Worcester Medicine - Fall 2023 by wdms

medicine worcester Volume 92

• Number 3

Published by Worcester District Medical Society

Fall 2023

WORKFORCE

VITALITY

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Workforce Vitality

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Workforce Vitality ContentsHumanities in Medicine WORCESTER MEDICINE Fall 2023

Workforce Vitality

Editorial 4

The Elephant in the Room 15

Steven B. Bird, MD, FACEP, FACMT

Carolyn H. Kreinsen, MD, MSc and Susan G. Krantz, MD, ScM

President’s Message 5 Giles Whalen, MD

Resiliency: An Essential Skill for Preventing Burnout and Compassion Fatigue 5

Behavioral Health Post-Pandemic: Self-Care is not Selfish 17 Amy Harrington, MD and Christopher Catalfamo, Psy.D.

Nancy McCool, LICSW, AHCP-SW, AHPSW-C

Hobbies and Leisure Activities in the Mitigation of Physician Burnout 8 Joel Popkin, MD, MACP

Announcements 10

WDMS 2023-2024 Calendar of Events, Committee Roster, WCCA Special Thanks

I’m OK-You OK? Best Efforts to Watch Over the Wellness of the Learners in the Three Mass Chan Graduate Schools 11 Michael Hirsh, MD

How I Discovered My Love of Medicine in the Midst of Burnout, with the Help of an Artificial Intelligence Scribe 12 Lauren Katz, FNP

Road to Burnout: An IMG Perspective 18 Arunava Saha, MD

Legal Consult: Objection to Impaired Physician Reporting Slapp’ed Down 20 Peter J. Martin, Esq. and Josh Lewin, Esq.

Society Snippets 22 Meet the Author Series “The Heart of Caring: A Life in Pediatrics”

Spoken History 23 Paul Hart, MD

In Memoriam

Francis A. Ennis, MD 23

A Health Resource Designed for Physicians 13 Mark J. Albanese, MD

published by

wdms editorial board

Worcester District Medical Society

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Editorial

WORCESTER MEDICINE

Massachusetts, and how Physician Health Services can help you, or your colleagues, who are in need. The pandemic pulled the curtain back on the broken behavioral health system in the U.S. Our patients must wait far too long to access outpatient or inpatient behavioral health services. But it’s not just our patients. Even savvy physicians have difficulty accessing behavioral health. Dr. Harrington’s essay provides some concrete ways to lessen the burden for accessing this important care.

GUEST EDITOR: Steven B. Bird, MD, FACEP, FACMT

urnout in healthcare workers, high turnover in the professionals, and the tremendous uptick in unfilled positions have become pervasive concerns in the last two years. The demanding nature of healthcare work, coupled with systemic challenges, has led to a rising tide of physical, emotional, and psychological exhaustion. This issue examines the factors contributing to healthcare burnout and turnover, explores the consequences for both medical professionals and patient care, and offers some hope and solutions through innovative solutions and initiatives. Healthcare professionals experience burnout due to a myriad of reasons, including heavy workloads, long hours, bureaucratic burdens, and limited control over their practices. The relentless pressure to provide high-quality care in an increasingly complex healthcare landscape often leaves medical professionals feeling overwhelmed and undervalued. The lack of work-life balance, moral distress, and the emotional toll of dealing with suffering and loss further contribute to burnout. While all of these stressors were present before the COVID-19 pandemic, the tremendous disruptions to all aspects of society accelerated the rate of burnout, turnover, and people leaving the healthcare professions. Burnout has immense consequences for our healthcare system and society as a whole. Decreased job satisfaction, reduced productivity (that is, more people working part-time), worse patient outcomes, and increased healthcare costs, just to name a few. Increased turnover exacerbates the already acutely-felt shortage of healthcare providers and also contributes to increased costs (think traveling nurses and locum tenens physicians). In this issue’s essays, a number of technological and support system improvements offer some hopeful solutions to our front-line clinicians. The ability of artificial intelligence (AI) to generate a chart in real-time, with minimal input from the clinician, has the potential to legitimately revolutionize how we document. Early testing of this system at UMassMemorial Health has shown the AI program to be liked by both clinicians and patients, with a significant reduction in documentation time and time spent in the electronic health record. AI also doesn’t miss a day of work or get fatigued throughout the day. Whether the return on investment is great enough to allow widespread adoption of the technology has yet to be determined. But I am hopeful. Articles written by Drs. Amy Harrington and Mark Albanese also describe what sort of behavioral health solutions exist here in

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Burnout has immense consequences for our healthcare system and society as a whole. Fortunately, it appears that the trends in physician and other healthcare worker turnover has reversed course to some degree. However, recent financial stressors on healthcare organizations are putting new strains on our fragile healthcare system, threatening (again) the well-being of the workforce. Despite these challenges, I remain hopeful. By addressing the underlying drivers of burnout and turnover and by leveraging technological advancements, we can create a more robust and resilient healthcare system that values and safeguards the well-being of its workforce. By maintaining a steadfast commitment to positive change, we can foster a future where healthcare professionals thrive, patients receive timely and optimal care, and hope and genuine caring remain the driving force in our pursuit of a healthier society. +

Steven B. Bird, MD, FACEP, FACMT Clinician Experience Officer (CXO) Professor of Emergency Medicine University of Massachusetts Medical School

President’s Message

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Resiliency: An Essential Skill for Preventing Burnout and Compassion Fatigue Nancy McCool, LICSW, ACHP-SW,AHPSW-C Dear colleagues, As the new academic year swings back into high gear, we have in this issue of Worcester Medicine a review and dissection of a phenomenon which is an indirect threat to the public’s health: burnout within the healthcare workforce. Doctors, like many healthcare people, have always worked hard and had trouble maintaining what is now known as work-life balance. But this is a curiously modern affliction in medical personnel - curious because we live and work in a time when access to knowledge and specialized consultation and physicians’ ability to treat injury and illness successfully have never been greater. Yet the problem seems to worsen as our skills, tools and technical resources improve. Perhaps it devolves from the stress of constant monitoring and a zero defects quality of care culture imposed on physicians as much as developed and accepted by them. Perhaps it is due to shifting societal expectations around child rearing, prestige or income, or even customer service. Perhaps it results from a larger proportion of physicians being employed rather than working for themselves so that it feels their practices are not theirs and not within their control. Likely the increasing amounts of non-medical bureaucratic work to ensure their patients get the tests, procedures, and medicines they need play a significant role too. It may be that different issues drive burnout differently in different generations of physicians. In any event, solutions have been elusive. In this issue edited by Dr. Steven Bird we are guided through the topic and an array of interesting potential palliatives which we all hope will help with this problem. As the fall kicks in, we are finalizing our annual calendar for 2023-2024. We have fantastic keynote speakers lined up and expect you will find our events to be educational and riveting and are excited to see you all in person. + Giles Whalen, MD, President, WDMS

he Covid-19 epidemic exacerbated the already critical situation of burnout and compassion fatigue among healthcare providers. Today, healthcare systems continue to struggle to hire and maintain a skilled workforce. Proposed solutions for supporting staff include proactive mental health treatment and support for caregivers experiencing burnout and improvements to the efficiency of electronic health records.

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…routine self-care has historically seen poor participation among healthcare workers… A large part of the attraction for those who choose to work in healthcare is compassion satisfaction. It derives from caregivers’ positive feelings about their ability to help others, and it also includes feelings of camaraderie among colleagues and the significance felt from contributing to the greater good. When burnout and compassion fatigue erode compassion satisfaction, self-care strategies are one of the most effective and extensively recommended methods for attaining it. Unfortunately, routine self-care has historically seen poor participation among healthcare workers, due in no small part to the culture of the medical field surrounding emotional exhaustion, which is seen as “just part of the job”. Clinicians may be aware that stress is an occupational hazard but may not be aware of just how much they have been affected by it. Stigma and isolation are barriers to the success of well-being efforts, and the ethos that vulnerability is a sign of weakness is reinforced regularly. As a result, programs that rely on self-referral often fail because they require clinicians to admit they need help, thus reinforcing the stigma around asking for it.

