MetroDoctors Winter 2021: Physician Health & Wellbeing: COVID-19 and Beyond

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Winter 2021

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

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PHYSICIAN HEALTH & WELLBEING COVID-19 and beyond

In This Issue: • Join TCMS in Building a New Kind of Medical Society • A Victory for Physician Mental Health: Grassroots Advocacy Leads to Change in BMP Language • Future Physician Leaders


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A Victory for Physician Mental Health TCMS Past President Ryan Greiner, MD Dear Colleagues, We did it. After years of advocacy, the Minnesota Board of Medical Practice has replaced the licensure question that has long served as a barrier for physicians and medical students seeking mental health care. This is a life-saving victory that was made possible by strong grassroots advocacy from Minnesota’s physicians and medical students, and by collaboration between leading Minnesota organizations, including Physicians Wellness Collaborative, Minnesota Medical Association, Zumbro Valley Medical Society, Minnesota Academy of Family Physicians, NAMI Minnesota, Twin Cities Medical Society, and many more. This is a change worth celebrating, but we all know that there is much more work to be done in service of physician and medical student mental health. I am asking you to join me in continuing to take action: • Spread the news – It is imperative that physicians and medical students across Minnesota know that they will no longer be required to report mental health conditions that are being appropriately treated when they apply for or renew their medical licenses. Please join me in sharing this news with your colleagues. • Save these resources – It can be difficult to know where to turn for support when you are experiencing a mental health condition or substance use disorder. I encourage you to bookmark the resources below, so they are readily available if you or a colleague needs support. • Our partners at the Physicians Wellness Collaborative provide independent, confidential counseling at no cost for all Minnesota physicians, residents, medical students or their families, as well as for advanced practice providers. Help is available by phone 24 hours a day, 7 days a week by licensed mental health professionals. Call (612) 362-3747 or visit pwc-mn.org. • Physicians Serving Physicians has over 35 years of experience supporting physicians with substance use disorders return to successful practice through physician-only monthly meetings and other support services. Receive secure login information by emailing psp.com. • Check in with your colleagues – The events of the past year and a half have challenged us all as physicians, as healers, and as human beings. If you are experiencing burnout, compassion fatigue, moral injury, grief, anxiety, or depression, you are not alone. Please take a few moments this week to have an honest conversation with your colleagues. It’s important that we continue to support each other and make checking in on each other the norm, not an exception. Thank you again for your advocacy. I hope you take good care of yourselves and each other during these challenging times.

Ryan Greiner, MD TCMS Past President

MetroDoctors

The Journal of the Twin Cities Medical Society

Winter 2021

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CONTENTS VOLUME 23, NO. 4 WINTER 2021

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IN THIS ISSUE

The “Unseen” Impact of COVID-19 on the Physician Community

By Peter J. Dehnel, MD

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PRESIDENT’S MESSAGE

Charting a New Future

By Sarah Traxler, MD

9 Page 10

A Victory for Physician Mental Health By TCMS Past President Ryan Greiner, MD

TCMS IN ACTION

By Annie Krapek, MPH, CEO

PHYSICIAN HEALTH & WELLBEING — COVID-19 AND BEYOND

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• COLLEAGUE INTERVIEW:

A Conversation with Natalia Dorf-Biderman, MD

15 • Wellness Efforts During Pandemic Times at Emergency Physicians PA By Wendy Laine, MD 16

• An Ethics Oasis in Our Pandemic Journey

By Mary Anderson, MD, Nancy O’Connor, MD and Joan Henriksen

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• SPONSORED CONTENT: It’s OK to Not Be OK

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By Suzanne Jasberg, MD and Anastasia Ristau, PhD, LP

20 • More Resiliency is Not the Answer By Bindi Parikh, MD 22

• COVID-19 Pandemic and Medical Student Mental Health

By Michael H. Kim, MD and Wm. Scott Slattery, PhD

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• PAID EDITORIAL: Better Patient Outcomes

Through Innovation in Chest Wall Injury Repair By Peter A. Cole, MD Page 32

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• YOUR VOICE: At the Root

By Kellie Lease Stecher, MD

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PHYSICIAN HEALTH & WELLBEING COVID-19 and beyond

• ENVIRONMENTAL HEALTH:

The Climate Emergency is Here —  Where is Health Care?1 By Bruce D. Snyder, MD

• Career Opportunities

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FUTURE PHYSICIAN LEADERS

A Student’s Ask for the Medical Profession By Christopher Johns, MS3

Page 9 MetroDoctors

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24 • The Cost of Compassion in Healthcare Professionals By Kristen A. Schmidt, MD

The Journal of the Twin Cities Medical Society

In This Issue: • Join TCMS in Building a New Kind of Medical Society • A Victory for Physician Mental Health: Grassroots Advocacy Leads to Change in BMP Language • Future Physician Leaders

Stress, burnout, moral injury. Just a few words that describe the challenges healthcare workers have had to overcome throughout 2021. Articles feature how physicians are responding with hope. Articles begin on page 10.

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Richard R. Sturgeon, MD Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Amber Kerrigan MetroDoctors (ISSN 1526-4262) is published quarterly by the Twin Cities Medical Society, Broadway Place East, Minnesota Medical Joint Services Organization, 3433 Broadway Street NE, Suite 187, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

Winter Index to Advertisers TCMS Officers

President: Sarah Traxler, MD, MSPH President-Elect: Zeke McKinney, MD, MHI, MPH Secretary: Cora Walsh, MD Treasurer: Alex Feng, MD, MBA Past President: Ryan Greiner, MD At-large: Matthew A. Hunt, MD TCMS Executive Staff

Advanced Brain & Body Clinic....................... 5 Children’s MN.................. Outside Back Cover COPIC.................................................................... 6 Crutchfield Dermatology...................................... Inside Front Cover Deaf & Hard of Hearing Services.................17

Annie Krapek, MPH, CEO (612) 362-3715; akrapek@metrodoctors.com

HealthPartners.....................................................13

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Lakeview Clinic..................................................31

Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com

Minnesota Department of Health PartnerServices.......................................... 6

MedCraft..............................................................29

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Lucy Faerber, MPH, Program Manager lfaerber@metrodoctors.com Amber Kerrigan, Program Coordinator (612) 362-3706; akerrigan@metrodoctors.com Kate Feuling Porter, MPH, Senior Program Manager (612) 362-3724; kfeuling@metrodoctors.com

Minnesota Department of Health Quit Partner.............................................14 Mounds Park Academy......Inside Back Cover Orthopedic Trauma Department, Regions Hospital....................................27 PrairieCare.............................................................. 2 Physicians Wellness Collaborative.................30 Superior Wealth Management Group........... 4

You. We only have one thing on our mind. GJ Lempe – Steve Powers – John Soukup (952) 885-5605 Securities Offered Through LPL Financial, member FINRA / SIPC

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The Journal of the Twin Cities Medical Society



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The Journal of the Twin Cities Medical Society


IN THIS ISSUE...

The “Unseen” Impact of COVID-19 on the Physician Community “Extraordinary times require extraordinary people.” Jane Kay, The Daily Guardian, 7/25/2020 It was two years ago that a novel coronavirus, designated SARS-CoV-2 and later better known as COVID-19, emerged on the world scene with an unprecedented impact in modern times. Its impact continues to this day, and it is not clear when we will really start seeing “light at the end of the tunnel.” At the time of the writing of this note, there have been 808,000 COVID-19 cases reported in Minnesota alone and 8,885 deaths attributed to this entity in our state. Society as a whole has been turned on its head, with previously “normal” social interactions being replaced by masked encounters, social distancing, and electronic connections in separated locations. With health care being at the forefront of treatment, mitigation, prevention, and disease education, the impact on not only the physician community, but also all members of the healthcare team and other essential workers has been unparalleled. In this edition of MetroDoctors, we focus on the personal and professional toll that COVID-19 is having on physicians and medical students in the greater Minneapolis-St. Paul region. More importantly, we’ve made an effort to highlight some of the responses that healthcare organizations are making to mitigate the adverse mental health impact experienced by physicians and students. As pointed out in these articles, addressing physician wellness is more than just a portfolio of individually based solutions. Organizational efforts highlighted in this edition include the following: • Dr. Natalia Dorf-Biderman, Hospitalist: Hospital Wellbeing committee – Methodist Hospital/Park-Nicollet/ Health Partners and MMA’s Physician Wellbeing Advisory Committee • Dr. Wendy Laine, Emergency Medicine: EPPA (Emergency Physicians, PA) – Director of Wellness • Dr. Mary Anderson, Hospitalist, Dr. Nancy O’Connor, Family Medicine and Joan Henriksen, Ethicist: Ethics Oasis, Allina Hospitals

Dr. Suzanne Jasberg, Psychiatry and Anastasia Ristau, PhD, LP, Psychology: PrairieCare • Dr. Kristen Schmidt, Psychiatry: Hazelden Betty Ford Foundation In “Your Voice” Dr. Kellie Stecher shares her thoughts on some root causes that need to be addressed before there can be “progress on physician burnout, depression, PTSD, and suicide.” The substantial impact of COVID-19 on medical students and residents, the next generation of our practicing physicians, is likely underappreciated and underrecognized. This is highlighted in three articles: • Dr. Michael Kim, Assistant Dean and Wm. Scott Slattery, PhD, Director of Learner Development, University of Minnesota Medical School • UMN Chief Neurology Resident Bindi Parikh • Christopher Johns’, MS3 On page 1, Dr. Ryan Greiner highlights the impact of replacing one of the Board of Medical Practice licensure questions as removing a barrier for physicians to receive mental health care. Finally, COVID-19 cannot be considered in isolation. Climate change and the murder of George Floyd are both impacting us on a continuing basis. The Environmental Health article highlights the climate crisis hitting us now, but the healthcare sector seems to be largely silent in terms of enacting solutions. We hope you enjoy reading this edition of MetroDoctors and find the articles applicable to your personal and professional situations. We thank you for your time, effort, and personal sacrifice to help address this pandemic in our community that has been forced upon us. Thank you for your support of your colleagues during these challenging times. In short, we thank you for being one of the “extraordinary people.”

