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Finding ‘bright lights’: Why family physician continues to love practicing mid-career
A few years ago I tracked down my medical school interviewer to thank him for giving me the opportunity to do what I felt I was called to do. I was surprised that, after 15 years, he actually remembered me and remembered details like walking to the courtyard to meet my father who’d driven me to the interview.
Sharing my gratitude and letting him know I was happy felt important to me.
Choosing to practice family medicine has a lot to do with why I am happy in my career today.
One of my frustrations with health care had been its emphasis on treatment of sickness, rather than a broader one that incorporated prevention of sickness. During my third year of medical school, I was following a family and sports medicine faculty member who was focusing on aspects of lifestyle medicine to help a patient remain active and age gracefully. Seeing opportunities to practice preventative medicine in family medicine made me realize the specialty was the perfect fit for me.
Food as medicine
While participating in rotations I also realized you can find a subspecialty within family medicine.
During my fourth year of medical school, I followed an attending who was seeing a patient for hypertension, prediabetes and hypercholesterolemia. The attending told the patient to eat “healthier,” gave her a handout, and scheduled a follow up appointment for 6 months later.
My thoughts were: “That’s it? That’s how we counsel patients to improve their dietary habits?”
As the patient was leaving the exam room, I asked her what type of oil she cooked with, and I proceeded to share culinary tips from my mother – who was a self-taught and early adopter of the food-as-medicine movement.
Once I started my residency, I knew I’d want to incorporate lifestyle and dietary approaches at many of my patient visits.
I scheduled patients every month to monitor their weight, follow up on chronic conditions, but more importantly, to engage them in their health and empower them to make small lifestyle changes each month and report their efforts. I felt like I was their health coach and cheerleader.
My career in family medicine
Entering the job market allowed me to form my philosophy of treating patients with a mind, body, and spirit approach. I chose to practice value-based care, which aligns with my lifestyle and preventative medicine approach .
I currently practice in a small family medicine–only clinic that is part of a larger multispecialty system. Primary care specialties in my organization are valued, respected and central to a patient’s well being and care. We are encouraged to spend time with patients, assess barriers to care and work collaboratively with our healthcare team, so that preventative medicine approaches take the lead in a patient’s health. This supportive culture and environment is one where my passion for food as medicine has thrived.
One day I forgot to pack a lunch and instead brought a grocery bag of items to make a salad. When I realized I made too much, I sent an email to my staff to get some “free salad in my office.” This serendipitous moment started an informal office “salad club” each week. Continued support from my staff and leadership, allowed me to consider further extending this teaching to my patients and my colleagues.
Three years ago, I helped adopt a sustainable plant-forward menu for our physician meetings, complete with a recipe from the menu for physicians to replicate at home or give to their patients.
I also pursued adoption of shared medical appointments for our medical group. These appointments apply the “see one, do one, teach one” model in medicine, but with culinary medicine as the focus.
Knowing that my patients are all connected to their families through food, I sought this as an opportunity to dive in further with wellness opportunities at their next meal. After almost 2 years of working on this project, I was able to host my first shared medical appointment with a group of patients on March 12, 2020. The next day schools closed, lockdowns occurred, and the world changed.
Opportunities highlighted by the pandemic
We always knew health care was broken but adding the increasingly longer hours and COVID vaccine–hesitant patients that the pandemic brought made everything look dark at times. What has helped me stay hopeful and energetic for system changes is feeling gratitude and seeking bright lights.
My experiences seeing patients in telehealth visits are examples of some of the bright lights I found in the pandemic. During these visits, patients showed me something from their pantry, and we’d go over nutritional labels together.
Additionally, my patients became engaged with their own conditions and wanted to improve them because of news articles highlighting risk factors for COVID-19, such as obesity. I had an active audience when it came to talking about food-as-medicine approaches to improving risk factors and immunity. And since everyone was listening, I didn’t stop at food. I also talked about physical health, stress resiliency, planetary diets, sleep, connections, and lastly vaccines!
Once the vaccines were distributed, I naturally gravitated to having those conversations with patients and colleagues and on social media. Plus, the pandemic gave us moments of simple times to slow down, take more rests, be less overscheduled, consider work-life priorities, and, lastly, to be okay with not being totally okay.
In practicing primary care, we have a unique role in seeing medicine from a whole body, whole person, whole family perspective. There is an opportunity to highlight what is broken in medicine and aim to make it whole.
I’m currently looking at shared medical appointments as a new standard way to provide care to all patients, because it improves access, provides better quality visits and aligns my values, mission, and purpose.
In the midst of the pandemic, I helped advocate for a sustainable plant-forward menu that was launched throughout four different hospitals in the Sharp HealthCare system, in California, in 2020. Knowing that patients were served a menu I played a role in, gave me solace.
As part of the hospital food and nutrition team, I am grateful for the opportunity I have to work on a broader mission to address social determinants of health and seek opportunities to help the system work for our patients.
Public health communication has been lacking in the pandemic, but another bright light is that we were still the trusted messengers to our patients and our communities. I’m continually honored and humbled to be trusted with a whole family’s health.
