives of physicians in Colorado and to improve the health of Coloradans and the Colorado health care system. I view leadership in health care as a three-legged stool of service: service to patients, to our clinical colleagues, and to the public interest. Each has its own challenges yet is considered in concert with the others. These challenges include, but are not limited to: PUBLIC/GOVERNMENTAL POLICY • Addressing the opioid crisis • Considering value-based care as an approach for improving quality and containing the unsustainable rise in cost of health care • Navigating ethical challenges related to conflict of interest and transparency in health care; these issues can be addressed through powered ethic committees and legislation PHYSICIAN WELLBEING/EMPLOYMENT/OTHER ISSUES • Enhancing the dialogue about resilience and wellness to include the systems-level contributors of burnout • Addressing the unique needs of the increasing numbers of employed physicians • Exploring mechanisms to avoid potential conflicts of interest between patients’ and physicians’ interests • Addressing scope of practice of other non-physicians working with patients • Advancing the science of medicine through unrestricted access to research
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COMMUNICATION • Increasing membership involvement and numbers with outreach to physicians at all stages of their careers and across all practice settings • Utilizing strategies to increase physician awareness of ongoing important work performed by CMS • CMS has a direct responsibility to advocate for honest, tough and open system changes, provide direct assistance to its membership, and support an environment where medicine is practiced on a foundation of caring and evidence rather than fear I believe that my experience in practice and organizational management, my dedication and passion for advocacy, and my formal leadership training combine to make me uniquely qualified to serve in CMS leadership. MY EXPERIENCE INCLUDES • Member, CMS Board of Directors • Member, Rocky Mountain Cancer Center (RMCC) Board of Directors • Member, RMCC Quality Committee, Managed Care Committee • Member, Research Executive Counsel RMCC and U.S. Oncology • Chair, Health One Institutional Review Board • Member, Medical Executive Committee at the Medical Center of Aurora (TMCA) • Member, CMS and U.S. Oncology Committees on Physician Wellbeing • Leader of several Quality Improvement Task Forces at the University of Texas San Antonio and RMCC I would be honored to serve all of you in this position and to work tirelessly to understand your concerns. I ask for your support to become president-elect of CMS to represent the interests of our patients, our profession and the public of Colorado.
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CANDIDATE FOR PRESIDENT-ELECT Patrick Pevoto, MD, MBA
I am relatively new to Colorado medicine, having moved to the Western Slope to practice in a rural setting after 25 years of practice in Austin, Texas. I am the son of a father who became a pharmacist, then a physician, as well as a mother who was a pharmacist. Medicine has been in my lifeblood and I knew my life calling was to become a physician. My father, who practiced pediatrics and emergency medicine, gave me many opportunities to shadow him as I grew up. I followed the same pre-medical track as my father in first becoming a pharmacist. I cannot think of a more excellent foundation moving toward medical practice.
I have been involved in organized medicine since medical school, which has included membership in the AMA. I was mentored by many fine physicians in Texas and I owe much to them for showing me that getting involved in organized medicine was truly an honor and special calling. I also discovered it is much harder to become involved than to stand on the sideline and criticize. To quote President Theodore Roosevelt from a speech given in April 1910: It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.
My practice in obstetrics and gynecology has involved all aspects of medical practice including solo, multispecialty, single specialty, and most recently as an employed physician. I have lived through the challenges of trying to run a practice, which included covering overhead when insurance companies stalled and delayed payments. There were times when I could barely make payroll. It was during those moments that the networks with other physicians available to me through involvement in organized medicine became priceless and kept me afloat during times of great adversity. I am grateful to the physician leaders in Colorado for giving me opportunities to serve in many capacities since coming to this great and beautiful state. I feel that I am well qualified to serve as your president-elect of the Colorado Medical Society. I humbly ask for your support and vote! You can reach me via my email at pspevoto@utexas.edu.
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CANDIDATE FOR AMA DELEGATION David Downs, MD, FACP, incumbent
I have practiced primary care internal medicine in Colorado for 35 years. I understand the challenges we face from payers and the support needed for us to practice high-quality, evidence-based medicine. Perhaps most important, I understand the need to sustain the intimate relationships we have with our patients. I have seen the benefits and pain caused by well-meaning policymakers who make decisions without understanding the complex world we work in. I have now served on the Colorado delegation to the American Medical Association for several years. I began as somewhat of a skeptic, having disagreed with AMA policy over the years. I found the organization to have arcane, sometimes byzantine, processes and politics. At the same time, it is one of the most democratic institutions I’ve worked in and offers a venue in which ideas, presented properly, are given a full vetting.
As the country continues to evaluate massive changes in how health care is structured and financed, the voice of the AMA is important and influential in the evolution of the health care environment. Our delegation is your avenue to express your concerns, aspirations and doubts into the process of policy development within the single largest physician organization in our country. While physicians see different paths to a better practice environment and alternative strategies to make safe, affordable, high-quality care available to everyone, I feel strongly that a consensus that respects differing points of view can be developed and that the AMA is a great place to begin the process of achieving that. Given our current political environment, consensus building in health care policy is sorely needed. I ask that you support me in bringing the voice of Colorado physicians to the AMA to promote the best policy options and to move them forward in national health policy development.
CANDIDATE FOR AMA DELEGATION Carolynn Francavilla Brown, MD, incumbent
I became an active member of the Colorado Medical Society almost the day I joined medical school. I was immediately drawn to this organization that championed the care of our patients and the betterment of our profession. I have always been a “big picture” person and identified organized medicine as the way to improve many issues in health care. I have been encouraged by the changes we have made in health care. At the same time, the day-to-day work of being a physician continues to become more burdensome; more physicians are employed by large medical groups and physician burnout is a serious problem. And, of course, more changes are coming. The AMA is a powerful voice in shaping health care evolution and I believe I have the experience to help move that change forward. We need to protect access to care while at the same time improving quality and reducing the cost of care.
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One year after residency, I decided to start my own practice, from scratch, with a partner. I have a small private practice in Lakewood that is a traditional insurance-based clinic seeing Medicaid, Medicare and private insurance. While many of my friends are already burned out and are disenchanted with the medical field, I love what I do and truly feel I get to help my patients every day. Starting a practice has been very educational and there have, of course, been many challenges along the way. For the Colorado Delegation, I bring a “boots-on-the-ground” perspective to the daily struggles of practicing medicine in a small practice. I am passionate about ensuring that physicians can still go into business for themselves. Thank you for letting me serve you in the Colorado AMA Delegation for the past two years, and I would look forward to continuing to represent Colorado physicians.