By Peter J. Dehnel, MD Member, MetroDoctors Editorial Board

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The Journal of the Twin Cities Medical Society

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President’s Message

Charting a New Future SARAH TRAXLER, MD, MSPH

As you may know, my term as President of TCMS is coming to an end. Some of the changes that have occurred over the past year have been staggering, to say the least. In other ways it feels like we’re still stuck in a status quo that simply doesn’t work anymore. Despite so much recent focus on issues like health equity and of course vaccine acceptance, these problems persist and continue to harm the health of our community. And yet I’m often reminded that there is much forward momentum and that we are gaining ground. I was lucky to join the TCMS Medical Student Public Health Fellowship opening workshop recently, and I was moved by the words of Dr. Ed Ehlinger. When asked why he participates as a mentor, even after all his years of service, Dr. Ehlinger said, “I’m here to get energized by students. They provide the hope and energy to overcome the cynicism that can set in when change doesn’t happen as quickly as it should.” I think those words exemplify how so many of us continue to do the work to improve the health and the lives of not only our patients, but also of our communities and our world. So many physicians are faced with the burnout and even trauma of continuing the fight against this pandemic on top of the deep, systemic problems in health care. Dr. Ehlinger reminds us that “hope and energy” are the fuel to keep moving forward toward the vision of a new kind of health care that supports better health for everyone. The journey may be challenging, but we know where we need to go. And most importantly, we know how to get there. That’s why TCMS is becoming a different kind of medical society. One wholly focused on public health, with three primary goals. First and foremost, we are here to help physicians and medical students serve and work alongside our community to create better health. Next, we are providing support and tools for physicians as we continue to fight the pandemic and move through a time of enormous change. And last but just as important, we are helping physicians reconnect with their original sense of purpose as healers. I’m inspired by the dedication of our members and eager to see what happens next for our organization. It’s exciting to see that our new focus is already bringing new members to TCMS. Coming together as physicians, and physicians in training, is the best treatment for cynicism and burnout. Collaborating on new ways to solve our most pressing problems is the prescription that will heal our patients, our communities, and our lives. My tenure as TCMS President has been filled with so many gifts, not the least of which are the relationships I’ve deepened between our Board and with our members. I’ll remember this past year with pride. Before I go, I’d like to ask for two things: First, please join me in giving the warmest of welcomes to our new President, Dr. Zeke McKinney. If you know Dr. McKinney, you know that he lives every day with passion and purpose, whether he’s treating patients, working on health equity initiatives, or playing one of his many bass guitars. If you don’t know this amazing human being, get ready to experience an enormous blast of energy sure to propel us forward in the coming year. Second, I’m asking that you support TCMS’s ongoing and future public health initiatives by joining or renewing your membership with us. You can join or renew in just a few easy steps at www.metrodoctors.com/membership or complete and mail the enclosed membership envelope. We create meaningful change when we come together. I’m looking forward to continuing to work with Dr. McKinney and all of you as we build a new TCMS and work to create healthy, thriving communities. You can now join TCMS independent of your other professional association memberships, making it easier than ever to be a part of TCMS. Please join/renew today!

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TCMS IN ACTION ANNIE KRAPEK, MPH, CEO

As we look toward 2022, advocacy is top of mind at TCMS. With the 2022 legislative session just around the corner, TCMS is hard at work planning our advocacy work with a focus on policies that create healthier communities. Our legislative priorities next year will include: • Prohibiting the sale of all flavored tobacco products, including menthol tobacco We know that flavored tobacco plays a significant role in introducing youth and young adults to tobacco products. Flavored tobacco is a significant driver of tobacco-related health inequities, and menthol tobacco has been aggressively marketed to Black and LGBTQ+ communities. That’s why TCMS has worked to support the restriction and prohibition of flavored tobacco products since 2015, engaging dozens of medical student and physician advocates and supporting the passage of local policies in over 21 municipalities across Minnesota. During the 2022 legislative session, TCMS will be on the front lines at the state level advocating for restrictions on all flavored tobacco products, including menthol tobacco.

Dr. Pete Dehnel speaking in favor of Healthy Kids Meals at a 2020 press conference.

• Dr. Alex Feng testifying in favor of restricting flavored tobacco at the Minnesota House of Representatives in 2020.

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The Journal of the Twin Cities Medical Society

Making healthy drinks the default for children’s meals in Minnesota Sugary drinks are associated with many chronic conditions including heart disease, high blood pressure, and Type 2 diabetes. There are also marked disparities in sugary drinks consumption — nearly 25% of American Indian youth and 21% of Black youth in Minnesota have three or more sugary drinks per day, compared with 9% of white youth. These statistics are due in large part to high-pressure marketing tactics used by the beverage industry. TCMS will continue to lead efforts to pass the Healthy Kids’ Meals Bill, making milk, water, and unsweetened milk alternatives the default for kids’ meals in Minnesota. House File 1307 and Senate File 1363 have strong bipartisan support and are backed by a coalition of healthcare and public health organizations. Providing access to free nutritious food at school for all Minnesota students One in every six children in Minnesota experiences food insecurity and nearly 30% of Black households with children have experienced hunger at some point during the pandemic.

Providing consistent, healthy food for all of Minnesota’s students is critical for our children’s health and learning. Federal waivers have allowed schools to provide free food to all students throughout COVID-19. It’s vital we guarantee that Minnesota’s children do not experience hunger when these Federal policies end. TCMS will work with our partners at Hunger Solutions to advance legislation to ensure that every child in Minnesota has access to free, nutritious school meals. In addition to these legislative priorities, TCMS will be working to expand our grassroots advocacy efforts around other key issues including homelessness, gun violence prevention, and COVID-19 vaccination requirements. During my time with TCMS, I’ve seen the incredible impact that physician and medical student advocacy can have on lawmakers. Doctors can make a real difference in the health of our community when they come together and advocate for important health policies. I hope you will join us in advocating on these critical public health and health equity issues in 2022. Please reach out to TCMS staff for ways you can get involved, and don’t forget to renew your membership with TCMS. You can renew at www. metrodoctors.com/membership or using the enclosed reply envelope.

Dr. Ryan Greiner testifying in favor of tobacco control policies at the Minnesota House of Representatives in 2021.

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Physician Health & Wellbeing — COVID-19 and Beyond

Colleague Interview: A Conversation with Natalia Dorf-Biderman, MD

D

r. Dorf-Biderman is an Internal Medicine practicing hospitalist at Methodist Hospital, Park Nicollet/Health Partners. She received her MD degree from Universidad de la Republica in Montevideo, Uruguay, and completed her internal medicine residency at the University of Minnesota. She is currently the medical director for Clinical Documentation Integrity and chairs the Hospital Wellbeing Committee. While promoting personal wellbeing programs in the workplace, she works to look at practice and documentation inefficiencies that add friction to clinical practice and seeks to find attainable solutions. In partnership with the MMA, she is currently chairing the Physician Wellbeing Advisory committee where leaders and champions from across the state collaborate to develop programs to impact the health and wellbeing of clinicians throughout Minnesota.

How is it you came to Minnesota from Uruguay? I was born and educated in Uruguay, attending medical school at the Universidad de la Republica, School of Medicine where I received my MD degree. During the 2004 economic recession, I moved to Santiago, Chile, to work and continue training in Internal Medicine. While living there, the Pan-American Maccabiah games, an athletic and cultural event for Jewish people from around the world, was held. I was one of the physicians organizing the medical and health response. Quickly, I was assigned as the physicians’ liaison with all the English-speaking medical directors. That’s where I met my husband, who was the medical director for the American delegation. A year later, we were married and moved to Boston for his fellowship in Palliative care. After completing the recertification process from Step 1-3, I again started an Internal Medicine residency at the University of Minnesota, and we have been here since.

Medical care delivery is organized differently in Uruguay and Chile. Are there practices that Minnesota physicians might apply to their advantage? There are so many differences in healthcare delivery in South America that it deserves a whole article itself. The biggest one is probably healthcare costs and access both with and without insurance. The public healthcare system is basically free, albeit with different resources than the insured sector, but no one goes without access to medicine for fear of bankruptcy. Additionally, from an access standpoint, communicating with your medical team is so much easier. You might even be able to text with your clinicians and, in most instances, get a same-day or next-day 10

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appointment. When you have a long-standing relationship with your physicians, and they know what matters to you as a patient, the care is much more personalized. I can’t recommend specific changes in practice to consider, but broadening their perspective as to how things can be done by either practicing abroad — which I know is hard to accomplish — or going to international conferences and engaging with international teams can spark a myriad of ideas of how to do things differently.

Have you been in touch with the community in Uruguay about Covid-19? Yes. My whole family still lives in Uruguay, and I have many friends and colleagues still practicing there. I am always paying attention to how my home country and surrounding areas are doing with COVID-19 in terms of transmission and the pandemic response implementation. The pandemic hit Minnesota earlier, and so, especially in the early days, we communicated a lot about what we were seeing at home in terms of numbers or transmission. Now, topics of discussion have mostly switched to vaccine acceptance, hesitancy, and recommendations. Personally, it has been fascinating — I would even go as far as to say — educational — to see the striking differences among communities and countries. Technology and social media have significantly impacted communications and have made the world a smaller place. This is both for the good and bad — unfortunately, misinformation is rampant, so it has been vital for me to share trustworthy and scientific information that is culturally sensitive so people can hear it. MetroDoctors

The Journal of the Twin Cities Medical Society


What physician wellness aspects fall or should fall to the organization/administration? These are challenging times for health care in general and specifically for our profession due to unprecedented changes. Our organizations are experiencing countless external challenges, including changes in reimbursement, increasing regulation, use of healthcare data, hiking clerical burden for staff across the board, changes in contracting practices due to consolidation within the market, and the implementation of new quality metrics and reporting, among others. To navigate this landscape, our organizations would, ideally, count on a committed and productive workforce. Unfortunately, now more than ever, physicians and other healthcare workers are exhausted, disillusioned, and have dropping engagement levels. There is a moral and ethical aspect to address this but, beyond that, studies indicate that physician wellbeing influences medical errors, quality of care, patient safety, patient satisfaction, and ultimately, the fiscal health of our healthcare system. When almost 80% of respondents to a survey by Medical Economics magazine respond YES to the question “Do you feel burned out right now?”, organizations have a vested interest in improving this metric. A host of factors can contribute to burnout or thriving/ engagement, and many models address them. Addressing these factors is a shared responsibility by the individual clinicians and the organizations they work in. Each practice and each organization might struggle with something different. Even each sector within a large organization might have areas that more prevalently affect one practice or another. However, the culture of medicine in which we practice and the leadership behaviors that foster wellbeing are key aspects that all organizations can and should address. Ultimately, what should always fall on the administration is to listen with intention, respect its teams, and empower its leaders to find and implement opportunities for improvement.