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Resiliency: An Essential Skill for Preventing Burnout and Compassion Fatigue Continued Programs in the workplace to enhance resilience skills, to prevent, rather than treat, burnout and compassion fatigue, and promote compassion satisfaction provide opportunities for team members to immediately apply what they learn to their day-to-day-work, thus experiencing the beneficial effect of the intervention in real time. When healthcare workers can address work stress at work, they have more emotional capital to spend with their families and loved ones. As the lead social worker on the inpatient palliative care team at UMass Memorial, I wanted to create a wellness program that would support the concept that resiliency is a skill that can be mastered and that doing so could mitigate distress for our team. Our wellness program is supported by many of the research findings, including leadership buy-in, peer support, practicing resilience as a community, short self-care interventions that take place at work, providing a safe space for debriefing and sharing of ideas, and practicing gratitude. The main parts of the program are listed below: Leadership support: The leadership of the palliative care team fully support and participate in the wellness program Peer support: A “Buddy System” was created to provide one to one support. Two colleagues are paired together. They check in with each other once per week via their shared preference of text, phone, email, or in-person. This provides a work environment of support and validation. It allows for addressing work related stressors at work. Opportunities to practice resilience skills as a community:

and was loved. They were someone’s family member and friend. In our own way and in silence, let us take a moment to honor them. Let us also honor and recognize the care provided by our team. 5 Minutes of Wellness: If time allows, 5 minutes of wellness includes one of the following: chair yoga, mindfulness meditation, quick journal exercise, music, or gratitude. Gratifriday: After Friday morning rounds, the team takes a few minutes to write 10 things for which they are grateful. They can share with the group what they’ve written for that day. A yearly retreat: This is an opportunity for the palliative team to get together in a non-work environment and participate in wellness activities. Access to resources: Since team members may have different needs and respond better to different kinds of wellness activities, all team members have access to wellness resources, including resources provided by UMass Memorial, as well as meditation sessions (walking, guided, and silent) yoga videos, CBT resources for countering negative thinking habits and relieving anxiety, journaling, access to art supplies, and musical instruments. All these resources are designed to provide a short respite (usually 5 minutes at the most) for team members to access throughout the day as the need arises. It’s worth considering implementing a wellness plan tailored to your group’s needs. For almost 3 years, the UMass palliative care team members continue to perceive the team wellness program as a useful, easy-toimplement intervention for mitigating personal distress, burnout, and compassion fatigue by providing a strong sense of support and connection to team members. Some have reported that it has reduced their emotional stress by giving them a safe person and environment to express their feelings and practice self-care without stigma. This program could be adapted to the unique needs of other healthcare teams owing to its simple design, leveraging of existing relationships and low cost. A strong team wellness program, especially the peer support “Buddy System” means that healthcare workers need not wait until they exhibit signs of stress before they ask for help, nor need they admit that they have a problem before they can access support. + Bibliography:

Shout Outs: The palliative care weekly interdisciplinary team meeting (IDT) begins with Shout Outs. This is an opportunity to publicly thank a team member for their teamwork, support or help at a crucial time during the week. Reading of the names: The names of the patients who have died are recorded in a book and read aloud by a team member during IDT. Colleagues who may have cared for that patient can say a few words about them if they wish. The Cleveland Clinic Pause: A team member then reads the Cleveland Clinic pause, which honors the personhood of someone who has died, and the work provided by the healthcare teams. It is followed by a moment of silence. “Let us take a moment to pause and honor our patients. They were someone who loved

1. Nancy McCool, Jennifer Reidy, Shawna Steadman & Vandana Nagpal (2022) The Buddy System: An Intervention to Reduce Distress and Compassion Fatigue and Promote Resilience on a Palliative Care Team During the COVID-19 Pandemic, Journal of Social Work in End-of-Life & Palliative Care, 18:4, 302-324, DOI: 10.1080/15524256.2022.2122650

Nancy McCool, LICSW, ACHP-SW, AHPSW-C is the lead palliative care social worker in Division of Palliative Care at UMass Memorial Medical Center Email: Nancy.mccool@umassmemorial.org

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prevalence was reported between 40-75%, even before COVID-19 devastated hospitals and private practices. In an online survey we received responses from more than 3000 US-based physicians (512 residents/ fellows) about their participation in our devised list of 117 individual hobbies, which we sub-grouped into 15 categories for analytic purposes (Fig 1). Examples of “categories” included team sports, non-team/ individual sports, playing musical instruments, reading for pleasure, writing, visual arts, playing Joel Popkin, MD, MACP games, etc. Respondents were asked to describe their personal activity status for each of the 15 categories in the last six months as “currently active” “formerly uring internship in 1974, when we often worked more than 100 hours per week – including the infamous 60-hour shifts – there active”, or “rarely/never participated.” Additionally, was no burnout in any training program. After all, the term we categorized the 117 hobbies into three perceived “burnout” wasn’t “invented” until 1975 [1]. Freuenberger initially defined levels of social interactivity – 36 as “social,” 47 burnout as “failure or exhaustion because of excessive demands on energy, “isolated,” and 34 “indeterminate.” We used the “Oldenburg Burnout Inventory” to quantitate strength, or resources.” But even in retrospect, while we interns were often terribly fatigued, we weren’t “burned out,” per se, by those “excessive burnout as well as disengagement from work (the demands.” The difference is that in 1974 our punishing workloads were latter a topic for another day). Significant differences were seen across age groups, largely meaningful, while today’s mandated “less excessive” work is degraded by ever escalating technology-based demands – e.g., the genders, and physician specialties in the level of EHR, bureaucratic tasks, regulations, etc. – all resulting in painful burnout. Younger providers (age < 60), women and distancing from our patients [2]. trainees had higher levels of burnout. North American What follows is a look at a single potential mitigation of burnout: The graduates reported slightly higher rates of burnout and utilization of hobbies and other leisure interests. In contrast to mostly disengagement than international graduates. Nearly casual comments in the literature that hobbies are good things to do, our 94% of physicians felt it was important or extremely group performed a quantitative study on this topic [3]. important to have outside interests. Burnout among physicians is a worldwide burden. Clinician burnout In each of our 15 major categories of hobbies, burnout was significantly lower in those who were dramatically impairs physicians, with extension to their patients, peers, students, staff, and families [4]. The burnout epidemic is now active in that category vs. those who were not. The internationally recognized (International Classification of Diseases, highest levels of burnout, however, were directly associated with discontinuance of hobbies and Eleventh Revision), and its cost is in the billions of dollars [5]. The overall proportionately to the number of hobbies given up (Fig 1). Across Fig. 1. Activity Categories vs. Exhaustion and Disengagement all demographic groups, lower burnout was associated with a higher number of active hobbies and leisure activities, as opposed to higher burnout being directly proportional to the number of hobbies given up (Figs 2a and 2b).

Hobbies and Leisure Activities in the Mitigation of Physician Burnout

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Fig. 2. Association of Number of Active and Former Hobbies With Exhaustion

Fig. 2a. Burnout negatively associated with the number of active hobbies

Fig. 2b. Burnout directly associated with the number of former (given-up) hobbies

As shown in Fig 3, despite being among the top favorite hobbies by the majority of respondents, listening to music (C4) and watching TV, movies, internet, video games or other media at home (C11) were associated with the highest level of exhaustion. On the other hand, participating in team sports (C1) and group games/role play (C12) were associated with the lowest level of exhaustion. In other words, the least burnout was associated with the subsets of the 15 categories that we defined as the most “social”. Fig. 3. The bubble colors correspond to hobby categories, while the height represents burnout level (mean exhaustion score), and the size of the bubbles represents reported hobby frequency.