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CANDIDATE FOR AMA DELEGATION Jan Kief, MD, incumbent
Engaged and effective advocacy is my mantra as a Delegate for Colorado at the AMA! I also am proud to announce that I have been appointed to the national AMA Council on Long Range Planning and Development for the next four to eight years by the AMA Board of Trustees and the Speaker of the House. This prestigious council of 10 physicians looks ahead at how the AMA will position itself for the next decade. I am very honored to begin this work. It takes time to be known at the AMA and I feel that I am in an ideal position to represent you at the PacWest, a powerful coalition of 14 states, as the chair of one of their three standing committees. I have served in several capacities at the AMA and continue to learn as much as I can and work hard to understand the evolving climate of medicine – addressing physician burnout, AI, cybersecurity, EHR, genomics, payment reform, student debt, GME and more.
It is a privilege to be part-time faculty at Rocky Vista University and also to be 2017-2019 president of the CU School of Medicine Medical Alumni Association. Medical students are our physician leaders of tomorrow and we must be optimal mentors and partners with them on their journey. As a past president of CMS, I know how special Colorado is and how we lead the way in so many aspects of medicine. I am here to listen to your needs and be a responsive representative to you in Colorado and nationally at your AMA. I ask for one of your FIRST votes for delegate for AMA to continue this vital work. Contact me anytime at janmd@mac. com or 303-808-5325.
CANDIDATE FOR AMA DELEGATION Rachelle M. Klammer, MD, incumbent
The Colorado Medical Society and the American Medical Association have been an important part of my medical career. Except for my four years outside of Colorado for residency, I have been a part of our delegation since the spring of my first year of medical school. This year policy was passed in the AMA that was a culmination of items myself and others have been working on for greater than 14 years. It is a true testament to why institutional memory is important in health policy. As a medical student, I had the privilege to serve for two years on the AMA’s Council on Medical Service. This experience advanced my knowledge of health affairs and how government policies affect physician practices, and further broadened my understanding of how the AMA functions. Serving on the council also increased my network within the AMA; I worked with many members outside of my region and section.
Currently, I am an emergency medicine physician working at the Medical Center of Aurora where I see largely Medicaid and uninsured patients. Our hospital also serves a large immigrant community and has a high percentage of mental health and substance abuse patients. Every issue that is being discussed in local and national politics affects my patients and work environment. It is important that my patients are represented in health policy discussions. Since returning to Colorado, I have been a part of CMS’ delegation as one of our YPS delegates and am currently serving as an alternate delegate from CMS to the AMA. I would be honored to continue to serve and I respectfully ask for your vote.
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CANDIDATE FOR AMA DELEGATION Tamaan Osbourne-Roberts, MD, incumbent
There is much currently challenging the House of Medicine: novel payment models, changing systems of care, new and growing threats to public health, protecting the viability of independent practice, supporting the growing numbers of employed physicians. Within this context, physicians are too often separated from each other. The AMA has become a critical nexus of physician unity, a place where all voices can come together, share innovative ideas, and seek agreement to move forward. It has been my privilege to serve as a member of Colorado’s delegation to the AMA for the past eight years, including my recent election to the AMA’s Council on Science and Public Health; and I once again ask for your vote to continue as AMA delegate and councilor. My medical career, serving the underserved in both outpatient and inpatient settings throughout urban and rural Colorado, has given me an on-the-ground appreciation for the work of
practicing physicians in multiple settings, at the same time as honing my skills in finding creative solutions to the often difficult and intractable problems physicians face in the current business environment. My policy experience, as past president of CMS, past president of CAFP, alternate delegate to the AAFP Congress of Delegates, former trustee of the Colorado Hospital Association board, and in multiple other roles, has given me a deep well of policy experience from which to draw. Most recently, my work as CMO for both HCPF and CIVHC has allowed me to work to reshape Colorado’s, and America’s, health care system from the ground up, with a view to keeping physicians at the center of it. I hope that you will allow me the privilege of continuing to serve you, and our entire House of Medicine, during such a critical time. I ask for your support, and your vote.
CANDIDATE FOR AMA DELEGATION Lynn Parry, M.Sc., MD, incumbent
I am humbled and delighted to ask for your vote to continue to represent you as your delegate to the AMA. You should be as enthusiastic as I am that the AMA is protecting your relationship with your patients by suing HHS to prevent the new federal rule in Title X from going into effect. There is now a national injunction to prevent the “gag rule” – an attempt to tell physicians what they could tell their patients and where they could refer – from going into effect (http://cdn. cnn.com/cnn/2019/images/04/29/ama.pdf). As part of your Colorado Delegation, I have and will continue to advocate for decreasing administrative burdens for physicians, seamless integration of mental health into primary care, and eliminating discriminatory barriers for patients and physicians. Health care is likely to continue to be a political battle-axe in the foreseeable future. As your delegate, I recognize the importance of respecting and understanding all points of view as well as the
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passion that drives those viewpoints. However, I believe that each of us on your delegation places patient outcome, trust in the profession and the stability of science as our primary focus. Maintaining the integrity of the profession of medicine requires the voice of physicians to be heard above the chaos of other agendas. I will continue to work for addressing the systemic burdens that burns out physicians, changing the incessant demands that interfere with the joy of just taking care of patients. The AMA continues to diversify, change and move forward. I, my fellow Colorado delegates and our medical students are part of that evolution. I am continually learning: please continue to educate me on how you see the evolution of health, medicine and health care. I will listen.
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CANDIDATE FOR AMA DELEGATION Brigitta Robinson, MD, FACS, incumbent
I ask for your vote for AMA Delegate. I have attended the AMA meetings since I was a first-year medical student in 1991. Over the last 28 years, I was president of the Indiana State Medical Student Section and a delegate from Ohio in the Resident Physician Section during my surgery residency. In Colorado I began as YPS delegate and then chair of the Young Physician Section to the AMA (a national position). I became part of the Colorado Delegation to the AMA HOD in 2009. As vice speaker of our CMS House of Delegates I loved running our meetings. I helped our AMA caucus reform our bylaws, currently serve on our election committee and am a vocal member during our meetings. On the Physician Satisfaction Committee to the AMA I provide feedback on how to best support AMA members. There are so many benefits of being an AMA member. I believe all Colorado physicians should join.