The culture of a team can influence the wellbeing of the team members. How should physician leaders emphasize and promote wellbeing on their teams? The importance of leadership in the success of organizations has been well described. A 2013 study of more than 2,800 physicians at Mayo Clinic found that each 1-point increase in the leadership score (60-point scale) of a physician’s immediate supervisor (was associated with a 3.3% decrease in the probability of burnout (P < .001) and a 9.0% increase in satisfaction (P < .001).1 Additionally, an excellent study on “zero burnout practices” authored among others by two of our local physicians used a measure called “adaptive reserve.”2 This measure evaluated leadership along with five other factors. They called it “facilitative leadership.” The Institute of Health Improvement (IHI), “Joy in work” white paper calls it “participative management.”3 The key learning here is that the culture of a team is directly impacted by their direct leader. This kind of leadership is based on listening and engaging, even when the leader cannot change a significant, for example, regulatory issue. We know that involving staff in understanding MetroDoctors

The Journal of the Twin Cities Medical Society

problems and even building solutions creates an environment of psychological safety and teamwork and helps us build healthy, effective teams and systems that are ultimately an asset in highly complex settings like health care.

Within the scope of your work with CDI, Wellness, and QI, what tools exist to acknowledge and address individual variation? Understanding and managing variation is essential to quality improvement and my work with CDI and performance data. These processes require data to understand, provide a common reference point, track our impact with specific actions, and predict future performance. We must realize that every process, especially in complex settings with humans (like health care), has inherent variation. This variation can be intended or unintended, variation from common causes or special causes. And we have many tools to better understand variation of which control charts and run charts are some of them. Frequently, physicians perceive these strategies as a cover to question their ability to provide appropriate care and to question the quality of care they give their patients. In truth, we implement best practices and benchmark performance to improve overall outcomes and value. Ultimately, physicians are critical stakeholders in this process, and the more we understand and get involved, the more partnerships we build, the more our perspective will be taken into account. It is through those partnerships that we can impact the future of health care and build sustainability within our practice.

If a physician is employed in a larger group practice, how can they contribute to improving their wellbeing and the wellbeing of their colleagues? Reclaiming the agency of one’s professional experience is fundamental to improving our wellbeing. There are several aspects to this, of which I will mention two. Many of us physicians have practiced in a culture in which our own health is not a priority. The Stanford WellMD Center has done significant research in what they have termed “self valuation”4 as a way of constructive prioritization of personal wellbeing and a growth mindset applied to the practice of medicine itself. They have shown that the higher the self-valuation scores, the lower the burnout scores. This study matters because this practice is something we can “take the reins” on; we don’t need any external factors to change to be able to do this work for ourselves. Additionally, we know that we all have unique talents and interests. Evidence shows that physicians who spend 20% of their professional effort focused on dimensions of work they find meaningful are at a dramatically lower risk for burnout. Health care is a diverse, expansive, varied field so finding a unique area is possible. This could be caring for a particular patient population or patients with a given health condition or engaging in other activities such as advocacy, medical writing, patient education, (Continued on page 12)

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Physician Health & Wellbeing — COVID-19 and Beyond Colleague Interview (Continued from page 11)

quality improvement work, or involvement in local or national organizations to impact the healthcare environment, and many more. Finding something we feel especially connected with and pursuing it gives us a sense of meaning and purpose that protects us from burnout. Both are hard work; both involve a significant amount of personal development and understanding of oneself, where we currently are, and then, potentially, pursuing change. This is all energy-consuming and sometimes difficult. But the cost of staying exactly where we are personally and professionally might be much higher.

How prevalent is pandemic burnout among various healthcare professionals? Burnout continues to be a critical problem, and it seems to be getting worse. A Medscape survey showed that about an average of 42% of physicians feel burned out right now, ranging from 29% to 51%. That is a minimum of one in three physicians in the lowest burnout specialty. Interestingly, women comprise 51% and men 36%. While 79% of respondents answered that their burnout started before the pandemic, happiness among physicians took a massive plunge after the COVID-19 pandemic started, and 47% of respondents reported burnout as having a strong or severe impact on their lives. A recent article by Maunder et al. showed that the prevalence of severe burnout in the spring of 2020 was 30%-40%. But by spring 2021, rates of more than 60% were found in Canadian physicians, nurses, and other healthcare professionals.5 Lastly, burnout extends well beyond physicians. A study co-authored by the AMA and the Hennepin Healthcare team, which was published by The Lancet,6 showed that stress scores were highest among nursing assistants, medical assistants, and social workers, inpatient vs. outpatient workers, women vs. men, and in Black and Latinx workers vs. whites. This national cross survey study of 20,947 healthcare workers shows what we anecdotally already knew, stress and burnout affect the gamut of health practitioners across the board.

What wellbeing practices and resources can medical students and residents incorporate now to avoid burnout in their future career? It is never too early to start practicing how we stay healthy. Sleep, sleep whenever you can. You are young, and sleep seems dispensable instead of studying for tests, but sleep deprivation has been shown to affect mood and productivity. Know your limits, start practicing self-compassion/self-valuation right now. Find your community; they will keep you afloat and walk with you during hard times. You will have challenging moments — many of them throughout your career. Reach out to your team early on and, while a student or a resident, find someone on staff you 12

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can trust and look up to. They, too, are trying to figure out how to best care for themselves.

Minnesota is home to a significant number of foreign medical graduates who cannot practice because they can’t get into residency programs. Do you have any advice for them? The answer here has two, almost opposite takes. On the one hand, if practicing medicine at the bedside has always been your dream, keep trying. Get creative, connect with others who have walked the same path, explore many options. There is no shame in reaching out for help to local people. Many of us International Medical Graduates (IMGs) will be more than happy to help through that journey. On the other hand, bedside medicine is not the only path to being in health care. Your MD degree is invaluable. You might need to get some training in another field, which is usually not as taxing as medical school. But the field of medicine and health is expansive, and you might be as happy working in an adjacent field.

What advice would you give to a 2021 graduate of the Universidad de la Republica, School of Medicine regarding where to practice medicine? Every place on earth has its pros and cons. That also applies to the practice of medicine. Adam Grant, an organizational psychologist at Wharton School, recently suggested that “for generations, we have organized our lives around work” and that we should consider “reversing that and start planning our work around our lives.” Interestingly, I believe he was basing his recommendation on how Americans organize their lives, not on how the culture in Uruguay works. I would never tell anyone how to live their lives or practice their career. What I hope everyone can see is that health, happiness, and professional fulfillment are available to all of us. We must know ourselves and pursue what matters unapologetically. References: 1. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432440. 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. Samuel T. Edwards, Miguel Marino, Leif I. Solberg, Laura Damschroder, Kurt C. Stange, Thomas E. Kottke, Bijal A. Balasubramanian, Rachel Springer, Cynthia K. Perry, Deborah J. Cohen. Cultural And Structural Features Of Zero-Burnout Primary Care Practices, Health Affairs VOL. 40, NO. 6: 4. Mickey T Trockel 1, Maryam S Hamidi 2, Nikitha K Menon 3, Susannah G Rowe 4, Jessica C Dudley 5, Miriam T Stewart 6, Cory Z Geisler 7, Bryan D Bohman 3, Tait D Shanafelt 3Self-valuation: Attending to the Most Important Instrument in the Practice of Medicine. Mayo Clin Proc 2019 Oct;94(10):2022-2031. 5. Maunder RG, Heeney ND, Strudwick G, et al. Burnout in hospital-based healthcare workers during COVID-19. Science Briefs of the Ontario COVID-19 Science Advisory Table. 2021;2(46). https://doi.org/10.47326/ ocsat.2021.02.46.1.0. 6. Kriti Prasad, Colleen McLoughlin, Martin Stillman, Sara Poplau, Elizabeth Goelz, et al. Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: A national cross-sectional survey study. https://pubmed.ncbi.nlm.nih.gov/34041456.

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Wellness Efforts During Pandemic Times at Emergency Physicians PA

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t began with confusion and fear. New walls were being put up in our departments. Everything was unfamiliar. Would some of us die? After a shift, many of my partners at Emergency Physicians PA (EPPA) took off their scrubs in their garages and ran through their houses to take showers before hugging their children. Initially it was just about survival. As spring began, in my position as the Director of Wellness, I wanted to know what to expect and facilitated a webinar on the effects of a disaster on healthcare workers. The good news was that ultimately, we should land at a place better than where we started. The bad news was that after the “healthcare heroes phase” we should expect a time of decompensation before the slow climb back up hill. Our host predicted civil unrest before things would improve. When George Floyd was murdered we witnessed the civil unrest and drove through curfews to get to work. We responded by attending a White Coats for Black Lives event and hosted a book club on How to Be an Antiracist. I was thrilled that Dr. Priya Sury was named to serve in our new position of Director of Health Equity and Inclusion. I partnered with our health coach intern from the University of Minnesota to develop a battle buddy program. Ten percent of our providers asked to be matched. They received reminders that included facilitated questions to check in with each other. For about three months peer dyads met for coffee, texted, walked, or even kayaked. By Wendy Laine, MD MetroDoctors

I further strengthened camaraderie by creating a peer support team. They received six hours of training on how to support their peers through active listening and were empowered to reach out after a particularly difficult case or event. Individuals who went through the training felt it had also improved their relationships with their patients, significant others, and children. National Physician Suicide Awareness Day was acknowledged by sharing data, resources, and reminding physicians to check in with themselves and their partners. I presented CME on physician/professional coaching, and the evidence of coaching’s ability to decrease burnout and increase enjoyment in our work. We had volume losses that caused pay cuts in 2020, with volumes surging back with crisis pay for emergency sick calls in 2021. Our leadership did a great job partnering with our systems early on to develop safety plans, asking us about our access to PPE, and offering tokens of appreciation such as Yeti mugs and facemasks. (Be careful with this, though, this can backfire if people think the only support they are receiving is trinkets.)

The Journal of the Twin Cities Medical Society

As we move out of survival mode deeper questions will arise. Wellness thought leaders anticipate higher rates of depression, substance abuse, burnout, suicide, and providers leaving health care in the next two years. Burnout has been shown to be 80% — a manifestation of systemic dysfunction, not individual failure to thrive. Even the most resilient individuals can be burned out. Now is the time to double down on developing a culture of wellness, creating system efficiencies, and supporting individual wellness. As I write this article we are experiencing unprecedented boarding times. We will continue to adapt and meet whatever challenges come our way. Hold dear the relationships that you have with your patients and coworkers. We all worked so hard to get where we are and deserve to end each shift feeling like we made a connection and made a difference. Wendy Laine, MD is an emergency medicine physician with EPPA since 2004 and the Director of Wellness since 2017. She believes that professionalism, compassion, and intention are key if we want to finish each shift and career with satisfaction. Recommended reading: Mayo Clinic Strategies To Reduce Burnout: 12 Actions to Create the Ideal Workplace and The Business Case for Investing in Physician Well-being, Shanafelt et. al. as guides for developing a wellness strategy for your group. She can be reached at wlaine@eppahealth.com. Emergency Physicians PA (EPPA) is an independent group of 200+ emergency physicians. We partner with 11 hospitals in the greater twin cities area and operate three free standing Urgency Rooms. Winter 2021

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Physician Health & Wellbeing — COVID-19 and Beyond

An Ethics Oasis in Our Pandemic Journey Come, be heard, you are not alone with the discomfort, we are here with you.