Music listening and home entertainment registered highest on the burnout scale of associated hobbies, but perhaps these findings reflect more of a compensatory mechanism secondary to levels of stress that initially led to the pursuits. Recent articles have addressed the potentially isolating nature of these passive digital-based activities [5]. Socialization is a remarkably powerful factor in mental and physical health, with loneliness and isolation linked to heart disease, cancer, depression, diabetes and suicide [5]. In pre-COVID 2018 – when our survey was conducted – former Surgeon General Vivek Murthy had already described a “loneliness epidemic [6],” in which nearly a quarter of physicians reported suicidal thoughts or even attempts. Indeed, social isolation has always been injurious; COVID-19 only proliferated the psychosocial/ medical/economic risks of seclusion. Although this study identified associations rather than causality, emphasizing hobbies and non-medical outside interests might well

prove useful to temper epidemic burnout among healthcare professionals. We especially encourage those hobbies with stronger social underpinnings. Who has time for hobbies, particularly overworked residents? Probably no one. But lifelong interests don’t develop at age 65, so time must be made. A study from Germany, in which 200 physicians were interviewed about resilience strategies, put this in perspective: “Respondents did not simply pursue hobbies when they had time to do so. Rather, they made sure to find the time they needed to pursue the hobbies that were important to them [7].” I hasten to emphasize that the objective here is not to address the fundamental system issues (see above) that relentlessly afflict practitioners. But we must be

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Hobbies and Leisure Activities in the Mitigation of Physician Burnout Continued especially mindful to avoid placing blame on providers for “inadequate coping skills” that invite burnout. Dean et al. [8] remind us that this pseudo-culpability may be likened to “gaslighting” – i.e., system-induced self-doubt, rather than the system-inflicted “moral injury” that is truly responsible for these crises. As to comments about the importance of hobbies and interests, please note: Share them with family and friends. And with current recommendations of “social prescribing,” it seems time to get out our prescription pads. + References 1. Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research & Practice 1975; 12(1):73–82. 2. National Academies Press (US). Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington (DC); 2019. 3. Li Y, Lai C, Friedrich B, Liu C, Popkin J. The Association of Hobbies and Leisure Activities with Physician Burnout and Disengagement: Journal of Wellness 2023; 5 (1): 1-13 4. Yates SW. Physician Stress and Burnout. Am J Med 2020; 133(2):160–4. 5. Klinenberg E. Is Loneliness a Health Epidemic? The New York Times Feburary 9, 2018 [cited 2019 Mar 20]. Available from: URL: https:// www.nytimes.com/2018/02/09/opinion/sunday/loneliness-health.html. 6. Schawbel D. Vivek Murthy: How To Solve The Work Loneliness Epidemic. Forbes 2017 Oct 7 [cited 2020 Mar 12]. Available from: URL: https:// www.forbes.com/sites/danschawbel/2017/10/07/vivek-murthy-how-to-solve-the-work-loneliness-epidemic-at-work/?sh=748ae2997172. 7. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med 2013; 88(3):382–9. 8. Dean W, Dean AC, Talbot SG. Why ‘Burnout’ Is the Wrong Term for Physician Suffering. Medscape; 2019. Available from: URL: https://www. medscape.com/viewarticle/915097.

Joel Popkin, MD, MACP is a Professor Medicine at UMass Chan Medical School and a Program Director Emeritus at St. Vincent Hospital.

Announcements 2023-2024 Calendar

WDMS is pleased to present our 2023-2024 Calendar of Events. Each event will be promoted in advance, including registration details. We look forward to seeing you in person this year! Scan the QR code below to view the full calendar, or click/tap here.

2023-2024 Committee Roster

The 2023-2024 WDMS Committee Roster is now available. We are so very thankful for the members who have served on our Committees and are delighted to welcome our newer members. Thank you for your dedication. Scan the QR code below to view the full Committee Roster, or click/tap here.

Special Thanks

Thank you to our local station, WCCA TV, for all of their hard work in producing our television program, Health Matters.

Visit our friends at WCCA TV by clicking or tapping here or on the WCCA TV logo to the left! Click or tap here to view episodes of Health Matters!

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I’m OK-You OK? Best Efforts to Watch Over the Wellness of the Learners in the Three Mass Chan Graduate Schools

Michael Hirsh, MD

have been involved with the UMass Medical School since I first took a job as an academic pediatric surgeon there in 1986. Although I did take a nineyear break to hone my skills in Pittsburgh from 1992 to 2000, I returned in large part to Worcester because of the wonderful relationship that I always had with the medical school and its students. A lot of what I imparted to medical students was based on the negative role modeling that I had experienced as a trainee and later as a young attending. There was no focus on wellness or work/ life balance, or any of the catchphrases that one uses nowadays to show that there is a world outside the four walls of the hospital. I suppose the philosophies and approaches I took to both my work life and my home life did play a big part in what I shared with the students. They were always very receptive and always asked me how I continued working hard when there were so many obstacles in my way – i.e. short staffing; poor subspecialty representation to support multi system critically ill/ injured patients; inadequate administrative support for pediatric services. My standard answer was if you pick a career that you love, it doesn’t feel like work, so you can work like crazy, which I think I did. The generation of medical students coming up now, are not willing, ( justifiably so), to make the same imbalanced life part of their future. Despite the imbalance that I represented, Dean Terry Flotte tapped me in 2019 to start an Office of Health and Wellness Promotion within the Office of Student Life of the UMass Chan Medical School. At the time that I was opening this office, there was a great deal of concern about the level of

pressure being put on students with the Step One and Step Two exams, and how they greatly detracted from the level of enjoyment that the students had in their med school experiences. The first approach I embarked on in assessing the situation was partnering with an expert focus group leader, Dr. Kristin Mattocks, to evaluate representative students from all three grad schools about what stressed them and when. We also talked about what distressed them too. We have recognized financial stress detracts from overall wellness so we work closely with financial aid to assist students. We also work closely with Coaching services and Student Counseling Services to make sure that students who need extra help with coping skills or a safe place to speak freely about problems can get on board with these services promptly. One of the overarching themes that came from those focus group sessions was that students felt very isolated in the time that they were studying for their Steps, going for their nursing licensure, or completing a set of experiments in their lab, particularly if their lab work wasn’t going well. The isolation was something that I felt we could mitigate by establishing group experiences outside of a hospital. We therefore took the budget that was allotted to us and bought tickets for various events in Worcester and surrounding towns that might give the students an experience of calm, no-pressure fun. We had tickets that students could sign up for in groups to go to the Woo Sox, Mechanics Hall for Music Worcester, the Worcester Art Museum, and Tower Hill Botanical Gardens in Boylston. The rate that these tickets were gobbled up convinced me that we were on to something. We then planned welcoming ice cream socials and picnics and tried to emphasize the 3-school participation in these events. We also worked out a deal with the City of Worcester, where I serve as the Medical Director for the Division of Public Health, to rent out the ice-skating rink behind City Hall, called the Oval, for our three school students to enjoy for free. This included music, food, and skate rental. Nearly 200 students participated each year we did it. When the Pandemic arrived, the isolation became much more profound. But here an old maxim I have touted came mightily into play- “Advocacy prevents burnout”. As the word we were getting from Washington was that