Two years ago, I slipped back into an alternate delegate spot. My peers now hold many elected positions in the AMA and I want to serve you as a delegate again. I need your support to do that. I was president of Clear Creek County Medical Society and president of the PTO, and I aspire to have a fourth term on the CMS Board of Directors and run for CMS president-elect once my middle-school-aged children are a bit older. In short, I am committed to serving the physicians of Colorado on the state and national levels. Once again, I ask for your vote to be elected as one of your Colorado AMA delegates. I have made lasting relationships in the House of Delegates and life membership in the AMA has created bonds that are an asset to Colorado. I will help our voices be heard.
CANDIDATE FOR AMA DELEGATION Mike Volz, MD, incumbent
As physicians we share the same goals, mission and purpose as the American Medical Association – to promote the art and science of medicine and the betterment of public health – and the Colorado Medical Society – to promote the science and art of medicine, the betterment of public health, and the welfare of the medical profession and the patients it serves. We trained hard, work hard and pursue what is in the best interest of our patients. Today, there are more challenges and complexities in achieving these results than ever before. Single voices are not as well positioned, able or effective as organized groups of physicians to hear, understand and make changes in our efforts to overcome or mitigate these barriers. Connecting with our colleagues to best define areas and opportunities to unify and work has been and will continue to be at the core of being successful in these efforts. What is at stake is just too important to Colorado for us to not be fully engaged in an organized manner.
Throughout my career, my love and passion for medicine has been strengthened by caring for patients and being involved in CMS and the AMA. I have had the honor to serve as president of CMS, in my component society, and nationally and locally in my subspecialty of allergy and asthma. My solo practice has provided me with a rich source of experiences managing a practice and interacting with stakeholders critical to the day-to-day realities of providing medical care in the Denver metropolitan area and in my Kansas outreach clinic I’ve attended twice per month for 25 years. I believe my qualifications will provide the effective voice and mechanisms that Colorado physicians want and need to give to the AMA. I ask for your vote to continue to serve you. ■
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2019 CMS Annual Meeting Presidential Celebration and Inaugural Gala SATURDAY, SEPT. 14, 9 A.M. - 11 P.M.
JOIN US IN A CELEBRATION OF THE PRECIOUS ROLE OF PHYSICIANS AT THE DENVER MUSEUM OF NATURE & SCIENCE ONLINE REGISTRATION IS NOW OPEN AT WWW.CMS.ORG With all of the demands and stressors placed on physicians in practice today, it’s easy to lose track of what calls most to medicine – the desire to help people live full and healthy lives. This gift comes from our hands, hearts and minds and creates a precious bond that extends through the physician to patients, their families and the larger community. We are healers and leaders. Framed by this unique role of physicians, the Colorado Medical Society invites all members to celebrate the inauguration of incoming CMS President David S. Markenson, MD, MBA, on Saturday, Sept. 14. CMS will mark the occasion with an engaging day at the highly celebrated Denver Museum of Nature & Science – a delight to people of all ages that ignites passion for understanding and protecting our natural world through fascinating exhibits and interactive displays – culminating with a semi-formal Inaugural Gala that evening. All museum exhibits, including the special “Extreme Sports” exhibit, will be open to CMS members and their guests during normal daytime operating hours, with exclusive evening access to the Gems and Minerals exhibit during the Inaugural Gala. The gala will feature dinner, music, dancing, recognition of CMS and component society leaders, and the swearing in of 2019-2020 CMS President Markenson.
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The afternoon will include three hours of education geared toward the latest knowledge needs for members in all stages of their careers, from medical students and early-career physicians to late-career physicians and emeritus members. A ticket fee will be charged for admission to the gala; CMS will provide daytime admission tickets to the museum at no cost to members and their guests. Be sure to register all of your guests (including children) for each component of the event they will attend so staff can have an accurate count. Supervised childcare will be provided onsite through the Children’s Activity Center (recommended ages 2-12) throughout the day and evening. Advance registration is required. Ticket cost for the gala is $70 per person for active/emeritus physician members and their guests, and $30 per person for medical students. SPONSOR A STUDENT: If you would like to cover the cost of a medical student’s ticket to the gala, please indicate this during registration or contact dianna_fetter@cms.org.
SCHEDULE* 9 a.m. - 5 p.m. Denver Museum of Nature & Science open 9 a.m. - 11 p.m. CMS Children’s Activity Center open 12 p.m. - 1 p.m. CMS Finance Committee meeting 12 p.m. - 1 p.m. CMS Board of Directors lunch 1 p.m. - 4 p.m. CMS Board of Directors meeting 1 p.m. - 4 p.m. COPIC educatonal presentations 6 p.m. - 6:45 p.m. Exhibitor and Meet the Candidate reception 7 p.m. - 11 p.m. Inaugural Gala and COPIC dessert reception 6 p.m. - 11 p.m. DMNS Gems and Minerals Exhibit open for CMS members and their guests only *subject to change ACCREDITATION STATEMENT The Colorado Medical Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Colorado Medical Society designates this live activity for a maximum of 3.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Each presentation is valid for 1 COPIC point.
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Visit the 2019 CMS elections webpage Visit www.cms.org/articles/ 2019-cms-elections to view candidate statements and CVs for all candidates The following CMS physicians are running for office. President-elect (two candidates running for one position)
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Thank you to our event sponsors
The Colorado Medical Society thanks the sponsors of the 2019 CMS Annual Meeting, Presidential Celebration and Inaugural Gala. Be sure to visit with these companies during the Exhibitor and Meet the Candidate reception at 6 p.m. on Sept. 14. PRESENTING LEVEL SPONSOR COPIC GOLD LEVEL SPONSORS CareAllies CARR HEALTHCARE REALTY Colorado Drug Card Sunflower Bank & Guardian Mortgage The Therapist Group at Maria Droste Counseling Center UnitedHealthcare To learn about other marketing opportunities, including sponsorships, contact Mike Campo at 720-858-6310 or e-mail mike_campo@cms.org. ■
HOTEL ACCOMODATIONS Discount hotel accomodations of $99/night per room are available at Courtyard Denver Cherry Creek, 1475 S. Colorado Blvd., Denver, CO 80222, just four miles from the Denver Museum of Nature & Science. You must book before Aug. 14, 2019, to receive the group rate. Go to the event page www.cms.org/events/2019-presidential-celebration-and-gala for a link to make your reservation online.