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patient rips off their mask, yelling at the doctor that COVID is a hoax. A masked doctor wonders if their nearly deaf patient, no longer able to read lips, really understands the procedure they consented to. In the hours prior to intubation, a COVID patient is not allowed to see their loved ones. A clinical team weighs one life against another to determine who receives ECMO when demand exceeds capacity. Healthcare workers are no strangers to moral distress, the painful experience of the gap between what we think should happen and what we can make happen. Since the arrival of COVID-19, we are getting toxic doses. How often do we wonder if we’re doing the right thing, or know we cannot? This comes at a time when we are increasingly distanced from the support of our colleagues — break rooms closed, masks covering our expressions, hugs not allowed. It’s enough to make anyone’s moral compass spin. One way to realign to our moral north star is to speak our experience. Our moral fibers, wounded by our experiences on the wards and clinics, can be strengthened by giving them voice. When we articulate out loud the conflict between how we want things to be versus how they actually are, we bolster our integrity and values. But who can we talk to? Our loved ones might not understand our work experiences. Coworkers are busy. What about HIPAA and liability issues? When By Mary Anderson, MD, Nancy O’Connor, MD and Joan Henriksen

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Mary Anderson, MD

Nancy O’Connor, MD

we cannot air our thoughts, our struggles are compounded by loneliness. However, no caregiver is alone in experiencing ethical tensions. We are all familiar with that anguish in various ways, and that makes us uniquely qualified listeners. We ourselves are an underutilized community ready to support one another, if only we could find each other. In our organization, we created the Ethics Oasis to allow for that human connection. It is a twice a week meeting hosted online via Zoom. It lasts 50 minutes. No RSVP, special invitation, or registration is needed. It is open to all patient-facing caregivers. Topics of discussion are determined by those who attend. Conversations are confidential, peer-protected, non-judgmental, and moderated by an ethicist and a clinician. Participants voice their first-hand experiences of their ideals conflicting with their reality — all in the unique fellowship shared by healthcare workers. Ethics Oasis is not about critiquing care or performing an ethics consult. It’s not even meant for problem solving per

Joan Henriksen

se. We don’t have curriculum or didactic sessions. We ask that all speak solely from their own experience and avoid patient identifiers. All voices and perspectives are respected. We ask for presence — by minimizing distractions, using the video function of Zoom, and respecting silence as time for reflection. The Ethics Oasis model has many strengths. Being online, we are immune to social-distancing mandates. The online venue also dodges the challenges of finding physical meeting space. On Zoom we can see faces (with expressions, honesty, vulnerability) that are otherwise hidden by masks. We hope that attending from home lets participants feel safer and more comfortable, while also reducing the barriers of time and distance. We are pleased and gratified by the widespread support the Ethics Oasis has received across our organization. Ethics Oasis was initiated by a professional clinical ethicist with expertise in moral distress. Additional start-up energy came from the Clinical Care Committee, which

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The Journal of the Twin Cities Medical Society


was tasked with managing scarce resources during the pandemic. Its subgroup, the Moral Experience Team, provided a wonderful cadre of committed volunteer facilitators. Essential support then came from the Practitioner Health and Wellness Committee, which endorsed peer-protected confidentiality. Person-power and ideas poured in from the Employee Assistance Program, the Resiliency and Physician Satisfaction Committee, and the Spiritual Care team. Our media services published an informational webpage and created a QR code. The Zoom account came through the Ethics department funding. And sure enough, morally distressed partners have come to the oasis. The breadth of topics discussed is a testament both to the challenges of being a caregiver and to the elastic nature of Ethics Oasis absorbing most anything that attendees bring. Here is a sample of the topics discussed so far: • Guilt for leaving things undone. • Fear of transmitting COVID to others. • Families firing their doctor. • Responding to structural racism. • Struggling to set limits on patient care to make room for self-care. • Exhaustion from enforcing mask and visiting policies. • Witnessing patients and families making irrational and futile care decisions. • Feeling loss of empathy and dehumanization with an angry patient at the end of the day. • Change fatigue. • Feeling vulnerable when patients threaten violence. • Uncertainty when you reach the limits of your expertise. If only we could say “if you build it, they will come.” But we’ve had significant struggles with low attendance. Those who are burned out and exhausted (perhaps most in need of an Ethics Oasis) are particularly unlikely to have the time and energy to attend “yet another meeting.” Getting the word out is also a challenge. We’ve tried every tool of promotion we could think of; a write-up in the company-wide newsletter, word of MetroDoctors

mouth, posters in break rooms, handing out business cards with a QR code, and enlisting team managers to endorse attendance. We’ve discussed Ethics Oasis at nurse shift-change meetings, huddles, and doctor group meetings. We offered different times of the day and even a weekend meeting time. We wonder if people feel too intimidated to share personal and difficult feelings both online and with an unknown group of people. Another possible barrier seems a little ironic — perhaps it is too easy to attend. Does no RSVP also mean no commitment? Does little effort to attend translate into little value? Despite challenges, we believe the Ethics Oasis does have significant value. Even when COVID has left the headlines, our clinical experiences will continue to generate ethical tensions. We have shown Ethics Oasis is a sustainable way to honor and heal our moral ideals. Our time reflecting together helps give us peace between our internal values and our external workplace. As a result, we are stronger, more resilient, and happier physicians.

The Journal of the Twin Cities Medical Society

We are optimistic that when a tool is helpful it will be adopted. But we are realistic about the difficulty of any change, even a positive one. The trouble recruiting attendees to the Ethics Oasis is more likely a reflection of the slow pace of cultural change, rather than a sign that ethical tensions don’t exist or don’t need addressing. Right now, experiencing moral distress is an expected part of our job, but dealing with it isn’t. We envision a future with Ethics Oasis where it’s normal in our medical culture to acknowledge and heal from moral distress. Mary Anderson, MD practices Internal Medicine as a Hospitalist at Allina Health’s Abbott Northwestern Hospital. She lives in Minneapolis with her husband. Nancy O’Connor, MD is a family physician in Shakopee. She is interested in the intersection of medical humanities and healing the Healers. Joan Henriksen serves as a full-time clinical ethicist at Allina Health’s Abbott Northwestern Hospital.

Do your patients have trouble using the phone due to a hearing loss, speech or physical disability? The Telephone Equipment Distribution Program offers easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Web: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

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Sponsored Content

It’s OK to Not Be OK Contributed by Suzanne Jasberg, MD and Anastasia Ristau, PhD, LP

Well before COVID-19, there were already multiple crises facing our country’s healthcare sector — from high costs of care to hospital staff shortages. Now, nearly two years since the first COVID-19 case was reported in the United States, healthcare workers are exhausted, burned out, disheartened, disillusioned and unsure how much longer they can endure. And there doesn’t seem to be an end in sight. At PrairieCare — one of the nation’s fastest-growing psychiatric health systems — we are seeing an exacerbation of existing mental health struggles as well as the development of new illnesses among healthcare workers. For those we treat as well as our colleagues, this seems, in part, a result of what healthcare workers are facing each day on the front lines of this pandemic. This is especially concerning when considering the hesitancy among physicians to seek care or treatment for a mental health condition because of fear of medical license repercussions.1 To do their best work in taking care of others, doctors, nurses, and healthcare workers need to take care of themselves first, starting with their mental health. Compassion fatigue at the forefront

When the pandemic began, healthcare workers were constantly discussing PPE shortages, ventilator settings and how to ration ICU beds. They were afraid — in a way that many have never experienced — that their career could harm their families if they brought the virus home. As a psychiatrist and psychologist, we watched our colleagues endure this, knowing that the psychiatric ramifications 18

Winter 2021

Suzanne Jasberg, MD

Anastasia Ristau, PhD, LP

would be next — from trauma responses and insomnia to anxiety and guilt. Healthcare workers are also challenged with fighting a constant stream of misinformation. Topics of vaccines and masks have become controversial and political. Some individuals are dismissing advice to get vaccinated or refusing to practice basic public safety measures, and down the line require care for something that is largely preventable. Some doctors are facing violent threats while trying their best to provide evidence-based medicine. And we’re all worried about protecting those who are vulnerable, including children under 12 who just recently became eligible for the vaccine. We’ve heard many doctors and nurses ask questions like, “I’m losing my faith in humanity, what do we do next?” Once the vaccine arrived, we had more hope, but our efforts are falling short and compassion fatigue has set in. These thoughts do not make us bad healthcare professionals, or bad people — we have been subjected to prolonged

trauma and these feelings are valid, and they must be addressed with care and support. Healthcare workers struggle with mental illness-related stigma, too

There’s still a stigma in this country associated with having mental illness symptoms, and an even more pervasive stigma exists for healthcare providers. We’ve heard firsthand the concerns healthcare providers have around getting mental health care, starting with fear that this could impact licensing status and ability to practice. For many years, Minnesota’s licensure application required physicians to disclose mental health conditions even if the individual is being appropriately treated and the condition does not impair their ability to practice medicine with reasonable skill and safety. Thankfully, this has recently been addressed by the Minnesota Board of Medical Practice. In September, the board unanimously

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The Journal of the Twin Cities Medical Society


voted to change the language for initial and renewal applications for licensure.2 The question, thought to have been a barrier for physicians, nurses, and medical students to seek appropriate care, has been changed to: “Do you currently have any condition that is not being appropriately treated which is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical and professional manner?” This will take effect Jan. 1, 2022 and will mean better mental health for the medical community and, ultimately, better care for patients. Real change must come