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I’m OK-You OK? Best efforts to watch over the wellness of the learners in the three Mass Chan Graduate Schools Continued Operation Warp Speed would produce vaccinations by the end of 2020, I realized that we were going to need an army of capable vaccinators to meet the demand of a mass vaccination program against COVID-19. I dialed up my dear friend Professor Jill Terrien of the Tan Chingfen Graduate School of Nursing (GSN) who had helped teach med students how to administer vaccinations using her GSN students as trainers during the H1N1 outbreak in 2009 and in subsequent school-based flu clinic campaigns. She was completely on board with doing this once again for COVID-19 vaccinations. In the space of approximately five months, we had collaboratively trained approximately 800 vaccinators to be part of the Vaccine Corps. They were mobilized in January of 2021 and never looked back. Many are still involved today. With 68% of our community successfully vaccinated we owe a huge debt to these students. But they too saw how giving to others in this way made their own feelings of isolation or malaise diminish if not disappear altogether. Taking a similar approach of using our students to help the community as a way of lessening their own feelings of sadness, we employed students to work with seniors at the Worcester Senior Center by connecting with them and giving them support when the Center was closed. We called these students Elder Buddies, and they made thousands of phone calls, navigating food and medical problems for their seniors. In the Worcester Public School System, there were many students who did not handle remote learning on computers well. We started a buddy program for those students that the school adjustment counselors identified as worrisome. With some training with the counselors, our three schools provided support for hundreds of students helping with tutoring, pep talks, or just playing video games to ameliorate the situation. This program continues today. These activities not only got the students to see themselves as part of the Greater Worcester Community, but to feel they were fighting off the Pandemic that had so radically altered their own educational pathways and experiences. Now that the Pandemic is over, there is a certain malaise that we have observed amongst the medical community at large. Despite the dangers and hassles of the Pandemic, there was a unanimity of focus and a collaborative spirit that made us feel like we were pulling the oars together. That spirit has dissipated. So moving forward, our office will have to continue to find ways to increase the sense of wellness, camaraderie and belonging in our student body. The health inequities that the Pandemic highlighted give us an opportunity for advocacy that could play a huge role in getting our students to feel that sense of common purpose once again. I will do my darndest to push this agenda forward. I know I will find many willing collaborators in this endeavor. + Michael Hirsh, MD Assistant Vice Provost for Health and Wellness Promotion Medical Director for the Worcester Division of Public Health

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Lauren Katz, FNP

first realized I was experiencing burnout when my patient experience scores dipped—a really unusual occurrence for me. It was during the pandemic and, like so many other healthcare workers around the world, my colleagues and I were under immense pressure. I was splitting my time between two roles, working in the frontline respiratory clinic as a family nurse practitioner, and supporting other clinicians as the Advanced Practice Clinician (APC) Chief of Primary Care at Reliant Medical Group. In times of burnout, you’ll be in a consultation with one patient, but already thinking about the next one. You’re worrying about the stack of paperwork you have to sign, and the scripts you need to put through. You’re trying to balance being attentive at work with being attentive at home. For me, burnout even sometimes led to a panicked 2 a.m. awakening where I realized I hadn’t placed an order or submitted a referral. Around two years ago, I couldn’t seem to shake these feelings. I didn’t want my burnout to negatively affect my patients, so I considered stepping away from my clinical role for a while as I looked for something that could reinvigorate my love of practicing. During this time, I had the opportunity to try an artificial intelligence (AI) scribe in my patient-facing work. AI automatically documents the conversations you have with your patient using AI-powered voice recognition, creating a clinical note that you simply review and approve in the EHR. Working with an AI Scribe allowed me to focus entirely on the patient; I could just sit and have a discussion, face to face, and only worry about looking at the computer when I needed to check test results, place orders, or review a previous note. With this program, everything the patient says is recorded in his or her own words, which means there is no room for misinterpretation, and we are not relying on memory to get a fully detailed, accurate note into the system. This is so important for making sure patients get the right care, but also so they feel heard— especially now they can view their notes online.

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How I Rediscovered My Love of Medicine in the Midst of Burnout, with the Help of an Artificial Intelligence Scribe At the end of the consultation, I make sure to reiterate the care plan, so it’s laid out specifically in the note. That way, the next step is always clear, which is especially useful when other practitioners are involved. I know that when I leave that consultation room and have a full inbox of patient-related messages to catch up on, I can work through those in a timely manner. I can balance both my roles more effectively, ensuring I’m delivering projects my organization is relying on— without neglecting my patient documentation. I’m sure all my fellow practitioners have experienced something like this: toward the end of a consultation about knee pain, the patient also asks questions about their existing medications, or unrelated chest pain. When I was burned out, adding an extra, unexpected factor to the cognitive burden could be really frustrating. However, I realize there are so many reasons why patients do this. They might live a long way away, or have a deductible that limits the number of consultations they can afford, or maybe they don’t feel like their other concerns are worth another appointment. They have my attention for 20 minutes, and they want to get the most out of that small window. We’re there to give patients a safe space to talk through their worries, and my AI Scribe means I have the time to be present with

them in what is often a vulnerable moment. It’s no surprise that my patient scores have risen again since I started using this tool. Being present at home with your family and friends is so important, too. At the height of my burnout, excessive pajama time was making it hard to be as attentive as I wanted to be with my young family. Before my AI Scribe, tee-ball games, bath time, and family dinners used to be overshadowed by thoughts of the hours I’d need to spend completing documentation after my child went to bed. Now, if I ever need to log on in the evenings, it’s a matter of minutes as I approve a note. I think we’d all agree that your home team comes first, but you’re also in the business of caring for people—and you need to care for yourself too. The AI Scribe is, I think, a piece of the puzzle that can really help clinicians achieve balance between all those different forces. An AI Scribe helped me leave that fog of burnout and get myself back to a place where I’m happy and productive at work—and giving my patients the attention and support they deserve. In my role as APC chief of primary care, I’m now looking at opportunities for more of my colleagues to adopt this program, in the hope that it will help them alleviate their burnout too. + Lauren Katz, FNP APC Chief of Primary Care at Reliant Medical Group Primary Care APC in Family Practice at Neponset St Lauren.katz@reliantmedicalgroup.org

has been an emphasis on physician self-care, which is important, the focus has been turning to what others can do to support the health of physicians. In the words of a recent Surgeon General report, “We must shift burnout from a “me” problem to a “we” problem” [1]. I will describe one resource available to Massachusetts physicians, whose mission is to support physician health. That resource is the Physician Health Services, Inc. (PHS), a fully owned subsidiary of the Massachusetts Medical Society (MMS). PHS is a physician health program (PHP), and most states have a PHP like PHS. Now in its 30th year, PHS was preceded by the MMS Impaired Physicians Committee. The creation of PHS brought not only a more politically correct name, but a real emphasis on prevention and wellbeing. And all of the services that we provide are free of charge, thanks to the generous support of MMS, the malpractice carriers, healthcare

A Health Resource Designed for Physicians

Mark J. Albanese, MD

hysicians have been aware of the scourge of burnout since well before COVID, which played a big role in accelerating the burnout epidemic. The health challenges of physicians resulting from burnout have been well documented. While there

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A Health Resource Designed for Physicians Continued systems, medical staffs, and many appreciative individuals. Our staff, consisting of MDs and non-MD clinicians, provide confidential, peer-review-protected consultation to Massachusetts physicians. The population we serve includes medical students, DOs and MDs in training, as well as DOs and MDs who have completed training. While one may self-refer, most referrals are made by somebody else, usually a healthcare facility or a colleague. The focus of the consultation is to identify healthcare issues, including substance use, behavioral health, and neurocognitive disorders. Increasingly, referrals have been in the context of burnout-driven, unprofessional behavior. In addition to assessing for the presence of a health condition, PHS may recommend health resources. Over the years, PHS has established working relationships with many healthcare providers who have experience caring for physicians. These providers, including psychiatrists, psychologists, and therapists, enjoy caring for colleagues. In addition, we work with a very experienced group of professional coaches who are especially skilled at helping referred physicians navigate the interpersonal world of healthcare. I am frequently asked: How is PHS related to the Board of Registration in Medicine (BRM)? I am happy to say that PHS enjoys a collegial and collaborative relationship with BRM. That said, we are not “part of the BRM” and a referral to PHS is not “like calling the Board.” Recently, we worked with BRM on their initiative to include less stigmatizing language in the licensing and relicensing applications. The goal was to eliminate one of the barriers to physicians accessing care for health conditions. I want to both briefly describe a couple of recent trends that PHS has observed and offer advice on how to counter these trends. Starting in March 2020, the consumption of alcohol increased significantly in the United States. Physicians have not been immune from this trend. One of my colleagues refers to this as “the alcohol creep”, meaning that the consumption gradually and somewhat unconsciously increased as people experienced a more restricted lifestyle. For the most part, this “creep” has not led to significant issues. What we have found, however, is that physicians who become aware of it and challenge themselves to either decrease their alcohol consumption or eliminate alcohol entirely remark about “how much better” they feel. Therefore, I encourage my colleagues to take stock of how much they drink daily or weekly. If they have any questions or concerns, PHS is available for consultation. Another trend that we have noticed is the ongoing isolation that predated COVID but was magnified by the pandemic. Many physicians may take pride in their “rugged individualist” streak. The isolation that can accompany this individualism, however, contributes to burnout. The above-mentioned report from the Surgeon General emphasizes the importance of peer connection in mitigating burnout. The report underscores the crucial role of the healthcare system in encouraging connection: “Strengthening social connection and community enhances job satisfaction, protects against loneliness and isolation, and improves the quality of patient care. Peer and team-based models are one way to strengthen collaboration, create important opportunities for social support and community for health workers, while also mitigating burnout and moral distress.” I recently had a text exchange with a