• Sami Diab, MD • Patrick Pevoto, MD, MBA AMA Delegation (eight candidates running for eight positions) • David Downs, MD, FACP, incumbent • Carolynn Francavilla Brown, MD, incumbent • Jan Kief, MD, incumbent • Rachelle Klammer, MD, incumbent • Tamaan Osbourne-Roberts, MD, incumbent • Lynn Parry, MSc, MD, incumbent • Brigitta Robinson, MD, FACS, incumbent • Michael Volz, MD, incumbent The election will be held in August and all ballots will be cast electronically. All CMS members are encouraged to use this opportunity to vote, affirming the significant commitment of our organization to engage all members in the governance process. We also ask you to consider seeking a leadership position next year. More details on the 2020 nomination period will be available in September. Thank you for your participation in your medical society. ADVOCATE. EDUCATE. NAVIGATE.
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An overview of the Colorado Candor Act
RECENTLY PASSED LEGISLATION OFFERS A NEW APPROACH TO ADDRESSING ADVERSE OUTCOMES WITH PATIENTS Jean Martin, MD, JD, COPIC Legal Department Nobody wants to see an adverse outcome in health care, yet despite best efforts, these types of incidents occur. How providers deal with them and address the needs of patients is important because the provider-patient relationship forms the foundation of health care. Now, medical providers and facilities in Colorado have a new option to utilize in these situations — the Colorado Candor Act.
The recently passed Colorado Candor Act establishes a voluntary framework for health care providers and facilities to offer compassionate, honest, timely and thorough responses to patients who experience an adverse health care incident. It is designed to benefit patients, their families, clinicians, and health care systems by formalizing a non-adversarial process where there can be open communication about what happened, why it happened, and what can be done to prevent this in the future. Under certain circumstances, the process may include an offer of compensation.
WHERE DID THE LEGISLATION FOR THE ACT ORIGINATE?
HOW DOES THE CANDOR PROCESS WORK?
The Colorado Candor Act emerged from discussions between the Colorado Academy of Family Physicians (CAFP) and legislators at the beginning of the 2019 state legislative session. CAFP served as a strong advocate for the health care community and its patients by highlighting the benefits of Candor. CAFP worked closely with other stakeholders, including the Colorado Trial Lawyers Association and patient safety advocates, to garner support for this bipartisan measure that passed as legislation (SB19-201). WHAT TYPES OF INCIDENTS QUALIFY UNDER THE COLORADO CANDOR ACT? Adverse health care incidents arising from or related to patient care resulting in the physical injury or death of a patient. WHAT TYPES OF MEDICAL PROVIDERS AND FACILITIES CAN UTILIZE THE COLORADO CANDOR ACT? Physicians, physician assistants, podiatrists, licensed practical and registered nurses, advanced practice nurses, pharmacists, and others who are licensed, certified, registered or otherwise permitted to provide health care services in Colorado. In addition, hospitals and health care facilities including clinics, community health centers, community mental health centers, surgical centers, and residential care or nursing homes are eligible to participate jointly with a health care provider involved in the adverse health care incident. 5 3 C O LO R A D O M E D I C I N E
A brief overview of the process is as follows: 1 The process is initiated by the health care provider. 2 The written notice must be sent to the patient within 180 days of the incident. 3 The notice must include specific details about the patient’s rights and the nature of the communications/discussions under the Colorado Candor Act. 4 Under the Colorado Candor Act, health care providers and facilities may investigate and communicate about how the incident occurred and what steps are being taken to prevent a similar outcome in the future. 5 As part of their assessment, health care providers and facilities can determine whether an offer of compensation is warranted. 6 To facilitate open communication under the Colorado Candor Act, discussions and offers of compensation under the Act are privileged and confidential.
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CAN A PATIENT STILL FILE A LAWSUIT AFTER A CANDOR DISCUSSION? The Colorado Candor Act does not limit a patient’s ability to use the legal system. Patients can choose to withdraw from the Candor process at any time. However, the discussions and communications that occurred during the Candor process, including any offers of compensation, remain privileged and confidential. Under the Act, an offer of compensation does not constitute an admission of liability. In addition, if a patient chooses to accept an offer of compensation, a provider or facility may require a patient to sign a release of liability, so he or she cannot bring a subsequent lawsuit. WHAT REPORTING REQUIREMENTS APPLY TO THE COLORADO CANDOR ACT? Because no payments are made as a result of a written complaint or claim demanding payment based on a practitioner’s provision of health care services, incidents handled through the Candor process are not required to be reported to the National Practitioner Data Bank. Patients participating under the Colorado Candor Act do not waive their right to file a complaint with the relevant licensing board or the Colorado Department of Public Health and Environment, which oversees health care facilities. Where indicated,
a provider’s actions can also be addressed through Colorado’s professional review process for physicians, PAs and APNs, or a facility’s quality management process for other licensed health care professionals. States outside of Colorado may require notification of incidents where there is compensation under the Candor process for providers who are licensed in those states, including through the Interstate Medical Licensure Compact. WHAT ARE SOME OF THE OTHER BENEFITS OF THE COLORADO CANDOR ACT? A health care provider or health facility that participates in open discussions under the Act may provide de-identified information about an adverse health care incident to any patient safety-centered nonprofit organization for use in patient safety research and education. Such a disclosure does not constitute a waiver of the privilege for open discussions and is not a violation of the Act’s confidentiality requirements. The Colorado Candor Act goes into effect as of July 1, 2019. The Colorado Medical Society will work closely with partners, such as COPIC, to provide additional information and resources about the Act and how to utilize it in the coming months. ■
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Underlying principles that support the Candor process Gerald Zarlengo, MD Chairman & CEO COPIC Insurance Company
Candor can be defined as “the quality of being open and honest.” In health care, this term has been adopted to describe a framework for addressing adverse medical incidents in a way that preserves the provider-patient relationship, allows for open communication, and supports improvements in patient safety. The recently passed Colorado Candor Act enables health care providers and facilities to utilize this voluntary framework with patients.
While Candor may be a new term to some, it is based on a decade of research and ideas that many of us have come across during our careers. Candor emerged out of efforts by the Agency for Healthcare Research and Quality (AHRQ) as part of a toolkit developed to promote open, honest conversations with patients after adverse outcomes occur. The toolkit outlines a process designed to investigate and learn from what happened, to address patients’ needs, and to disseminate any lessons learned to improve future outcomes.