It’s one thing to talk about how we, as healthcare providers, need to take care of ourselves so we can take care of others, but it’s much more difficult to translate that into action. Systemic changes are needed. To keep expecting more and more of ourselves and each other as the pandemic continues is not only unrealistic, but also dangerous to doctors and patients alike. If society wants healthcare providers to be able and willing to seek mental health support, they must receive more acceptance, guidance, and free time. With the increase in teletherapy, mental health care is more convenient and accessible now than ever before, but it still requires that healthcare providers can take time out of their busy schedules. Healthcare workers shouldn’t just be able to access mental health care, they should be encouraged to seek it out. Changes like the board language update are a great step in the right direction. But efforts on a more micro-level have tremendous impact as well. Checking in with ourselves and our fellow healthcare providers regularly with a “How are you?” and then acknowledging that it’s OK if the answer is “not OK,” can go a long way. Put on your own mask first before assisting others

Tending to our own personal mental and physical health provides us a critical buffer against the impact that our minds, bodies, MetroDoctors

and spirits take from caring for others day in and day out. One way to mitigate feelings of exhaustion, helplessness, and potentially disillusionment about work is to refocus your “why.” Why did you choose a career in health care, what drew you to this work in the first place, and why is it fulfilling right now? That fulfillment from helping others or solving problems can keep us inspired and motivated and help us be more intentional about the day — refocusing on the things that can be controlled and positively impacted, rather than on what seems impossible or like a losing battle. Small efforts, such as pausing for slow, deep, and restorative breaths before your next patient, or taking a few minutes before and after work to focus on something you are grateful for in your life, can make a world of difference in recharging your batteries, staying calm, and minimizing toxic feelings. The daily work we do matters and every person we care for matters. Know that every time you educate someone to get the vaccine and have that difficult conversation, you are making a huge difference. Healthcare providers are used to pushing beyond our limits, even before the pandemic, but the more we tend to our mental health needs, the more resilient we will remain. We’re more willing to talk about mental health and acknowledge those limits when we have a strong support system scaffolding us. Try seeking out a trusted colleague who you are comfortable with and look out for each other. Make daily efforts to check in on each other with intention and mutual support. Healthcare employers also have a responsibility to focus on the needs and wellbeing of their staff. At PrairieCare, we’ve been providing group listening sessions to support our clinicians during this time. And of course, healthcare workers deserve to seek out specialized mental health care if and when they need it. Call PrairieCare at 952-826-8475 for a no-cost mental health screening to determine next steps and access any needed services for mental

The Journal of the Twin Cities Medical Society

health support. There’s also the Physician Support Line3 that was developed during the pandemic, offering free, confidential peer support from U.S. licensed psychiatrists to doctors and medical students navigating the many stresses of their personal and professional lives. It’s available from 8 a.m. to 1 a.m. ET, seven days a week, at 1-888-409-0141. While there’s no chance everyone will go to sleep tonight and wake up tomorrow in a COVID-free world, as healthcare workers, we can still wake up with the goal of taking care of ourselves and watching out for our healthcare colleagues. Suzanne Jasberg, MD, adult interventional psychiatrist, director of the Center for Neurotherapeutics, PrairieCare. Anastasia Ristau, PhD, LP, licensed psychologist, director of psychotherapeutics, PrairieCare. References 1. Dyrbye LN, West CP, Sinsky CA, Goeders LE, Satele DV, Shanafelt TD. Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions. Mayo Clin Proc. 2017;92(10):1486-1493. doi:10.1016/j. mayocp.2017.06.020. 2. A Victory for Physician Mental Health – Twin Cities Medical Society. Twin Cities Medical Society. https://www.metrodoctors.com/tcmsblog/2021/9/11/a-victory-for-physician-mentalhealth. Published September 11, 2021. 3. Physician Support Line. https://www.physiciansupportline.com/.

Disclaimer: The contents of this article are for informational purposes only. The content is not intended to be a substitute for professional advice, diagnosis, or treatment. Always seek the advice of your mental health professional or other qualified health provider with any questions you may have regarding your condition. If you are in crisis or think you may have an emergency, call 911 immediately. If you’re having suicidal thoughts, call 1-800-273TALK (8255) to talk to a skilled, trained counselor at a crisis center in your area at any time (National Suicide Prevention Lifeline). If you are located outside the United States, call your local emergency line immediately.

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Physician Health & Wellbeing — COVID-19 and Beyond

More Resiliency is Not the Answer

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hysician suicide has received greater attention due to an acute rise in rates during the COVID-19 pandemic. But this is not a new problem — physician suicide has been on the rise for 150+ years though it has remained medicine’s best kept secret until recently. Although more than one physician dies by suicide every day, institutions are only now facing criticism for their responses, or lack thereof, to this mental health crisis and their roles in perpetuating a culture of silence.7 Physicians are dying at a rate two times higher than the general public and suicide is now the #2 cause of death among resident physicians.1 This year, we will lose at least 400 physicians to suicide in the US — the equivalent of two full medical school classes.1 It was heartbreaking to learn that one of our own, in our community, had died by suicide — an intern only seven months into residency. I couldn’t help but to wonder what we — as a system and a community — had done to this young, driven resident to take away his will to live? Like many physicians practicing medicine for decades, one leader at our institution chose to question his resiliency. “[He] had a different idea of what medicine is and when he got here, he just couldn’t handle it,” he stated. It was clear — none of us were immune to this toxic culture and the silent epidemic. They believe the higher suicide rates are a result of millenials not being By Bindi Parikh, MD

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resilient enough, often citing their own experience in “surviving” harsher residency conditions with no duty hour policies. However, many fail to consider the higher patient volumes and greater complexity of medical management today as a result of advancements in medicine. Patients are older, sicker, and face far different complications than they once did. Medical protocols and documentation have become more time consuming than they once were. Although the practice of medicine has clearly evolved in recent decades, the culture has not. The culture of medicine has hinged on the principle that being exposed to greater stress builds better, more resilient physicians. However, research has shown that when humans are exposed to uncontrollable stress, they tend to give up and this response is maintained even when opportunities to escape that stress are presented to them later — a concept

known as learned helplessness, which can render individuals vulnerable to mental illness in the future.2 Although duty hour rules were established to prevent medical errors made by overworked physicians, many programs violate these policies and continue to overwork residents. In fear of retribution by program administrators, residents often never report these violations and therefore, only some programs get cited for these violations. After the death of Dr. Deelshad Joomun in 2018 at Mt. Sinai St. Luke’s Hospital, one resident reported “her program had a resident meeting — not to address the death, but to discuss an upcoming survey by the ACGME [and] what they should and should not include on the surveys, advising them not to air their dirty laundry out in public.”3 Unfortunately, it is common practice for programs to coach residents on how to fill out these surveys — at times, justifying survey results by blaming poorly worded questions and misunderstandings. This results in the silent suffering of medical residents who are pressured to continue working in an abusive environment due to a state of learned helplessness. Prolonged exposure to this toxic environment can erode one’s resilience and mental health, too often leading to a tragic ending as it did in the case of Dr. Joomun. These silencing behaviors by residency programs reflect an unwillingness to acknowledge the systemic problems contributing to resident mental illness. Without acknowledgement by

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The Journal of the Twin Cities Medical Society


institutions, it is impossible to create effective change — as seen by the increasing rates of resident depression and suicide. The data supports that medical trainees are at increased risk of depression with more than 28% of residents experiencing at least one major depressive episode, compared to 7-8% of the general population.1 Interestingly, studies have shown that after only four web-based cognitive behavior therapy sessions, suicidal ideation decreased by nearly 50% among interns. However, physicians who die by suicide are less likely to have received mental health treatment than non-physicians.6 In combination with the stigma of mental illness and long work hours, getting help can be daunting for medical residents.5 In an effort to acknowledge my role as a chief resident in addressing these barriers and prioritizing mental health, neurology residents were excused from work to attend free, confidential

counseling sessions that were pre-scheduled by the Physicians Wellness Collaborative (PWC). I hope to inspire other programs to effectively use PWC’s resources by continuing to schedule multiple sessions throughout the year to ensure our residents have a provider they can feel comfortable calling during times of increased stress. Furthermore, I want to encourage an open dialogue to normalize seeking help. This year, the neurology and radiology residents and faculty came together to honor National Physician Suicide Awareness (NPSA) Day with a grand rounds lecture given by Dr. Michelle Chestovich, who lost her physician sister, Dr. Gretchen Butler, to suicide this year. By honoring this day annually, I hope to educate faculty, residents, students, and administrators at our institution. I am writing today to ask institutions to hold themselves accountable by joining us in making physician mental

It is time for institutions to acknowledge that more resiliency is not the answer, and a new approach involving systemic change is needed. Every life lost is one too many and we cannot afford to keep losing this battle.

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The Journal of the Twin Cities Medical Society

health a priority and helping build a new culture of transparency to destigmatize depression, mental illness, and suicide.7 It is time for institutions to acknowledge that more resiliency is not the answer, and a new approach involving systemic change is needed. Every life lost is one too many and we cannot afford to keep losing this battle. For every physician and trainee reading this, I want to echo Dr. Chestovich’s words to you and your colleagues — do not let anyone tell you that you are not resilient, you are among the most resilient people out there. Remind your peers of this and please empower each other to take a stand and advocate for future generations of physicians — for our safety, our loved ones’ safety, and our patients’ safety. Dr. Bindi Parikh is currently a chief resident in her 4th year of training at the University of Minnesota Neurology Residency Program. She plans to continue her training as a neurocritical care fellow at the University of Maryland, starting in July 2022. Dr. Parikh is dedicated to improving awareness of physician suicide and empowering institutions to make changes to help heal physicians. Resources: 1. https://wichita.kumc.edu/Documents/wichita/ asa/NPSAfastfacts.pdf. 2. https://www.psychologytoday.com/us/blog/ the-other-side/201902/the-resilience-paradoxwhy-we-often-get-resilience-wrong. 3. h t t p s : / / w w w . r e f i n e r y 2 9 . c o m / e n us/2018/02/189624/mount-sinai-st-lukes-suicides. 4. https://payneresilience.com/blog/what-resilience-is-not. 5. https://nam.edu/addressing-burnout-depression-and-suicidal-ideation-in-the-osteopathic-profession-an-approach-that-spans-the-physician-life-cycle/. 6. https://www.acgme.org/globalassets/PDFs/tenfacts-about-physician-suicide.pdf. 7. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8170626/.