Dr. Neison practices family medicine and culinary medicine at Sharp Rees-Stealy Medical Group in San Diego, and is cochair of climate and planetary health for SRS Medical Group. You can follow her on Instagram, LinkedIn, and Facebook @Flavors4WellnessMD.
A few years ago I tracked down my medical school interviewer to thank him for giving me the opportunity to do what I felt I was called to do. I was surprised that, after 15 years, he actually remembered me and remembered details like walking to the courtyard to meet my father who’d driven me to the interview.
Sharing my gratitude and letting him know I was happy felt important to me.
Choosing to practice family medicine has a lot to do with why I am happy in my career today.
One of my frustrations with health care had been its emphasis on treatment of sickness, rather than a broader one that incorporated prevention of sickness. During my third year of medical school, I was following a family and sports medicine faculty member who was focusing on aspects of lifestyle medicine to help a patient remain active and age gracefully. Seeing opportunities to practice preventative medicine in family medicine made me realize the specialty was the perfect fit for me.
Food as medicine
While participating in rotations I also realized you can find a subspecialty within family medicine.
During my fourth year of medical school, I followed an attending who was seeing a patient for hypertension, prediabetes and hypercholesterolemia. The attending told the patient to eat “healthier,” gave her a handout, and scheduled a follow up appointment for 6 months later.
My thoughts were: “That’s it? That’s how we counsel patients to improve their dietary habits?”
As the patient was leaving the exam room, I asked her what type of oil she cooked with, and I proceeded to share culinary tips from my mother – who was a self-taught and early adopter of the food-as-medicine movement.
Once I started my residency, I knew I’d want to incorporate lifestyle and dietary approaches at many of my patient visits.
I scheduled patients every month to monitor their weight, follow up on chronic conditions, but more importantly, to engage them in their health and empower them to make small lifestyle changes each month and report their efforts. I felt like I was their health coach and cheerleader.
My career in family medicine
Entering the job market allowed me to form my philosophy of treating patients with a mind, body, and spirit approach. I chose to practice value-based care, which aligns with my lifestyle and preventative medicine approach .
I currently practice in a small family medicine–only clinic that is part of a larger multispecialty system. Primary care specialties in my organization are valued, respected and central to a patient’s well being and care. We are encouraged to spend time with patients, assess barriers to care and work collaboratively with our healthcare team, so that preventative medicine approaches take the lead in a patient’s health. This supportive culture and environment is one where my passion for food as medicine has thrived.
One day I forgot to pack a lunch and instead brought a grocery bag of items to make a salad. When I realized I made too much, I sent an email to my staff to get some “free salad in my office.” This serendipitous moment started an informal office “salad club” each week. Continued support from my staff and leadership, allowed me to consider further extending this teaching to my patients and my colleagues.
Three years ago, I helped adopt a sustainable plant-forward menu for our physician meetings, complete with a recipe from the menu for physicians to replicate at home or give to their patients.
I also pursued adoption of shared medical appointments for our medical group. These appointments apply the “see one, do one, teach one” model in medicine, but with culinary medicine as the focus.
Knowing that my patients are all connected to their families through food, I sought this as an opportunity to dive in further with wellness opportunities at their next meal. After almost 2 years of working on this project, I was able to host my first shared medical appointment with a group of patients on March 12, 2020. The next day schools closed, lockdowns occurred, and the world changed.
Opportunities highlighted by the pandemic
We always knew health care was broken but adding the increasingly longer hours and COVID vaccine–hesitant patients that the pandemic brought made everything look dark at times. What has helped me stay hopeful and energetic for system changes is feeling gratitude and seeking bright lights.
My experiences seeing patients in telehealth visits are examples of some of the bright lights I found in the pandemic. During these visits, patients showed me something from their pantry, and we’d go over nutritional labels together.
Additionally, my patients became engaged with their own conditions and wanted to improve them because of news articles highlighting risk factors for COVID-19, such as obesity. I had an active audience when it came to talking about food-as-medicine approaches to improving risk factors and immunity. And since everyone was listening, I didn’t stop at food. I also talked about physical health, stress resiliency, planetary diets, sleep, connections, and lastly vaccines!
Once the vaccines were distributed, I naturally gravitated to having those conversations with patients and colleagues and on social media. Plus, the pandemic gave us moments of simple times to slow down, take more rests, be less overscheduled, consider work-life priorities, and, lastly, to be okay with not being totally okay.
In practicing primary care, we have a unique role in seeing medicine from a whole body, whole person, whole family perspective. There is an opportunity to highlight what is broken in medicine and aim to make it whole.
I’m currently looking at shared medical appointments as a new standard way to provide care to all patients, because it improves access, provides better quality visits and aligns my values, mission, and purpose.
In the midst of the pandemic, I helped advocate for a sustainable plant-forward menu that was launched throughout four different hospitals in the Sharp HealthCare system, in California, in 2020. Knowing that patients were served a menu I played a role in, gave me solace.