Since the AHRQ toolkit was released, the Candor framework has been utilized in various health care systems, demonstrated positive results, and Candor-related legislation has been enacted in Massachusetts, Oregon and Iowa. Throughout these efforts, some key underlying principles have been identified as crucial to the Candor process based on the insight derived and expert evaluation on what factors made a difference. These include the following:
FOCUS ON MEETING THE PATIENT’S NEEDS AND EXPECTATIONS DURING THE PROCESS Trust forms the basis of the provider-patient relationship. Crucial to this, after an adverse outcome, is providing an explanation of what occurred and what actions are being taken to prevent this in the future as well as an apology when appropriate.
ASSESS AND IMPROVE COMMUNICATION SKILLS Breakdowns in the communication process, whether with patients/family or other members of the medical team, are often at the root of medical liability claims. Communication is not an equally shared skill. There are good communicators and there are good systems to enhance the coaching of communication. The Candor process seeks to develop the skills required in these situations such as empathy, sincerity, active listening, patience, tact and emotional intelligence.
we want to learn what happened, why it happened, what normally happens, and what applicable procedures are required. Only then can we learn why adverse events occurred, and how we can implement policy, process and improvement mechanisms to prevent these from happening again.
REINFORCE EARLY REPORTING AND THE IDENTIFICATION OF ADVERSE EVENTS Creating an effective reporting culture around this requires a shift from blaming the individual to focusing on identifying system processes and related factors that contributed to the adverse outcome. Supporting a system that encourages rapid response also allows those involved to gather valuable information while the incident is fresh in everyone’s minds.
The Colorado Candor Ac t became effective on July 1, and it provides an opportunity to shift the way we address
CONDUCT INVESTIGATIONS FROM A SYSTEMS ANALYSIS APPROACH The reason for using a systems approach is that managing individual performance alone doesn’t ensure that an adverse event won’t happen again with a different provider. The Candor process highlights that, to strengthen system accountability,
adverse outcomes and improve health care. COPIC will be on the forefront of this and we look forward to supporting
SUPPORT EDUCATION BASED ON LEARNING All too often, we only learn about preventable causes of medical harm after the harm has occurred. Building a robust education platform based on analysis of adverse events will protect the next patient from harm. The educat ion should be case based, interactive and involve all members of the health care team. Debriefing following near-misses is an example of case-based education that protects the next patient and improves outcomes.
the health care community in embracing this change. ■
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The amazing nurse Miles Viseur
Miles Viseur is currently a fourth-year medical student at the University of Colorado School of Medicine. He is a Colorado native and the first in his family to pursue a career in medicine. He is interested in providing quality health care to underserved populations and plans to match into family medicine where he can provide holistic and comprehensive care.
The hustle and bustle of the emergency department. It is bright and loud and smelly Doing this and that Presenting him or her My stomach is gurgling Where is my coffee? The call comes in “Elderly found down” 10 minutes out Now we wait Some nurses’ chit chat Small talk and jokes. The snap of a glove. The patient arrives. No more smiles She looks so small I can see her bones She is sedated and intubated EMS did compressions The pulse returned. Is she alive?
The daughter arrives She is a DNR How did this happen? The pain is palpable What is this emotion? Anger? Sadness? Hopelessness? My emotions mix together I cannot think straight The daughter is POA. She wants all life support removed The forms are signed Is this going to happen now? The room gets quiet. The chaplain seems young. You want me to extubate? I see some struggle Morphine now, please I cannot look at the daughter Where is the suction? The color fades No more struggle
“Time of death 1705” . . . An amazing nurse breaks the silence “Tell us about her life,” she says The daughter smiles. “She ran a daycare for 25 years” “She liked to knit” “She loved to sing” I now look at the daughter. We all pray together. I think about that amazing nurse a lot She knew what to say When we were overwhelmed I now know what death is We have the privilege to undo a wrong to make a death honorable and to celebrate life. ■
Reflective writing is an important component of the CU School of Medicine curriculum. Beginning in the first semester, medical students write essays, stories or poetry that reflect what they have seen, heard and felt. Reflections is edited by Steven Lowenstein, MD, MPH, and Tess Jones, PhD. It is dedicated to the memory of Henry Claman, MD, Distinguished Professor of the University of Colorado, founder of the Arts and Humanities in Healthcare Program, and original co-editor of this column. 57 C O LO R A D O M E D I C I N E
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The vaccine divide Alexandra Koontz
Alexandra Koontz is a second-year medical student at Rocky Vista University who grew up in Eaton, Colo. She received a Bachelor of Arts in Health Science at Grace College. Her goal is to provide medical care to underserved populations, perhaps in a rural setting. She is passionate about building trusting physician-patient relationships. After losing most of her own hearing over the past year, she also has a special interest in connecting with other people who experience hearing impairment and combating the isolation that comes with hearing loss.