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Physician Health & Wellbeing — COVID-19 and Beyond

COVID-19 Pandemic and Medical Student Mental Health

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n Wednesday March 11th, 2020 at 1:02 PM President Gabel notified the University of Minnesota community that in-person instruction, due to the COVID-19 pandemic, was suspended and all courses would return in virtual form. Those on clinical clerkships finished the week but soon afterward, the wards and clinics were empty of medical students. Faced with the prospect of student training grinding to a halt across the UME continuum, faculty and staff responded swiftly and in remarkably innovative ways. Course directors and the Curriculum team scrambled to transform the Year 1 and 2 Pre-Clerkship Foundation courses to an all virtual platform. Year 3 and 4 Clerkships were split with didactic components (and Shelf Exams) placed in virtual (Part A) courses while the (Part B) clinical experiences were deferred to an undetermined future period. On May 25th, four miles away from the Twin Cities Campus, the challenges of COVID were exacerbated when the murder of George Floyd sent reverberations across the world and reminded us of the other ongoing pandemic of institutional racism. All students faced increased isolation, uncertainty about their futures, living in fear of being infected with COVID-19, and concerned about the equity of their education. Meanwhile, nationwide, average anxiety and depression severity scores

By Michael H. Kim, MD and Wm. Scott Slattery, PhD

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Michael H. Kim, MD

Wm. Scott Slattery, PhD

increased 13% from August to December 2020.1 Data is now emerging suggesting that impacts on medical students associated with the pandemic resulted in even higher levels.2 As the year progressed, uncertainties lingered, and the new-normal set in. The 2020 graduates were left with a virtual Match Day and Commencement and entered residency programs clouded by an evolving pandemic few were prepared for. The class of 2021 lost access to advanced training and away rotation opportunities, faced a virtual Match, and joined their 2022 peers in encountering a seemingly relentless barrage of USMLE Board exam cancellations. These same 3rd year peers also faced a summer without clinical experience, and concerns about being adequately prepared to be doctors. The Class of 2023 completed their first year virtually and faced the prospect of another year of isolation from classmates. Lastly, the incoming matriculants of 2020 didn’t physically meet most of their classmates until a year later. In short, this has been

an unquestionably horrible year, and, with the customary world of medical education turned on its head, how are we doing? Prior to the 2020 Spring, considerable efforts were already underway to improve the mental health support of our medical students. Described previously3 and built upon a prevention model, efforts focused on a theoretical conceptualization of wellbeing in terms of three interdependent dimensions: 1. impact of the learning and working environment; 2. access to supportive relationships and community; and, 3. ability to engage in an effective self-care plan. Prevention efforts in each dimension further intersect to foster a sense of belonging, emotional capacity, and self-efficacy. These efforts guided responses to the impacts of the dual pandemics as well as how to monitor and respond to them. For example, the year before a pulse survey process where randomized student groups across classes were surveyed on wellbeing, empathy, and depression at the start of the school year and then longitudinally as part of follow-up groups

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over the subsequent 10 months. This process allowed us to monitor the health of students across the four years. Our preliminary data showed stable levels of depression and increased empathy across all four years during the early months of the COVID pandemic. These unexpected findings are suggestive of a resilient and highly empathetic group of students and validating our initiatives to support their mental health. From the perspective of a safe and effective learning environment, downsizing the Year 1 and 2 curricula and implementing more small group active learning experiences facilitated an effective transition to the virtual learning environment. The reduced number of in-person laboratory sessions enabled wearing full PPE to be more realistic, and the prior transition to a Pass-Fail assessment process eased student concerns of working over Zoom. For Year 3 and 4 virtual Clerkship courses, residents and faculty provided small group didactic and case presentations that students felt were adequate preparation for their eventual return in Fall of 2020. Without the requirement of didactic demands, these shortened clinical experiences were appreciated by students as often being more immersive. Regarding community support, the academic advising program was a mainstay for students (especially in the first six months). In the face of persistent uncertainties, our Academic Advisors were critical in providing peace of mind to students through flexible month-to-month scheduling solutions in the face of regular Step exam cancellations, uncertain transitions back to the clinical environment, and a need to accelerate specialty discernment. Our newly created in-house Confidential Bridging Counseling program saw little disruption in support to students as it transitioned to a telehealth service platform. In many respects, this shift offered MetroDoctors

greater access and flexibility for students, especially those on Clerkships where the ability to find an hour to step away, meet with our psychologist, Dr. Reilly-Spong, and then return to their clinical assignments was notably less disruptive to all.

Variant reminds us to remain vigilant but, again, lessons learned from efforts of past months combined with their resiliency are enabling students to make due and continue the process of learning how to be great doctors.

In the face of persistent uncertainties, our Academic Advisors were critical in providing peace of mind to students through flexible month-to-month scheduling solutions in the face of regular Step exam cancellations, uncertain transitions back to the clinical environment, and a need to accelerate specialty discernment. To date, nearly 25% of medical students accessed the short-term counselling offered with the program. Supporting a self-care plan was challenging due to availability limitations such as closures to UMN Rec Center facilities and uncertainties in how to stay active. However, efforts such as expanding time off for rest and relaxation during Clerkships (from two to three and a half days every two weeks) were appreciated. Overall we believe it can be said that our students persevered and signs of returning to some semblance of normalcy are emerging. Nearly all impacted students in the 2021 Class graduated on time and despite virtual interviews we had one of our best Match rates in recent times. Strong vaccination rates enabled the Class to hold their commencement in Northrup, and we welcomed our new Class this Fall with a mostly in-person orientation and more classes on campus. The hospital halls are abuzz again with students, albeit looking similar in scrubs and masks. The Delta

The Journal of the Twin Cities Medical Society

Dr. Michael Kim obtained his MD and specialty training in Internal Medicine-Pediatrics at the University of Minnesota. He became the Assistant Dean for Student Affairs in 2015. He advocates for and promotes student academic success, a culture of wellbeing, and a supportive learning environment. Wm. Scott Slattery, PhD joined the Office of Medical Education as Director of Learner Development in 2014 after previously serving as a Sr. Psychologist at the University of Minnesota’s Student Counseling Services. Dr. Slattery earned his bachelor’s degree from the College of William and Mary, and doctorate at the University of Pittsburgh. References 1. Jia H, Guerin RJ, Barile JP, et al. National and State Trends in Anxiety and Depression Severity Scores Among Adults During the COVID-19 Pandemic — United States, 2020–2021. MMWR Morb Mortal Wkly Rep 2021;70:1427–1432. 2. Nikolis, L., Wakim, A., Adams, W. et al. Medical student wellness in the United States during the COVID-19 pandemic: a nationwide survey. BMC Med Educ 2021;21,401. 3. Kim, MH and Slattery WS. Evolving Support for the Mental Health of Medical Students. MetroDoctors 2020;22(3):18-19.

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Physician Health & Wellbeing — COVID-19 and Beyond

The Cost of Compassion in Healthcare Professionals There is a cost to caring too much. Compassion — like a taken-for-granted, worn Achilles’ tendon pulled too taut — may rupture and wound. We physicians, within these bodies, also can fall to the ground; how long we stay there may depend on how stubbornly we resist admitting that we own an Achilles at all. “Compassion fatigue” is a very real problem for healthcare professionals. In a recent Healthcare Professionals and

Professionals who are repeatedly exposed to the traumatic experiences and narratives of their patients, and who have a desire to alleviate that suffering, are at especially high risk of compassion fatigue. This includes physicians but also psychologists, oncologists, pediatric clinicians, HIV/AIDs care workers, emergency medical responders and others, with nurses being the most notably affected due to the overtly

While burnout is an insidious process that is often the result of a challenging work environment, compassion fatigue results from doing the work itself. Compassion Fatigue Research Update, the Hazelden Betty Ford Foundation’s Butler Center for Research distinguishes the condition from burnout, describing it as an acute onset of the following symptoms: exhaustion, apathy, irritability, negative reactivity, diminished sense of purpose, hopelessness, and an inability to maintain objectivity.1 While burnout is an insidious process that is often the result of a challenging work environment, compassion fatigue results from doing the work itself.

By Kristen A. Schmidt, MD

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caring nature of their job.1 In 2019, one study demonstrated that 86% of nursing respondents reported high levels of compassion fatigue.2 In the age of COVID-19, compassion is a precious commodity. Since its existence is invariably linked with the material ability to extend help, the dearth of hospital and community resources available makes caring for patients in a pandemic landscape especially challenging. In her essay entitled, “Regarding the Pain of Others,” Susan Sontag suggests, “It is because a war, any war, doesn’t seem as if it can be stopped that people become less responsive to

the horrors. Compassion is an unstable emotion. It needs to be translated into action or it withers.”3 The pandemic’s uncertain terminus has the potential to anesthetize providers; callouses may form where compassion was born. Such a shift away from our ability to experience compassion would, according to positive-emotion proponents, be unnatural. Humans release dopamine, oxytocin, opioids, and other soothing biological chemicals when helping someone in need.4 Compassion has therefore been assumed to exist as an evolutionary advantage with recurrent reinforcement through neurohormonal feedback. With the advent of COVID-19, however, self-protection and care for others are placed in uncomfortably close proximity. Compassion fatigue has bloomed in the cracks of contradiction, since healthcare professionals are continually asked and encouraged to go to work, while others remain isolated at home to keep their own families safe. Symptoms of anxiety, fear, irritability, and distress have been the result.1 Because it implies a limit in our capacity to care for patients, talking about compassion fatigue feels taboo. Accepting or admitting vulnerability is seen as a sign of weakness for many healthcare providers. In one study, acknowledging compassion fatigue was synonymous with shame.5 In an effort to manage symptoms privately, physicians may resort to substance use and develop a co-occurring disorder. A study evaluating compassion fatigue in general

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practitioners found that approximately 15% of them had turned to alcohol, prescription drugs, or both to help them cope with work demands.6 Similarly, nurses have also demonstrated difficulty accessing positive coping patterns to combat clinical stress. One recent investigation highlighted the frequent use of cigarettes, sleeping pills, and power drinks among those nurses reporting significantly higher compassion fatigue scores than those who did not.7 In a culture comprised of healing warriors, how do we better address our wounded? Some organizations have adopted programs educating healthcare professionals on symptoms of compassion fatigue. Others have targeted coping strategies. One such program, lasting five weeks with five 90-minute sessions on resiliency, was found to ameliorate symptoms of distress in its healthcare staff.8 Mindful-Based Stress Reduction Training (MBSRT) and Compassion Cultivation Training (CCT) have also been popping up in healthcare organizations.9 With administrative support for clinical schedule allowance, such trainings may result in positive outcomes for physicians. These outcomes may include improved empathy, professional quality of life and self-compassion. I encourage healthcare providers to also monitor themselves for the symptoms mentioned earlier, establish go-to relaxation techniques, build a positive support system, make time to tend to physical wellness, and ask for help whenever needed. Individual therapists can help, and if MetroDoctors

substance use becomes a problematic coping mechanism, please know you are not alone and that places like the Hazelden Betty Ford Foundation can help. Self-compassion is a paradoxical concept and one that eludes most of us in the early stages of our doctoral development. What we understand is self-sacrifice. As someday-to-be psychiatrists, surgeons, pediatricians, and pathologists, we receive scrubs and a scalpel, place our sameness on a shelf, and begin to dissect what is human with our hands. It is the first in a series of us splitting from our mortal shapes in the hopes of becoming even better healers. In a context of formaldehyde and fortitude, it is our compassionate intentions that distinguish us from deviants. In time, our bladders learn to expand for the sake of the child’s surgery, our circadian rhythms tune to the beat of the trauma pager, and we always return to our scheduled rotation the morning after. To say that we are tired seems a sin and sine qua non. And still, we are human. We are human. As an addiction psychiatrist, and practicing human, allow me to simply suggest: accepting help from another healer may be your most heroic act yet. Kristen A. Schmidt, MD, is board certified in addiction psychiatry and practices as Lead Psychiatrist at the Hazelden Betty Ford Foundation in Center City and St. Paul, Minnesota. References: 1. Butler Center for Research. (2021). Research Update. https://www.hazeldenbettyford.