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colleague that demonstrates this and illustrates that connecting does not need to take a lot of time. I texted him to ask how he was doing. He responded: “I’m overworked yet not feeling like I’m doing enough!” I replied in somewhat off-color language that I felt the same way. He acknowledged: “I’m glad to hear it’s not just me feeling that way! Thanks for checking in. We’re overdue for lunch!” Approximately one-third of those referred to PHS remain connected to us for one to three years on a formal monitoring contract. These contracts are designed to support physicians in attending to the treatment for any health condition that has been identified. The structure provided by a monitoring contract seems to be quite helpful to those physicians who participate. About 80% of physicians who successfully complete a contract are still licensed and practicing at the 5-year milestone. I want to give the final word to one of the physicians who recently completed a monitoring contract. Shortly after completion, she wrote to PHS: “Entering a PHS contract has saved my life, my relationships with family and friends, my mental wellness and my career. I am so grateful to all of you for treating me with care and respect and keeping me afloat throughout this challenging process. I do not take for granted how fortunate I am to have had this kind of care. I am eternally grateful to all who have been a part of my journey and I am eager and honored to help others in my position. It truly takes a village and I have been blessed with a very special one.” + Mark J. Albanese, MD, Medical Director, Physician Health Services of Massachusetts Medical Society Reference: 1. U.S. Department of Health and Human Services, Office of the U.S. Surgeon General, “Addressing Health Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce,” 2022.

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The Elephant in the Room

Carolyn H. Kreinsen, MD, MSc Susan G. Krantz, MD, ScM

eing a physician has always been difficult, fraught with responsibility, intellectual challenges and stress. Physicians often enter the profession with altruistic goals to help other human beings and to lessen the burden of illness and pain. They may pursue medicine to address complex diagnostic challenges, to make contributions through education or research or to serve the greater good through volunteerism. Given the nature of the work, no one embarks on a career in medicine expecting routine hours and predictable work days; however, for many physicians, the current realities of the job barely resemble the profession for which they trained. Burnout is widely defined as a long-term occupational stress reaction characterized by depersonalization, emotional exhaustion and a sense of low personal accomplishment. Burnout is not a new concept, having been described over the past several decades in physicians, other healthcare professionals and other individuals in myriad work environments. In 2019, the National Academy of Medicine reported burnout had reached “crisis levels” among the U.S. health workforce, with 35-54% of nurses and physicians and 4560% of medical students and residents reporting symptoms of burnout [1]. Since then, mounting pressures in the U.S. healthcare environment, in addition to severe stressors and staffing shortages associated with the COVID pandemic, have only exacerbated problematic imbalances. Demands on physicians consistently exceed the available resources to support their efforts within the existing infrastructure [1]. Burnout not only results in high personal cost for individual physicians, but also negatively impacts patient care with substantial economic and societal costs. It has been estimated that burnout costs the U.S. healthcare system at least 4.6 billion dollars per year, with the greatest burden attributed to physician turnover and work hour reduction [2]. A recent Massachusetts Medical Society (MMS) survey reported an alarming level

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of physician burnout currently impacting the physician workforce in Massachusetts, with overall 55% of physician survey respondents experiencing symptoms consistent with burnout. Their data indicated that a large number of Massachusetts physicians have already reduced or intend to reduce their clinical effort, with approximately 1 in 4 respondents planning to leave medicine in the next 2 years [3]. These alarming statistics may actually underestimate the true scope of the crisis; many physicians do not reveal their symptoms of burnout due to personal and professional reasons, and often suffer in silence.

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While many different contributors to burnout have been described…often ill-conceived performance metrics have been consistently identified as underlying drivers. While many different contributors to burnout have been described, the widespread implementation of the electronic health record (EHR) and often ill-conceived performance metrics have been consistently identified as underlying drivers [4]. Rather than supporting clinicians in delivering care more effectively and efficiently, existing EHR designs essentially

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The Elephant in the Room Continued manage physicians and how they do their work, with prioritization of billing functions [5]. Instead of spending time and attention on meaningful work that prioritizes utilization of their unique clinical skill sets and training, physicians today are frequently burdened by a high volume of irrelevant and rote administrative clerical tasks. Those would include time consuming documentation and EHR clicks that do not require physician-level expertise and are unrelated to clinical care [4]. Practicing physicians today often experience a disheartening lack of autonomy reflected in limited control over their time, attention, content of patient encounters and structure of the related documentation [6]. One qualitative study of 57 practicing physicians in several different ambulatory specialties reported that every hour of direct clinical time in the ambulatory setting generated nearly 2 additional hours of EHR and desk work within a clinic day. The authors also documented that the studied physicians routinely spent an additional 1 to 2 hours of personal time each night, outside of office hours, addressing unfinished EHR and other clerical work [7]. Initial proposed solutions for the burnout epidemic approached this as a “physician problem” and targeted the individual clinician with interventions such as exercise classes and mindfulness/relaxation techniques. There was emphasis on increased efficiency and maximization of productivity as a means of reducing stress. However, while burnout exerts detrimental effects on the individual, the problem in reality is collective and macroscopic in nature. Targeting the individual physician fails to address the actual underlying causes existing within the larger healthcare system. Realistic solutions to address the physician burnout epidemic and to support physicians in delivering high quality care must examine the multifaceted contributors to burnout at all levels of the healthcare infrastructure - local, organizational and governmental. Interventions could include efforts to optimize EHRs and to utilize innovative and appropriate AI approaches to support physicians in patient care activities. Further initiatives must reduce the burden of overwhelming unnecessary administrative work, adopt reasonable expectations for physician clinical workloads and schedules, and prioritize adequate clinical support staff capable of handling non-physician issues. The current clinical healthcare environment has left many excellent physicians exhausted and disillusioned. Given the multitude of competing demands facing the healthcare infrastructure at all levels, it remains imperative to keep the issue of burnout in the forefront. The current exodus of physicians and other healthcare professionals from medicine is a serious crisis. Rather than merely scrambling to supplement clinician availability with non-physician providers when physicians leave their jobs, effort must go towards nurturing and retaining the committed, experienced and very capable physicians who have already been functioning as integral forces within the healthcare system. The elephant in the room permeating the healthcare system looms large and must be addressed; facing and solving the issue of physician burnout is critical and necessary to ensure a robust and sustainable healthcare system today and in the future. +

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References: 1. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician WellBeing.Washington (DC): National Academies Press (US); 2019 Oct 23. 2. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med 2019; 170(11) 784-790. 3. Massachusetts Medical Society. Supporting MMS Physicians’ Well-Being Report: Recommendations to Address the On-Going Crisis. March 2023. 4. Hartzband P, Groopman J. Physician burnout, interrupted. NEJM 2020: 382:2485-2487. 5. Detmer DE, Gettinger A. Essential electronic health record reforms for this decade. JAMA 2023;329(21):1825–1826. 6. Khullar D. Burnout, Professionalism, and the Quality of US Health Care. JAMA Health Forum. 2023;4(3):e230024. 7. Sinsky CA, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016; 165:753-760.

Carolyn H. Kreinsen, MD, MSc is Assistant Professor of Medicine at Harvard Medical School. She has been a long-term Associate Physician at Brigham and Women’s Hospital with appointments in the Division of Women’s Health and Department of Medicine. Susan G. Krantz, MD, ScM is Instructor of Medicine at Harvard Medical School. She previously worked as a primary care physician at VA Boston Healthcare System for more than 25 years.