Recently, I had a conversation with a few friends outside of medical school in which I passionately promoted the benefits of immunizations. I talked about herd immunity, the need to protect those too young to receive vaccinations, and the massive amount of false information circulating the internet. I felt justified in my stance, and I desired to educate my audience. Later, my friend approached me and said, “I didn’t feel safe to disagree with you when you were talking about vaccines. I haven’t decided one way or the other yet, but I didn’t feel safe talking with you about my indecision.” Hearing that she didn’t feel like she could talk to me about her decision-making process made me concerned that my future patients may not feel safe talking to me about vaccines either. Throughout my education, I have formed the belief that immunization is an important part of preventative health care, directly impacting the patient, the health of the patient’s contacts and society. I feel convicted about vaccines because I care about the health of my patients and the community. However, my stance has its weaknesses. I am not a parent, so I have not been confronted with the actual choice between disease prevention and
potential adverse effects of vaccines. mous decision. I fear that even within The conversation with my friend brought medical education, the way we talk about to light two conflicting ethical principles “anti-vaxxers” undermines our intention of I hold: the patient’s autonomy regarding respecting our patients and convincing their own health care and the impact the them of vaccine benefits. An article from patient’s decision will have on others. the BMC Medical Ethics journal says, “To accept vaccines readily, people need Because I feel passionately about confidence that, in the face of uncertainty vaccines, I want to find the best way and risk, [health] professionals have their to have these conversations. Medical best interests at heart.” 3 This requires a literature addresses many strategies genuine relationship between provider regarding how to talk with patients who and patient. More than being berated have concerns about vaccines. Some with facts, patients want physicians “to facilities have policies that dismiss use a consultation style that cultivates patients who choose not to participate ‘open, non-confrontational dialogue.’” 3 in certain vaccinations from their prac- Defensive language has been shown to tices.1 In France, legislation was passed produce the opposite effect when trying to make 11 vaccinations mandatory for to convince patients to vaccinate.4 When children born after Jan. 1, 2018. 2 These making a recommendation as a physician, methods do not require an open conver- I must consider the patient’s values just sation with the patient, and they may as strongly as I consider my education threaten the patient’s autonomy. Ethically regarding vaccines. Autonomy requires helping patients make informed choices that I respect the patient’s decision in regards to vaccination requires three whether or not I agree. Shaming vaccine components: (1) explaining the risks refusal is not ethical. I must do my best and benefits of vaccinating and of not to build a trusting relationship where the vaccinating, (2) creating trust between patient can feel free to ask questions and the provider and patient, and (3) treat- raise concerns. ing the patient with dignity and respect, empowering them to make an autono-
Critical reflective writing holds a prominent place in the Medical Humanities curriculum at Rocky Vista University, College of Osteopathic Medicine. Beginning in the first semester of Medical Ethics, students engage in critical reflection to explore their own assumptions and biases and how their values impact their practice. This submission is selected and edited by Nicole Michels, PhD, chair of the Department of Medical Humanities, and Alexis Horst, MA, writing center instructor. 5 9 C O LO R A D O M E D I C I N E
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Realizing the weight of my words has “vaccine-hesitant” instead of “anti-vaxxer” made me more intentional in my approach when referring to patient who has not to discussing vaccination with hesitant made a choice about vaccination. I want patients, other physicians and my friends. my patients to feel respected by me even My previous strategy may produce the when we disagree. opposite effect of what I believe is best for my patients. In the conversation with A culture that promotes an “us-vermy friend, I may have pushed her away sus-them” mindset by implying that from vaccinating herself or her children people who do not vaccinate are uninby not building a trusting environment telligent or ill-intentioned deepens the where she could raise her concerns with divide between patients and evidenceme. To implement a new strategy into based medicine. Sarcastic remarks and my practice as I move into my clinical online content making fun of “anti-vaxxyears, I have decided I will use the term ers” further polarize the issue and put the
health of our community at risk. Vaccines are too important for the health of our patients and society to be jeopardized by our arrogant dismissal of the choice not to vaccinate. Our priority should be cultivating trust and protecting common ground. We are faced with finding the difficult balance of not relinquishing what we believe is best for our patients while championing their autonomy. Ultimately, it is not my belief about immunization that will impact my patients. Rather it is a relationship of trust that will protect the patient’s health and benefit society. ■
1. Haelle T. As More Parents Refuse Vaccines, More Doctors Dismiss Them -- With AAP's Blessing. Forbes. https://www.forbes.com/sites/tarahaelle/2016/08/29/as-more-parents-refuse-vaccines-more-doctors-dismiss-them-with-aaps-blessing/#69de60e51f22. Published August 29, 2016. Accessed March 29, 2019. 2. Lévy-Bruhl D, Desenclos J-C, Quelet S, Bourdillon F. Extension of French vaccination mandates: from the recommendation of the Steering Committee of the Citizen Consultation on Vaccination to the law. Eurosurveillance. 2018;23(17). doi:10.2807/1560-7917.es.2018.23.17.1800048. 3. Williamson L, Glaab H. Addressing vaccine hesitancy requires an ethically consistent health strategy. BMC Medical Ethics. 2018;19(1). doi:10.1186/s12910-018-0322-1. 4. Gesualdo F, Zamperini N, Tozzi AE. To talk better about vaccines, we should talk less about vaccines. Vaccine. 2018;36(34):5107-5108. doi:10.1016/j.vaccine.2018.07.025.
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SIM addresses provider burnout
While the Colorado State Innovation Model (SIM) ends July 31, resources created with funding from the federally funded governor’s office initiative are available for free to all providers in the state. The initiative (www.co.gov/healthinnovation) worked with 25 percent of the state’s primary care practice sites and accomplished its goal of expanding access to integrated physical and behavioral health. New practice data shows that SIM-participating practices also
gained the skills they need to succeed with alternative payment models. SIM also invested in workforce development, including online educational modules that prepare providers for success in integrated settings and address provider burnout: https://cuelearning.org/courses/burnout/. Recognizing the challenges to delivering integrated behavioral and physical health or whole-person care in primary care settings, the SIM team customized educational modules to help care teams ensure that all providers are effective and working up to their licensure. With increasing demands on provider time and energy, the risk of burnout and dissat-
isfaction is high. Research shows that primary care providers more frequently report burnout due to growing demands of conflicting priorities – beyond actual patient care – and integrated care teams can help mitigate these issues. To build resilience, a SIM-funded team built a resource repository (www.co.gov/ cdhs / behav ioral - healt h - work force development) that can be accessed f re e o f c h a r g e b y re g i s te r i n g a t https://cuelearning.org/ and using the “SIM” registration code. SIM encourages all physicians and practices to access and use these resources for your care teams. ■
Legislative committee on opioids to continue crucial policymaking work For the third year in a row, the General Assembly will convene an interim study committee on opioid and other substance abuse disorders. The 2019 Legislative Study Committee on Opioids and Other Substance Use Disorders, as in the past, will be bipartisan and focused on subject matter areas important to all stakeholders. “The opioid interim study approach has proven very beneficial,” says CMS Government Affairs Senior Director Susan Koontz, JD. “The forum provides the time for stakeholders and elected officials to take a much deeper dive into these complex issues without the pressure and rush of a legislative session.” The study committee will hold six meeting as follows: July 9, July 30, Aug. 13, Aug. 27, Sept. 24 and Oct. 29. Once again CMS will be an active participant, providing recommendations for policy solutions in addressing opioid and other substance use disorders in Colorado, and facilitating physician testimony on topics as needed. Any CMS member can contact the committee by emailing individual committee members or the staff to the committee at OpioidInterimComm.ga@state.co.us.
The committee is comprised of the following legislators: • Sen. Brittany Pettersen, Chair (D-Lakewood), brittany.pettersen.senate@state.co.us • Rep. Chris Kennedy, Vice Chair (D-Lakewood), chris.kennedy.house@state.co.us • Rep. Perry Buck (R-Greeley), perrybuck49@gmail.com • Rep. Bri Buentello (D-Pueblo), bri.buentello.house@state.co.us • Rep. Leslie Herod (D-Denver), leslie.herod.house@state.co.us • Sen. Dominick Moreno (D-Commerce City), dominick.moreno.senate@state.co.us • Sen. Kevin Priola (R-Commerce City), kpriola@gmail.com • Sen. Jack Tate (R-Centennial), jack.tate.senate@state.co.us • Rep. James Wilson (R-Salida), representativewilson@gmail.com • Sen. Faith Winter (D-Westminster), faith.winter.senate@state.co.us
Get involved in the effort to reduce public health crisis of opioids by volunteering on the CMS Committee on Prescription Drug Abuse, or joining a workgroup of the Colorado Consortium for Prescription Drug Abuse Prevention.