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2.

3. 4. 5.

6.

7.

8.

9.

org/education/bcr/addiction-research/healthcare-professionals-compassion-fatigue. Sullivan, C. E., King, AR., Holdiness, J., Durrell, J., Roberts, K. K., … Mandrell, B. N. (2019). Reducing compassion fatigue in inpatient pediatric oncology nurses. Oncology Nursing Forum, 46(3), 338–347. doi:10.1188/19.ONF.338-347. Sontag S. (2003). Regarding the Pain of Others. Picador Modern Classics: 129. Vaillant G. (2008). Spiritual Evolution a Scientific Defense of Faith. Broadway Books, 198. Selamu, M., Thornicroft, G., Fekadu, A., & Hanlon, C. (2017). Conceptualisation of job-related wellbeing, stress and burnout among healthcare workers in rural Ethiopia: A qualitative study. BMC Health Services Research, 17(1), 412. doi:10.1186/s12913-017-2370-5. Kaffash, J. (2017). Revealed: One in seven GPs turns to alcohol and drugs to cope. Pulse. pulsetoday.co.uk/news/clinical-areas/ mental-health-andaddiction/revealed-one-inseven-gps-turns-to-alcohol-and-drugs-tocope/ Jarrad, R., Hammad, S., Shawashi, T., & Mahmoud, N. (2018). Compassion fatigue and substance use among nurses. Annals of General Psychiatry, 17(1), 1–8. doi:10.1186/ s12991-018-0183-5. Rajeswari, H., Sreelekha, B., Nappinai, S., Subrahmanyam, U., & Rajeswari, V. (2020). Impact of accelerated recovery program on compassion fatigue among nurses in South India. Iranian Journal of Nursing and Midwifery Research, 25(3), 249–253. doi:10.4103/ijnmr. ijnmr_218_19. Sansó, N., Galiana, L., González, B., Sarmentero, J., Reynes, M., Oliver, A., & Garcia-Toro, M. (2019). Differential effects of two contemplative practicebased programs for health care professionals. Psychosocial Intervention, 28(3), 131–138. doi:10.5093/pi2019a12.

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Paid Editorial

Better Patient Outcomes Through Innovation in Chest Wall Injury Repair Contributed by Peter A. Cole, MD Respiratory failure, pneumonia and tracheotomies are common complications of severe chest wall trauma resulting from automotive, motorcycle and snow mobile accidents — but they don’t have to be. Thanks to innovations in the treatment of flail chest and fractured sternums, people can recover faster and with less pain. However, only a small fraction of indicated patients receive the surgery that could help because few specialists have the proper expertise. The orthopedic trauma team at Regions Hospital is working to elevate care for chest wall injury through continued research, and by creating awareness about ways to improve outcomes for these patients. The role of surgical intervention in treating chest wall trauma Surgical stabilization of rib fixation (SSRF) is a procedure that uses titanium plates and screws to stabilize the ribs and hold them in place while they heal. Without treatment, rib fractures may heal in a nonanatomic way, resulting in chest deformity, chronic pain and health comorbidities. Good candidates for SSRF are generally patients with multiple, consecutive, displaced fractures in ribs 3-10, especially when they are intubated, require respiratory support or have labored breathing because of pain. Findings from our experience and growing scientific evidence, show that SSRF is associated with shorter stays in the hospital and intensive care unit, lower pneumonia rates and a reduced need for a ventilator or tracheostomy. Some studies show a decrease in mortality, as well as better long-term outcomes with fewer chronic symptoms. Improvements are optimized when surgical intervention happens within the first three days — and may be even better if treated within the first 24 hours. Bridging the gap in chest wall injury repair Despite these impressive results, chest wall trauma is currently undertreated. It is estimated that less than 10% of indicated patients in North America receive SSRF, according to the Chest Wall Injury Society. A significant obstacle is the number of surgeons with expertise in chest wall repair. It’s still uncommon to find SSRF

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specialists even in many Level 1 Trauma Centers — and especially rare to find more than a couple at a single location. That’s not enough to ensure that patients get expeditious care for their injuries. After all, these types of injuries don’t take a day off. The orthopedic trauma team at Regions Hospital takes both a departmental and interdisciplinary approach to treating chest wall trauma with our general trauma surgery colleagues. By having an advanced team of six surgeons who treat rib fractures, flail chest trauma and chronic injury-related complications, we’re available to provide optimal treatment every day of the year. Promising trends in chest wall repair While there’s still work to be done to make this surgery accessible to patients who need it, we’re seeing progress. • More success stories — 10 years ago, our team did 5-10 operations per year. Now we treat a patient almost every week. • New tools — Thanks to instrumentation and implants specifically designed for different anatomical locations, the procedure is now an option for more patients. • Expanded training — More doctors are gaining expertise in SSRF, including about a dozen fellows trained at Regions Hospital, who are now practicing at centers across the country. Partnering with the medical community to advance patient care Working alongside the other members of the Chest Wall Injury Society, the team at Regions Hospital is advancing innovation in the treatment of chest wall injury. We’re also proud to partner with doctors across the Twin Cities metro area to improve outcomes for patients with chest wall injury. If you identify patients who have chest trauma with contiguous broken ribs, we can help. To learn more about HealthPartners and how we support ortho trauma, visit www.healthpartners.com/orthotrauma. Peter A. Cole, MD is the Department Chair of Orthopedic Surgery at Regions Hospital. He is a recognized thought-leader, educator and researcher on numerous advanced trauma topics, including management of flail chest and rib malunions. He is the senior author of numerous publications and chapters about chest wall trauma.

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Innovation in chest wall injury repair Thanks to innovations in the treatment of flail chest and fractured sternums, we’re able to improve outcomes for patients, helping them recover faster and with less pain.

Bridging the gap in chest wall injury repair We take a departmental approach to treating chest wall trauma. By having an advanced team of six surgeons who treat chest wall injury, we’re available to provide optimal treatment every day of the year. This approach is working and we’re seeing promising trends: • More success stories – 10 years ago, our team did 5-10 operations per year. Now we treat a new patient almost every week. • New tools – Thanks to instrumentation and implants specifically designed for different anatomical locations, chest wall repair is now an option for more patients. • Expanded training – More doctors are gaining expertise in SSRF, including several fellows trained at Regions Hospital.

For more information, visit healthpartners.com/orthotrauma or call 651-254-8300.

640 Jackson St. St. Paul, MN 55101

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YOUR VOICE

At the Root Health care needs to remove the roots of sexism and racism to make any progress on physician burnout, depression, PTSD, and suicide. The culture has allowed toxicity to flourish, and we can’t help anyone until we heal the system. When I was a child and we moved into our first home, we were ecstatic to have the space. I remember my dad taking a full survey of the house. My sister and I loved the deck, and we would spend hours walking along the narrow wooden flower beds, pretending we were training for the Olympic gymnastics team. We noticed a tree in the side yard; it had been around since the house was built. It was functional and provided shade to a small flower bed. However, it was too close to the house and the roots were growing into the foundation; it was becoming destructive to our home and starting to act like a malignancy to the rest of the structure. The medical culture, at its root, has had years of toxic education, patriarchal agenda, and dismissal of ideas from women and minorities. Daily I hear stories of women’s ideas being taken, colleagues being propositioned sexually, belittled because of how they look, and even dealing with sexual assault in the workplace. Women, especially women of color, are subjected to a worldview that discredits their ideas before they open their mouths. I have personally seen men make fun of women for appearing too masculine, or labeling them as dramatic, disruptive, or annoying just to create changes that conflict with an individual in charge. The data shows that women face micro-aggressions about their appearance on a daily basis, even in medical school. For us to stay stable and create a foundation that will outlive the current pandemic, we need to dig out the roots of racism and sexism. Health care can’t fix itself; it needs a massive grassroots effort from other industries. I have spent the last two years working with legislators, advocacy groups, and entrepreneurs. They feel more of a sense of urgency to fix the climate of medicine because they are people experiencing our intrinsic failures. The problem, as it stands, is that women and minorities are often villainized for coming forward with problems. When men in power cause turmoil, it is still seen as strong and By Kellie Lease Stecher, MD

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decisive. When men in leadership have inappropriate sexual relationships with trainees, staff, colleagues, and patients, it is still often washed away, and seen as part of the normal culture. We have two current examples of predatory physicians in Minnesota that have been in the mainstream media. The Board of Medical Practice did not recommend their removal. In one case, however, a health system removed the credentials of a physician who had a long-standing history of sexual misconduct with patients. Prior to the pandemic, 2019, it was found that 40% of women leave medicine or move to part time before they are six years out of residency. For years, the incorrect assumption was being made that women were leaving because of the stress of being a mother. This may be the case for some, however, when the data has been gathered it appears to be for more nefarious reasons. The pandemic has shown women how little they are valued in some systems. Across the country there is growing concern about seeking mental health resources as well. In essence, we have created the perfect storm of toxic culture, increased stress, devaluing human beings, and lack of support. At the same time, we have seen the continued climb of physician burnout, depression, anxiety, and suicide. We need to make sure women and people of color have a seat at the table, can help make policy changes, are rewarded for their contributions, and can make meaningful changes. It is easier, as a physician, to get on a board in the business world, than one in health care. Women make up only 13% of CEOs in health care. I tried for over two years to get a safe reporting structure created for women, students, staff, and men who have been abused. I was given lip service as to why we couldn’t create change. I was told medicine takes a long time for the wheels to move. I then talked to the AAMC and ACGME and they offered to place me on another task force to advocate for change. They regretted not being able to help more. However, MetroDoctors