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Behavioral Health Post-Pandemic: Self-Care is not Selfish Amy Harrington, MD Christopher Catalfamo, Psy.D.

s a behavioral health provider, I recall a situation where one of my patients was reporting gastrointestinal symptoms to me in our appointment, but he could not get in to see a specialist for further work-up. The patient was on a waitlist that was months long, but each time I met with him his symptoms and his anxiety about them dominated our conversation. I can only imagine the frustration that providers in other specialties must feel about the growing lack of access to mental health services, despite an increased number of patients, particularly young people, seeking treatment for mental health related issues. Our region, like other parts of the country, has seen an increase in need for mental health services since the onset of the COVID-19 pandemic, with 3 in 10 residents of Massachusetts reporting symptoms of depression or anxiety in February of 2023. Unfortunately, only about 1 out of every 3 residents who need mental health services are able to access treatment [1]. One of the contributors to the worsening access to mental health care is the shortage of providers, and this is exacerbated by burnout within the mental health care provider community. In a survey of behavioral health providers published in April of 2023 by the National Council for Mental Wellbeing, 70% reported an increase in client severity since the COVID-19 pandemic, and 90% reported concern about the lack of access for new patients. An overwhelming 93% of behavioral health providers surveyed endorsed symptoms of burn-out [2]. Burnout is a problem facing medical providers across the entire spectrum of healthcare. Having rapid access to therapy or other behavioral healthcare services could help prevent medical providers from leaving clinical care, yet we struggle to meet the needs of our own colleagues. It creates an unfortunate feedback loop where lack of access exacerbates burnout which exacerbates lack of access. Fortunately, there appears to be some hope for the future. Medicine has always promoted

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stoicism, but since the pandemic there has been a greater recognition of the emotional impact that our profession experiences. An underutilized resource is an available Employee Assistance Program or EAP. This type of program used to be perceived as a place where a physician or other provider would go if he or she was impaired in some way. Now EAPs are robust programs, offering services from short-term counseling to help with financial planning, access to legal services or help finding child or elder care. Whenever I encounter a professional who is trying to access counseling, I encourage them to call their EAP as a first step. I am encouraged to see a greater emphasis being placed on mental health care services for our patients. MassHealth recently implemented a new, transformational system for addressing behavioral health needs in the ambulatory setting. The agency identified Community Based Health Centers (CBHC) throughout the state, and offered enhanced financial reimbursement in exchange for rapid access to services. Each geographic catchment area has a CBHC, so if a patient knows their zip code, they know where they can go to connect for behavioral health treatment. What gives me the greatest hope is the fact that there is a greater acceptance, both within medicine and in the general population, that mental health care is important. The stigma associated with seeking treatment for depression, anxiety or substance use, though still present, is improving [3]. One of the main reasons for this is that we all experienced the trauma of Covid and its consequences together. This was true, especially in the field of healthcare, although we may have experienced it in different ways. As a profession, we have an opportunity to lean more on our colleagues because we have all been through this common experience as a community. The explosion of telemedicine has created new opportunities and greater flexibility for providing mental health treatment. Although the pandemic created a secondary mental health pandemic in its wake, it also showed us innovative ways to provide services while reducing the stigma associated with seeking treatment for depression or anxiety. + Amy Harrington, MD, is the Assistant Professor of Psychiatry, Program Director of the Addiction Psychiatry Fellowship, and Medical Director of Out-Patient Psychiatry at University of Massachusetts Chan Medical School Christopher Catalfamo, Psy.D., is a Clinical Psychologist at UMass Memorial Medical Group References: 1. https://www.kff.org/statedata/mental-health-and-substance-use-state-factsheets/massachusetts/, accessed July 5, 2023 2. https://www.beckersbehavioralhealth.com/behavioral-health-news/thebehavioral-health-workforce-in-10-numbers.html, access June 27, 2023 3. https://www.optum.com/health-articles/article/healthy-mind/how-covid19-changed-conversation-mental-health/, accessed June 30, 2023

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Road to Burnout: An IMG Perspective Arunava Saha, MD

woke up with a start. The ear-piercing noise emanating from some dark corner of the room went straight through my eardrums and crashed into my auditory cortex. As I thrashed around dazed looking for my spectacles and waiting for my already terrible eyesight to adjust to the dark, the high-pitched sound reached a crescendo. After a few seconds of struggle, I finally managed to locate my spectacles lying on a corner of the bed, snooze the ongoing alarm, and discontinue the next five scheduled at 2-minute intervals. As I extricated myself from the blanket and put my feet down on the floor, the extreme cold— despite being in an airtight room with the heating on— sent a shiver down my spine. I turned the bedroom light on and gazed out through the window into complete darkness. The lone streetlight on the corner was trying valiantly to pierce the darkness surrounding it, but all I could see was the glare reflected off the layers of snow collected on the streets overnight. “Oh no, not again!” I wailed, as I realized that there was another bout of snowfall overnight. I opened the weather map only to be greeted with a 21F/-6ºC temperature and blizzard predictions for the whole day. This meant an added twenty minutes of working to get my car out of the snow, defrosting the windshield, and then driving along treacherously slippery snow-covered roads to reach work by 6:30 in the morning. For an international medical graduate from a warm tropical country like India, moving halfway across the world to the United States to pursue residency training had its fair share of joys and triumph, but also the associated sorrows and tribulations. Unfortunately, in this day and age of social media, it is only the glitz and glamour which is focused on, while we are expected to suffer the unsavoury aspects of our decision in silence. It is indeed an honor and pleasure to learn under the absolute best, with exposure to the best of clinical medicine, academic progress, and research. As international medical graduates, we work extremely hard during the training period in our home country. This involves taking on extra responsibilities from an early stage of medical school, a huge financial investment to travel for and complete clinical rotations in the United States, sitting through three of the most gruelling 8-hour examinations, getting certified to be considered on par with American graduates, and then going through the trauma of a match process, only for some to end up on the winning side, while a few are not as lucky and have to come back to try and match the next year. The people who do make it successfully have to battle umpteen other problems along the way. Staying away from home and family, adjusting to a new country and a new social and work culture, trying to survive on our own, figuring out finances on a resident salary, maintaining long distance friendships and relationships while making new friends, battling

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completely different climate and weather conditions, learning to drive on the opposite side of the road; all the while staying in a foreign environment and working long hours taking care of patients to the best of our ability. It takes a toll. In a recent study surveying J1 visa physicians, it was found that the most important challenges faced by international medical graduates included navigating cultural differences, followed by staying away from family and friends, bureaucratic barriers, language communication barriers and managing finances. Some of the factors which were identified as important to their wellness included having friends or family close by, exercising, socialization, healthy eating, and having a friend circle [1]. It is imperative to realize that international medical graduates form a very specific subset of the physician workforce in the United States. They have their fair share of problems, which they are often unable to share with anyone. The work hours and patient load is often never the problem for them when it comes to the U.S. healthcare system, but it is the social and cultural aspects which play a significant role. It is important to identify these stark differences in terms of the trigger for burnout in international graduates compared to American graduates, who have to deal with a very different set of social and financial issues. Once these obstacles have been identified, it is important to make sure that these issues are addressed appropriately, along with ensuring international graduates’ physical and mental wellbeing. It can involve small efforts on the part of their peers and friends to just check up on them as to how they are coping with the transition from time to time. It helps having dedicated mentors to follow up with them at periodic intervals about their well-being, and allowing them the flexibility to attend to their essential appointments as they get settled in. The resident training program as a whole can provide support and resources for obtaining accommodations and a means of travel as they arrive without any background credit rating, being vigilant about their needs in terms of training and supervision as they learn the new system; and overall, keeping an eye out for symptoms of burnout. In 2014, the tragic suicides of two interns in the field of internal medicine in New York caused shockwaves and brought attention back to the longstanding issue of physician suicide. This concern was further highlighted by more recent suicides involving a resident in Anesthesia and a resident in Psychiatry, also within New York programs. Another study published in 2017 examined aggregated data from the Accreditation Council for Graduate Medical Education (ACGME), encompassing 381,614 residents in training