Contact CMS for more information at: amy_goodman@cms.org ■ 61 C O LO R A D O M E D I C I N E
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AMA expands its efforts to prevent medical student and physician suicide
The American Medical Association (AMA) adopted policy during its Annual Meeting in June aimed at better understanding the incidence of depression and suicide among physicians and physicians-in-training. With reports showing a lack of systematic reporting and inconsistencies in available data, the new policy offers recommendations on studying and collecting data that better reflect the actual incidence of and risk factors for physician, medical student and resident suicide in the United States. Specifically, the policy calls for the AMA to explore the viability and cost-effectiveness of regularly collecting National Death Index (NDI) data, as well as confidentially maintaining manner of death information for physicians, residents and medical students listed as deceased in the AMA Physician Masterfile. Accordingly, the AMA plans to partner with a leading academic medical institution to conduct a pilot study using NDI to initially identify manner of death for a subset of the AMA Masterfile population.
their wellbeing and leading to better health outcomes for their patients.” The new policy also supports educating faculty members, residents and medical students to help them recognize the signs and symptoms of burnout and depression and supports access to free, confidential, and immediately available stigma-free mental health and substance use disorder services. A new education module available on the AMA Ed Hub will help participants better understand the risks of physician
suicide, identify characteristics to look for in patients who may be at risk of harming themselves, and recognize the warning signs of potential suicide risk in colleagues. Additionally, the AMA’s Steps Forward program offers a series of practice transformation modules designed to improve the health and wellbeing of patients by improving the health and wellbeing of physicians and their practices. These online modules focus on improving physician wellness, preventing burnout and increasing resilience. ■
“While it has been reported that the incidence of depression and suicide is greater in medical student s, residents and physicians than the general population, it is vitally important that we take action now to fully understand the actual impact of suicide on our physician workforce. Our goal is to have access to data that will help us identify the systemic patterns and risk factors that lead to suicide, and ultimately help us prevent it,” said AMA Board Member S. Bobby Mukkamala, MD. “We will continue working to reduce burnout and increase access to mental health services for physicians and physicians-in-training – improving C O LO R A D O M E D I C I N E 6 2
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Professional review reenactment, other bills signed into law Colorado Gov. Jared Polis signed SB19234 into law on May 16, reenacting the body of law governing professional review. Plaintiff attorneys engaged in a session-long campaign to breach the privileged nature of professional review activities, and at times threatened to persuade legislators to allow this vital body of patient safety law to lapse under the state’s sunset review process. CMS, COPIC, CHA, and specialty and component medical societies joined forces in a strategic coalition that was well coordinated and executed throughout the session to ensure they were not successful. Significantly, the law renews the Professional Review Act for 11 years and maintains the professional review privilege for all documents and information privileged under the current law. “A lot of work was done on this bill to get physicians, trial law yers, medical liability insurers, all by and large in agreement,” Gov. Polis said at the bill signing. “The professional review process is really important for protecting consumers from harm, for professional conduct, and for quality and appropriateness of care for physicians and physician assistants.” “We all know that the physician-patient relationship is an intimate one and these committees make sure
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patients get the best care and can trust medical professionals, and that the medical profession has best practices they can follow when taking care of everybody,” he said. Also signed into law was SB19-073, which creates a statewide system of advance medical directives that allows qualified professionals to upload an individual’s advance health care directive upon his or her request. The directive can contain medical orders for scope of treatment, a declaration as to medical treatment, a directive relating to cardiopulmonary resuscitation, or a medical durable power of attorney. The Northern Colorado Medical Society (NCMS) has worked on this concept for serveral years with bill sponsor Sen. Joann Ginal (D-Fort Collins). “This law creates a statewide registry for advance care directives and represents a huge step forward toward helping people have the care that they want at the end of life or when they cannot speak for themselves,” said NCMS Treasurer Jan Gillespie, MD, also medical director of the Northern Colorado IPA. “NCMS has partnered with SOCI [Systems of Care Initiative], a local 501(c)(3) organization, to provide onsite training
to medical providers and their staff to assist them in encouraging and enabling their patients of all ages to complete advance care directives. One of NCMS’ goals is to facilitate a cultural change in our community such that having discussions about end-of-life decisions will be acceptable and even routine.” Signed into law on May 23 were a suite of bills to address the opioid epidemic. HB19-1009: Substance Use Disorders Recover y (Kennedy/Singer - Priola/Pettersen) SB19-008: Substance Use Disorder Treatment In Criminal Justice System (Kennedy/Singer - Priola/Pettersen) S B19 -227: H ar m Re duc t ion Substance Use Disorders (Kennedy/ Herod - Pettersen/Gonzalez) SB19-228: Substance Use Disorders Prevention Measures (Buentello/Singer - Winter/Moreno) SB19 -219: Sunset Continue Licensing of Controlled Substances (Gonzalez-Gutierrez - Pettersen) For the past six years, CMS has been working with partners in the Colorado Coalition for Prescription Drug Abuse Prevention to develop policies, enact laws and make important strides to reverse the opioid epidemic. All the bills from the Opioid and Other Substance Use Disorders Interim Study Committee were introduced and worked their way through the legislature, as did other opioid-related bills introduced earlier this year. Stakeholders are hopeful these bills will continue to help in the effort to reduce the abuse and misuse of opioids in Colorado. ■
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1 Northern Colorado physicians attend the bill signing of SB19-073, which creates a statewide system of advance medical directives. From left: Lt. Gov. Dianne Primavera; Fort Collins family physician Cory Carroll, MD; Colorado Gov. Jared Polis; NCMS Treasurer Jan Gillespie, MD; and Sen. Joann Ginal. 2 CMS President Debra Parsons, MD, with Sen. Jessie Danielson. 3 CMS President Debra Parsons, MD, with Sen. Mike Foote. 4 CMS President Debra Parsons, MD, with Colorado Gov. Jared Polis. 5 Stakeholders gather following the signing of bills addressing the opioid epidemic. Front row from left: Rob Valuck, PhD, Stacy Pettersen, Sen. Brittany Pettersen, CMS President Debra Parsons, MD, and CMS Past President Dave Downs, MD. 6 CMS Past President Lynn Parry, MD, far left, attends a bill signing.