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we can’t view that as enough. If programs and institutions can’t do the bare minimum to protect trainees, they shouldn’t be an accredited program. Therefore, I started working with organizations around the country and we will either create a way to help through Linked Inclusion and the business world, or we will legislate standards. In 2021, in this current culture, there should be no way someone can get away with threatening a colleague, or trying to ruin someone’s career, because their ego was hurt. We need national oversight and accountability for institutions that continue to foster a culture of fear. We need to be allowed to have open dialogues, and honest vulnerable conversations around these topics. We can’t allow physicians to be gaslighted by others who don’t want to look in the mirror. In order to make any strides, we can’t be in denial of what is really growing out of our control. We need to lean into solutions to make sure everyone is safe. If you or a partner isn’t feeling safe in the workplace, please reach out to Minnesota Mental Health Advocates, or Linked Inclusion. We are dedicated to supporting anyone who needs assistance. Kellie Stecher is an OBGYN, Chief Medical Officer of Linked Inclusion, and Co-Founder and President of Patient Care Heroes, Founding Board Member for the Minnesota Branch of the League of Minority Voters, as well as the Governor of the 7th district of the American Medical Women’s Association. Her work has made her

an invaluable contributor to both local and national publications, news, and podcasts. Her focus is on advocacy and policy change, centering around safety and equity. Dr. Stecher recently released a memoir, “Delivering,” which is available at: https://www.amazon.com. She is focused on bringing further awareness to the stigmatized issues women go through, in the hopes that this will lead to meaningful change. References: • https://www.aamc.org/news-insights/why-women-leave-medicine. • https://19thnews.org/2021/05/women-health-care-leaving-breakingpoint. • https://nam.edu/gender-based-differences-in-burnout-issues-faced-by-women-physicians. • https://www.modernhealthcare.com/labor/women-healthcare-are-breaking-point-and-theyre-leaving. • https://associationofanaesthetists-publications.onlinelibrary.wiley.com/ doi/epdf/10.1111/anae.15361. • https://www.ingentaconnect.com/content/wk/. ane/2021/00000133/00000004/art00034. • https://bmjleader.bmj.com/content/early/2021/02/15/leader-2020-000221. abstract. • https://www.healthcaredive.com/news/women-make-up-only-13-ofhealthcare-ceos/545469. • https://link.springer.com/article/10.1007/s40615-019-00680-y. • https://www.annemergmed.com/article/S0196-0644(20)30259-6/fulltext. • https://journals.plos.org/plosone/article?id=10.1371/journal. pone.0211620. • https://cancerletter.com/the-cancer-letter/20210528_1. • https://www.startribune.com/allina-bans-twin-cities-plastic-surgeon-amid-latest-of-several-sexual-misconduct-allegations/600087250. • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565651.

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MetroDoctors

The Journal of the Twin Cities Medical Society


Environmental Health The Climate Emergency is Here — Where is Health Care?1 Accelerating climate disruption is impacting people’s health and the healthcare industry in every way from worsening infrastructure damage to supply chain interruptions and shortages to increasing morbidity and mortality from heat, fire, flood, drought, and pollution. Healthcare providers, researchers, and educators, deeply troubled by these trends, are joining with many others working toward urgent climate solutions, but these efforts are repeatedly thwarted by greed and political gridlock. The healthcare sector includes many concerned providers, pharmaceutical and device manufacturers, insurers, care systems, educational institutions, and professional societies that are known and trusted by policymakers at every level of government. We have the political and economic power to strongly influence policies for environmental preservation. What would this look like? • Executives of major pharmaceutical, device, and integrated care corporations should insist that legislators advance sound, equitable energy policies; or financial support for candidates and parties will be re-evaluated. • Leaders of medical associations should publicly express deep concern over the climate crisis and coordinate their legislative priorities with public health and environmental groups. • Medical school leaders should ask their universities to divest themselves of all fossil fuel investments and to publicly advocate for urgent retirement of all fossil fuel infrastructure.

There will be resistance, investigations, and denunciations by fossil fuel interests. There will be anxious boards and investors. The best defense is to create science-based, industry-wide coalitions. If our industry fails to help head off the worst aspects of the climate disaster, it is highly likely that our universities, businesses, investments, pension plans, and legacies will be washed away like coastal real estate. This will be a huge challenge for all of us, but what greater legacy could we all leave than to have fought hard for the future of humanity. Ethically, the shared mission of our

By Bruce D. Snyder, MD Health Professionals for a Healthy Climate MetroDoctors

The Journal of the Twin Cities Medical Society

industry is to save lives, reduce suffering, and promote good health for all. We have the knowledge, the expertise, the power and influence, and above all, the obligation to help control climate disruption. We must use our power to move our organizations from passive concern to active engagement in the fight for a healthy future. We have everything to lose by doing nothing. Business as usual is not playing it safe; it is blindness. 1.

Adapted with permission from Snyder, B.D. The climate emergency: where is health care?. J Public Health Pol 41, 24–27 (2020). https://doi. org/10.1057/s41271-019-00211-3.

CAREER OPPORTUNITIES

Lakeview Clinic has what you are looking for! Join an independent, physicianowned group of 50 providers in the SW Metro. Be a part of a collaborative work environment in a primary care group of family physicians, internists, pediatricians, general surgeons and OB/GYNs. • 4-day work week with 32 contact hours achieving excellent work/life balance • Excellent compensation with a 2-year partnership track to earn in the top 10% in the state • Outstanding benefits including 100% paid family health insurance and dental insurance, 401K and profit sharing • We have 4 sites in the southwest metro: Chaska, Waconia, Norwood, and Watertown

Due to retirements and growth, we are currently looking for: ◦ Internal Medicine

CONTACT: administration@lakeviewclinic.com PHONE: 952-442-4461 ext. 7215 WEB: www.lakeviewclinic.com

Winter 2021

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FUTURE

Physician Leaders By Christopher Johns, MS3

A Student’s Ask for the Medical Profession

I distinctly remember an early summer day in downtown Minneapolis two weeks after the murder of George Floyd. I sat on my porch, thankful for the nice weather that granted me reprieve from my dark basement office. The pixelated faces of my peers lit up the screen as we began our virtual lab on bleeding disorders. When broken into small groups, I felt a light tremor and heard the growing hum of engines round the corner of my street. A group of national defense soldiers in armored vehicles interrupted the otherwise quiet road. They passed in a seizure of clanks and groans. One soldier about my age waved at me — like a neighbor in passing while perched atop the assault vehicle. These soldiers would continue to round every 15 minutes. Eventually I logged off the group, my mind too preoccupied to focus on clotting factors. It’s difficult to reflect on the precipitating events of this past year and a half when their fallout still resonates into how we, as students, learn. For those of us familiar with pre-pandemic medical education, the transition to online learning was acute. One day we were engaged in a physical and social space designed for growth, the next moment we were resource deprived. All the while hoping desperately that our Wi-Fi was strong enough, and our preceptors savvy enough, to feign the environment we lost. Yet, these tumultuous times have provided a novel lens with which to critique our medical education. As I sat on my porch chair, the roar of engines pulling me from the classroom, I couldn’t help but question the status quo. In a time when our social and political movements tie directly to the health outcomes of our community — the community we are in turn aiding as health professionals — why are we pulling students from these critical moments for lectures and small groups? The answer boils down to a 110-year-old academic paper that remains the foundation of American medical education: the Flexner Report. This critique of medical training would establish the current standards of academic medicine with the pursuit of scientific discovery and academic prowess as its central ethos.1 Our medical system today; schooling structure, research, rankings, and student selection criteria connect back to these values. While this paper, and the proceeding reconstruction of medicine, have undoubtedly led to outstanding discoveries within the past century, its hyper-rational model has neglected to elevate those who excel in clinical care, 32

Winter 2021

community engagement, and human compassion. This has a direct impact on students and how we navigate medicine. Selective specialties that require intense academic pursuit pull students away from the communities we serve to prioritize scholarly endeavors. This is impossible for many individuals, especially those whose health and lives are directly impacted by the social and political changes taking place outside our doors. Academic and scientific prowess is a luxury. A luxury that has become increasingly scarce for marginalized students over the past year and a half. No greater time has this been outwardly visible than this past year and a half. Our colleagues are fighting a war on health disparity, one against Black and brown bodies, essential workers, and vulnerable populations. Protests have been orchestrated, relief efforts coordinated, and policies enacted thanks to students, all the while compromising their academic “success.” These students have profoundly impacted the health of our local communities and yet will never be appropriately credited within academic medicine. Policies to remove rank and implement pass-fail grading are institutional band-aids on a nationally ingrained preference for hyper-analytical values. Meaningful change toward compassion-centered priorities in medicine merits meaningful reflection on how we as healers evaluate one another. Change requires us to reprioritize medicine: to relook at the standards set those hundred years ago, and to embrace the human condition when we care for our patients. Acknowledgements to Chris Seaver, M3, for his contributions to the article. Reference 1. Flexner A. Medical Education in the United States and Canada. Washington, DC: Science and Health Publications, Inc.; 1910. [Google Scholar]

MetroDoctors

The Journal of the Twin Cities Medical Society


Discover the awe of the sciences. Grow the roots of social responsibility. Feel the soul of the arts.

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THE REGION’S PREEMINENT DESTINATION FOR

PEDIATRIC CARDIAC CARE AND HEART SURGERY.

LISA HOWLEY, MD

Medical Director, Fetal Cardiology

THIS IS WHERE THE PEDIATRIC CARDIOLOGY EXPERTS ARE

DAVID GREMMELS, MD

Chief of Cardiology, Medical Director

FRANCIS MOGA, MD

Associate Chief of Cardiovascular Surgery

ADVANCING THE FIELD OF PEDIATRIC CARDIOLOGY

YOUR PARTNER IN CARE ERICA MOLITOR-KIRSCH, MD Pediatric Cardiology Intensivist

The hearts we care for are small but they belong to the most important people. Our collective vision to offer the highest quality, kid-friendly and family-centered care is what makes our cardiovascular program successful. We’re working to advance the field of pediatric cardiology through innovation — with new procedures, technology and research. Our high volumes translate to better outcomes; in fact, Children’s Minnesota is among the top 20 teams in the nation in pediatric cardiac surgery volumes and treatment outcomes. Count on us to be your partner in caring for patients — from fetal through young adults — with cardiovascular health needs and a resource to support your decision-making.

ASK US ANYTHING: 866-755-2121 childrensMN.org/metrodocs

Ask Us Anything


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