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from 2000 to 2014 [2]. The study revealed that suicide was the second most common cause of death among residents, preceded only by neoplastic disease. The importance of resident well-being is increasingly acknowledged, particularly in light of these unfortunate incidents. It is imperative to establish preventive strategies and ensure access to confidential mental health services and counselling for all residents. Moreover, both faculty members and residents themselves involved in the clinical learning environment must be vigilant for signs of burnout, depression, social isolation, or significant declines in performance among residents. These indicators are often overlooked but can have catastrophic consequences. The well-being of physicians is crucial not only for the patients they serve, but also for the medical profession, the general public, and the physicians themselves. Disruptions in physician well-being can significantly impact patients and their loved ones, as well as the dedication of the medical profession to societal service. Initiatives to enhance physician well-being should start during medical education and prioritize targeted interventions that promote self-care habits and increase the utilization of mental and physical healthcare services, with a specific focus on residents. Ultimately, improved physician well-being will benefit patients, as evidenced by a meta-analysis that identified positive correlations between occupational well-being and patient satisfaction, adherence to treatment, and the quality of interpersonal care [3]. + Arunava Saha, MD, is an International Medical Graduate, and third year Internal Medicine Resident at Saint Vincent Hospital, Worcester, MA. Email: Arunava1.saha@stvincenthospital.com References: 1. Murillo Zepeda C, Alcalá Aguirre FO, Luna Landa EM, Reyes Güereque EN, Rodríguez García GP, Diaz Montoya LS. Challenges for International Medical Graduates in the US Graduate Medical Education and Health Care System Environment: A Narrative Review. Cureus. 2022;14(7):e27351. Published 2022 Jul 27. doi:10.7759/cureus.27351 2. Yaghmour NA, Brigham TP, Richter T, et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med. 2017;92(7):976-983. doi:10.1097/ACM.0000000000001736 3. Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM. A Systematic Review of the Impact of Physicians’ Occupational WellBeing on the Quality of Patient Care. Int J Behav Med. 2015;22(6):683-698. doi:10.1007/s12529-015-9473-3

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Legal Consult: Objection to Impaired Physician Reporting Slapp’ed Down

Peter J. Martin, Esq.

Josh Lewin, Esq.

he stress of practicing medicine sometimes manifests in substance use disorders. Recognizing this reality, in Massachusetts a system for reporting impaired physicians, including diverting them to a treatment program prior to referring them to the Board of Registration in Medicine (“Board”), has been created. The Massachusetts Medical Society, in turn, created Physicians Health Services, Inc. (“PHS”), a non-profit corporation founded to address physician health. While the applicable regulations create a requirement for physicians to report to the Board other physicians who are reasonably believed to be practicing medicine in violation of law, including while addicted to or impaired by drugs or alcohol, an exception exists if the physician impaired by drugs or alcohol is in compliance with a treatment program such as those offered by PHS. A recent appellate court decision, Berk v. Kronlund,[1] discussed protections afforded physicians who report or refer an impaired colleague to PHS, citing a statute designed to protect citizens’ first amendment rights to petition the government. While not potentially the final statement of the law on this issue, the decision does strengthen physician reporters’ protections and immunities from lawsuits by their allegedly impaired colleagues for raising such reports. The parties to the lawsuit were both physicians, with Dr. Kronlund being Dr. Berk’s primary care physician. The Dr. Kronlund became concerned about Dr. Berk’s ongoing use of opioids, and both agreed to a plan to taper Dr. Berk’s use of opioids by ten percent per month. Dr. Berk was compliant with this plan until a subsequent back injury resulted in a short-term plan to prescribe Percocet. Approximately one month later, Dr. Berk and his wife were found unresponsive in Dr. Berk’s garage due to accidental carbon monoxide exposure. Shortly thereafter, Dr. Berk informed Dr. Kronlund that he intended to open a medical practice that would involve surgery. Dr. Kronlund informed Dr. Berk of his concerns about Dr. Berk’s performing surgery

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while using opioids. Dr. Kronlund also told Dr. Berk he would be required to report Dr. Berk to the Board if Dr. Kronlund felt that Dr. Berk was practicing while impaired. Dr. Berk responded that he had seen patients in the past while prescribed Percocet and that he did not take Percocet prior to performing surgery while under the care of previous doctors. Dr. Kronlund then contacted PHS, and a PHS physician agreed to see Dr. Berk for an evaluation. Dr. Berk did see the PHS physician who recommended that Dr. Berk go into inpatient treatment for opioid addiction, and that if Dr. Berk did not, the PHS physician would inform Dr. Kronlund, who would then report Dr. Berk to the Board. Dr. Berk did attend two inpatient treatment programs over the next several months, and then returned to the practice of medicine under certain PHS conditions. Two years later, Dr. Berk sued Dr. Kronlund for reporting him to PHS, asserting four claims: (1) negligence; (2) interference with advantageous business relations; (3) violation of the Massachusetts Civil Rights Act; and (4) invasion of privacy. The gravamen of the lawsuit was that Dr. Berk had suffered business losses and other damages as a result of Dr. Kronlund reporting his suspected opioid addiction to PHS. The first claim was dismissed on the ground that the so-called “peer review privilege” conferred on physicians by Massachusetts General Laws chapter 112, section 5G(a) which protects physicians who report to peer review committees in good faith and with a reasonable belief that such communication was warranted. This dismissal was upheld on appeal, with a finding that PHS qualified as a peer review committee and a determination that Dr. Kronlund had ample grounds for reporting Dr. Berk to PHS. As to the other three claims, Dr. Kronlund made a special motion to dismiss under the Massachusetts “anti-SLAPP” statute, M.G.L. chapter 231, section 59H. This statute is so-called because it protects litigants against Strategic Lawsuits Against Public Participation. It was designed to protect citizens from being sued for the “valid exercise of their constitutional rights of freedom of speech and petition for the redress of grievances [1].” To discourage these types of lawsuits, the anti-SLAPP statute enables defendants to seek an immediate dismissal and mandates an award of attorney’s fees if dismissal is granted. Under the Anti-SLAPP law, protected petitioning activity is defined very broadly, to include any oral or written statements submitted to or “in connection with” any governmental

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proceeding, or any written or oral statements that are “reasonably likely to encourage” review of any issue by the government, or any other statement that falls within the constitutional right to petition government. The definition of petitioning activity is so broad that it has been interpreted to include even indirect petitioning activity: “Petitioning includes all ‘statements made to influence, inform, or at the very least, reach governmental bodies— either directly or indirectly [1].’” To these writers’ knowledge, it has never been used to protect the statements of a physician reporting an allegedly impaired physician either to the Board or to PHS. But the Courts had previously ruled that statements made by medical professionals in connection with matters under review by state regulators to constitute “petition activity” covered by the Anti-SLAPP law. In Blanchard v. Steward Carney Hospital, Inc., the Massachusetts Supreme Judicial Court held that statements by the hospital’s president to the Boston Globe about firings at a hospital unit made while the Massachusetts Department of Mental Health was considering revoking that unit’s license were covered [1]. The Court ruled that the hospital president’s comments to the Boston Globe, though not made directly to DMH, “had a plausible nexus to DMH’s investigation based on their content and the high likelihood that they would influence or at least reach DMH [1].” Thus, this indirect communication constituted protected petitioning activity under the anti-SLAPP statute. In Berk v. Kronlund, the issue to be decided was whether the reporting physician’s statements to PHS—which is not a government body— could constitute petitioning activity. While it appears clear that a report to the Board would be protected, PHS is a non-profit private corporation and, at the time the report to PHS was made, no government proceedings were pending. Still, the Massachusetts Appeals Court relied on the broad definitions given to petitioning activity in prior cases and concluded that the report to PHS qualified as protected petitioning activity because Dr. Kronlund “informed PHS of his concerns regarding the plaintiff with the implicit understanding that the communication to PHS would, by law, reach the Board if the plaintiff did not comply with the treatment plan created by PHS.” Dr. Kronlund’s communications with PHS were thus protected under the Anti-SLAPP law. This is the case even though there was never any

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proceeding pending at the Board, no report was ever made to the Board, and there was no government involvement in the matter at all. Dr. Kronlund was awarded his attorney’s fees for having to defend the lawsuit.