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An overview of the new out-of-network law Effective Jan. 1, 2020, a new law (HB19-1174) sets billing parameters and requirements for out-of-network (OON) services provided at an in-network facility. Examples include an out-of-network anesthesiologist, pathologist, radiologist, hospitalist, trauma surgeon or neonatologist. Physicians should become familiar with the new parameters and requirements and additional rules to be implemented before Jan. 1, 2020. The law does not apply to patients who intentionally seek services from an out-of-network provider.
New benchmark for OON reimbursement
No balance billing*
The benchmark reimbursement rate by carriers to out-of-network providers is the greater of either: (a) 110% of the carrier’s in-network reimbursement rate; or (b) The 60th percentile of the in-network reimbursement rate for the same service in the same geographic area from the All Payer Claims Database for the prior year.
Physicians can only collect any in-network cost-sharing amount from the patient. The insurance carrier is to send payment directly to the OON physician and inform the physician of the patient’s required coinsurance, deductible or copayment.
New notification/disclosure requirement
Any questions concerning the accuracy of the amount paid for OON services can be referred to the insurance commissioner for verification.
The Division of Insurance, Division of Professions & Occupations (Medical Board), and Department of Health will develop the language and timing for facilities and physicians to notify patients and provide a disclosure to patients concerning the potential for receiving OON services and patient rights under Colorado law. Estimate* The OON physician must provide a written estimate to the patient within three business days of a request. Timely claim filing* The OON physician must submit a claim for the total amount to the patient’s insurance carrier within 180 days of the date of service. If the claim is submitted beyond 180 days, then the physician will only be reimbursed at 125 percent of the Medicare rate for that service.
Verification procedure
Arbitration procedure The OON physician may initiate arbitration through the Division of Insurance to contest the reimbursement amount given the complexity and circumstances of the services provided within 90 days after receipt of payment. Prior to arbitration, the carrier and the physician may conduct an informal settlement teleconference. If the issue is not resolved the commissioner assigns an arbitrator. Each party submits their final “best” offer and the arbitrator will select one or the other (baseball arbitration). The loser pays the cost of the arbitration. Refund of overpayment* If the OON physician receives an overpayment from the patient, the physician must refund the overpayment amount within 60 days of receiving notice. If the OON physician does not refund the overpayment in time, then the physician must pay the patient interest at the rate of 10 percent per annum and include that amount with the refund. ■ *Failure to comply with these provisions is a deceptive trade practice in violation of CRS 6-1-105.
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Medical students: Join us Aug. 13 for White Coat Wisdom, the CMS-MSC annual meeting An exclusive, one-time convening the evening of Aug. 13 connects medical students to a broad array of full-time practicing doctors from a variety of settings and financial experts to help you navigate your future. At “White Coat Wisdom,” held at Colorado Medical Society headquarters in Denver, you’ll interact with faculty in small-group settings focused on work-life balance, public health, the practice of medicine and the business of medicine. Enjoy great food, socialization, and free drawings for subscriptions to study resources and question banks students will need.
Faculty comprises 15 real-world experts, including: The Honorable Yadira Caraveo, MD: A full-time practicing pediatrician with Peaks Pediatrics in Thornton, Colo., and a first-term State Representative. Tista Ghosh, MD, MPH: Colorado’s first female chief medical officer and director of public health programs who is trained in both internal and preventive medicine with an MPH from Yale. Gerald Zarlengo, MD: Chairman and CEO of COPIC Companies who is one of 10 physicians produced in the past two generations by Denver’s Zarlengo family. Dr. Z delivered over 5,000 babies during a 30-year run practicing OB/GYN before taking the leadership helm at the COPIC Companies. See the entire faculty and topics online at www.cms.org/events
WHITE COAT
WISDOM
Aug. 13
RSVP at https://members.cms.org/register Registration is free but you must enter your CMS member number to register online. If you do not yet have a CMS member number or if you have other issues, contact membership@cms.org. This event is brought to you by the CMS Medical Student Component and the COPIC Companies. ■
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It’s about changing the culture from individualism to collegiality F. Brent Keeler, MD CMS Past President Physician wellness and its inverse, burnout, is about the culture! The word “culture” is overused – and yet, it applies here. Hopefully, we are evolving from a destructive and negative “culture.” Where have we been – and, where will (or should) this evolution take us? Here are a few thoughts about the “then” and the “now.” From our earliest experiences in a “learning environment” we future physicians are rewarded for certain behaviors and attitudes. The incentives all seem to line up to reward and value resilient, rugged individualism. Our early credentials – GPA,
scores – are strictly individualized. We begin to adopt an isolated – and solo – sense of our own successes – and failures. As our career unfolds, we are then asked to become collaborative and team-oriented. Most of us actually make this transition with minimal disruption. Some of us? Not so much. “Asking for help is a sign of weakness.” This is the “resilience” piece. It’s part of the life of a physician. Our patients have a right to expect some resilience from us. Yet, we cannot possibly be “resilient” against all of the stressors that impact us. A little help along the way might do wonders. It is here that the “culture” blocks the road. We are reticent to ask for help and reluctant to offer it.
Collegiality and friendship? I submit that these often mean essentially the same thing. They are intertwined and interdependent. If we open our hearts, minds and eyes, a “troubled colleague” may just be in need of a friend. A few moments of empathetic listening, a.k.a. a “cup of coffee conversation,” may help your colleague begin to turn that proverbial “corner.” We physicians are “fixers” – we want to fix what’s wrong! Beyond listening, this probably won’t work out in the case of a troubled colleague. We sense that this is true and thus arises the reluctance to “offer help.” Few of us have the training and experience necessary to really help our colleague. Let us instead be “connectors,” helping that colleague engage with the right resources. It might be as simple as mentioning a forum at your hospital (and maybe accompanying your colleague to the forum) or encouragement to self-refer to a state physician health program. Your colleague is not radioactive – or infectious. The culture says to keep your distance. But wait! Doesn’t that then leave your colleague with a sense of abandonment? Maybe this is the time to be a friend? The era of denial is over. The culture that says “resilience” is the key to everything offers a false and empty promise. We need a new culture and a new sense of professionalism where friendship and collegiality are merged. Reach out to your fellow physicians. ■
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