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…physicians can feel secure in making a referral to PHS as an alternative without the risk of being sued by the addicted doctor as a result. This decision under the anti-SLAPP statute appears uncontroversial. If a hospital president’s statements to the press can be protected under that statute because the statements are intended to influence the outcome of a DMH investigation, how much more readily would the contact with a treatment program that acts as an exception to the mandated reporting requirement to the Board be considered to be “in connection with” a governmental proceeding? The decision in Berk v. Kronlund is an important affirmation of the protections for physicians making the difficult decision to report an impaired colleague who may be suffering from drug or alcohol abuse. The Court’s decision makes certain that the Anti-SLAPP law and peer review privilege will protect physicians who make good faith reports or referrals to PHS as an alternative to making a report to the Board. While physicians may be more reluctant to make a report to the Board in light of the serious and devastating consequences that could befall the suffering physician as a result, this case ensures that physicians can feel secure in making a referral to PHS as an alternative without the risk of being sued by the addicted doctor as a result. + Peter J. Martin, Esquire, is a partner in the Worcester office of Bowditch & Dewey, LLP, his practice concentrates on health care and nonprofit law. Josh Lewin, Esquire, is a partner in the litigation department at Bowditch and represents and advises clients with respect to all manner of business disputes and regulatory actions. Josh has litigated Anti-SLAPP motions in the Massachusetts courts and recently spoke as a panelist on the topic for the Massachusetts Bar Association. References 1. Berk v. Kronlund, Massachusetts Appeals Court, No. 22-P-4 (June 14, 2023)

Fall 2023

WORCESTER MEDICINE

Meet the Author Series "The Heart of Caring, a Life in Pediatrics" Held on Wednesday, May 24, 2023, Albert Sherman Center Auditorium WDMS and the WDMS Alliance collaborated with the Lamar Soutter Library at the UMass Chan Medical School by hosting Dr. Mark Vonnegut. Author: Mark Vonnegut, MD

Health Matters is a television program produced in collaboration with the WDMS and WCCA TV in Worcester, MA. Offering valuable information on disease prevention, treatment options, current public health issues and more. Health Matters is produced in a 1/2 hour interview format and the program airs on WCCA TV Cable Channel 194: Wednesday– Noon and 7:30 pm, Thursday-7:00 pm and Friday-9:30 am. Updates with COVID-19

Host: Lynda Young, MD

Guests: Beverly Nazarian, MD and Lloyd Fisher, MD

ClickClick or tap here to view the episode! Here to view the episode Or may visit our website: www.wdms.org www.wdms.org (Community Services/Health Matters) If you have an idea for a topic or guest or wish to be a guest Please contact Melissa Boucher- Email: MBoucher@wdms.org Call: 508-753-1579

Fall 2023

WORCESTER MEDICINE

Spoken History: Paul Hart, MD Our history is vital to our future. Visit https://www.wdms.org/spoken-history-project/ to listen to the stories of our local physicians. What did they see? How did they treat patients? What were their worries and successes? What was their life like outside of their practice? If you have a suggestion for an interview or wish to be interviewed, please contact WDMS at 508-753-1579. In this one-hour video interview, Dr. Paul Hart discusses his 50-year career in Family Practice medicine, why he became a doctor, how he evolved with managed care and electronic medical records, and the key to why he never experienced burnout. Scan the QR code or click/tap here or on Dr. Hart’s image to view the interview on YouTube!

In Memoriam

Dr. Francis A. Ennis May 12, 1938 – May 7, 2023 WDMS Member since July 8, 1999

Francis (“Frank”) Anthony Ennis, M.D., died peacefully, surrounded by family and his loving wife of nearly 60 years, Anne Marie (Cavanagh) Ennis, on Sunday, May 7, 2023, one week before his 85th birthday. Frank was a Massachusetts native, born in Boston, raised in Dorchester, and a graduate of Boston College (1960) and Tufts Medical School (1964). Residency and fellowship training took him to SUNY Upstate Medical University (Syracuse), the Boston VA Medical Center, NIH, and Cornell Medical School. He returned to Massachusetts for his first faculty position at Boston University Medical School, following which he reverted to Bethesda, where he served as Director of the Division of Virology in the Bureau of Biologics, FDA. Frank was induced to return to Massachusetts once more in 1981 to join the still young University of Massachusetts Medical School. Over a highly accomplished career at UMass spanning more than three decades, Frank helped to build the international reputation of the institution for research in the immunology of emerging viral diseases, including influenza, dengue, and hantaviruses, and vaccines against influenza, poxviruses, and flaviviruses. As Director of UMass’s Center for Infectious Disease and Vaccine Research and Program Director for an NIH training grant on viral pathogenesis, Frank led a large and diverse research team and mentored numerous faculty, post-doctoral fellows, students, and research staff. He built a global network of research collaborations, notably an NIH-funded research program on dengue in Thailand that launched the careers of a cadre of junior colleagues. Frank also served as an advisor to various U.S. and international organizations on vaccine research and development. Frank was a devoted and proud “father” to his research family. He delighted in recounting the accomplishments of prior trainees to new team members and visitors. The warm welcome he extended to new members was particularly appreciated by the many international scholars who came to Worcester to work with him, and he kept in touch with them throughout his career. Still, Frank’s true devotion was to his family, his wife, Anne, his six children, and their many grandchildren. Anne’s paintings were proudly and prominently featured in Frank’s office. Lab holiday parties were a common opportunity for Frank to share his pride in the Ennis children. Frank’s example of dedication to medicine and science, collegiality, supportive mentorship, and work-family balance is warmly remembered for its deep and lasting impact on the lives and careers of colleagues and trainees around the globe.+ Additional personal remembrances are posted at: https://brittonfuneralhomes.com/book-of-memories/5189543/Ennis-Francis/index.php Alan L. Rothman, MD Sharone Green, MD

Fall 2023

REDUCE STRESS AND BURNOUT WITH THE POWER OF MINDFULNESS Join us for a four- or eight-week program, or just drop in with one of our FREE weekly meditation sessions led by instructors certified in Mindfulness-Based Stress Reduction (MBSR). The Center for Mindfulness at UMass Memorial Health offers free and tuition-based online programs to support health and well-being, reduce stress and strengthen resilience. Jon Kabat-Zinn originated MBSR at the Center and it continues today, complemented by additional programs representing the gold standard in mindfulness.

To learn more, or to register for an upcoming program, visit www.ummhealth.org/ center-mindfulness.

Testimonials from program participants: “I am a physician with real burnout and have [been] looking for a way to see myself continuing for the next number of years. [With mindfulness practice,] this is the first time in a while I have felt somewhat hopeful about a happier outlook on my work.” “This was a life-changing course for me that came at the perfect time. I feel more grounded and less anxious and have more tools to combat everyday stressors.“ “The program was highly effective, wellorganized, and exceeded expectations, and the staff was extremely professional, knowledgeable, attentive, and compassionate.” “I found this course beneficial in that it provided multiple ideas to gently incorporate mindfulness into daily life. Everyone was able to work at their own pace, which I thought was a great model.”

Worcester Medicine - Fall 2023

Articles inside

Spoken History: Dr. Paul Hart

Legal Consult: Objection to Impaired Physician Reporting Slapp’ed Down

Road to Burnout: An IMG Perspective

Behavioral Health Post-Pandemic: Self-Care is not Selfish

A Health Resource Designed for Physicians

How I Rediscovered My Love of Medicine in the Midst of Burnout, with the Help of an Artificial Intel

I’m OK-You OK? Best Efforts to Watch Over the Wellness of the Learners in the Three Mass Chan Gradua

The Elephant in the Room

Hobbies and Leisure Activities in the Mitigation of Physician Burnout

Resiliency: An Essential Skill for Preventing Burnout and Compassion Fatigue

President's Message

Editorial