As part of the hospital food and nutrition team, I am grateful for the opportunity I have to work on a broader mission to address social determinants of health and seek opportunities to help the system work for our patients.
Public health communication has been lacking in the pandemic, but another bright light is that we were still the trusted messengers to our patients and our communities. I’m continually honored and humbled to be trusted with a whole family’s health.
Dr. Neison practices family medicine and culinary medicine at Sharp Rees-Stealy Medical Group in San Diego, and is cochair of climate and planetary health for SRS Medical Group. You can follow her on Instagram, LinkedIn, and Facebook @Flavors4WellnessMD.
A few years ago I tracked down my medical school interviewer to thank him for giving me the opportunity to do what I felt I was called to do. I was surprised that, after 15 years, he actually remembered me and remembered details like walking to the courtyard to meet my father who’d driven me to the interview.
Sharing my gratitude and letting him know I was happy felt important to me.
Choosing to practice family medicine has a lot to do with why I am happy in my career today.
One of my frustrations with health care had been its emphasis on treatment of sickness, rather than a broader one that incorporated prevention of sickness. During my third year of medical school, I was following a family and sports medicine faculty member who was focusing on aspects of lifestyle medicine to help a patient remain active and age gracefully. Seeing opportunities to practice preventative medicine in family medicine made me realize the specialty was the perfect fit for me.
Food as medicine
While participating in rotations I also realized you can find a subspecialty within family medicine.
During my fourth year of medical school, I followed an attending who was seeing a patient for hypertension, prediabetes and hypercholesterolemia. The attending told the patient to eat “healthier,” gave her a handout, and scheduled a follow up appointment for 6 months later.
My thoughts were: “That’s it? That’s how we counsel patients to improve their dietary habits?”
As the patient was leaving the exam room, I asked her what type of oil she cooked with, and I proceeded to share culinary tips from my mother – who was a self-taught and early adopter of the food-as-medicine movement.
Once I started my residency, I knew I’d want to incorporate lifestyle and dietary approaches at many of my patient visits.
I scheduled patients every month to monitor their weight, follow up on chronic conditions, but more importantly, to engage them in their health and empower them to make small lifestyle changes each month and report their efforts. I felt like I was their health coach and cheerleader.
My career in family medicine
Entering the job market allowed me to form my philosophy of treating patients with a mind, body, and spirit approach. I chose to practice value-based care, which aligns with my lifestyle and preventative medicine approach .
I currently practice in a small family medicine–only clinic that is part of a larger multispecialty system. Primary care specialties in my organization are valued, respected and central to a patient’s well being and care. We are encouraged to spend time with patients, assess barriers to care and work collaboratively with our healthcare team, so that preventative medicine approaches take the lead in a patient’s health. This supportive culture and environment is one where my passion for food as medicine has thrived.
One day I forgot to pack a lunch and instead brought a grocery bag of items to make a salad. When I realized I made too much, I sent an email to my staff to get some “free salad in my office.” This serendipitous moment started an informal office “salad club” each week. Continued support from my staff and leadership, allowed me to consider further extending this teaching to my patients and my colleagues.
Three years ago, I helped adopt a sustainable plant-forward menu for our physician meetings, complete with a recipe from the menu for physicians to replicate at home or give to their patients.
I also pursued adoption of shared medical appointments for our medical group. These appointments apply the “see one, do one, teach one” model in medicine, but with culinary medicine as the focus.
Knowing that my patients are all connected to their families through food, I sought this as an opportunity to dive in further with wellness opportunities at their next meal. After almost 2 years of working on this project, I was able to host my first shared medical appointment with a group of patients on March 12, 2020. The next day schools closed, lockdowns occurred, and the world changed.
Opportunities highlighted by the pandemic
We always knew health care was broken but adding the increasingly longer hours and COVID vaccine–hesitant patients that the pandemic brought made everything look dark at times. What has helped me stay hopeful and energetic for system changes is feeling gratitude and seeking bright lights.
My experiences seeing patients in telehealth visits are examples of some of the bright lights I found in the pandemic. During these visits, patients showed me something from their pantry, and we’d go over nutritional labels together.
Additionally, my patients became engaged with their own conditions and wanted to improve them because of news articles highlighting risk factors for COVID-19, such as obesity. I had an active audience when it came to talking about food-as-medicine approaches to improving risk factors and immunity. And since everyone was listening, I didn’t stop at food. I also talked about physical health, stress resiliency, planetary diets, sleep, connections, and lastly vaccines!
Once the vaccines were distributed, I naturally gravitated to having those conversations with patients and colleagues and on social media. Plus, the pandemic gave us moments of simple times to slow down, take more rests, be less overscheduled, consider work-life priorities, and, lastly, to be okay with not being totally okay.
In practicing primary care, we have a unique role in seeing medicine from a whole body, whole person, whole family perspective. There is an opportunity to highlight what is broken in medicine and aim to make it whole.
I’m currently looking at shared medical appointments as a new standard way to provide care to all patients, because it improves access, provides better quality visits and aligns my values, mission, and purpose.
In the midst of the pandemic, I helped advocate for a sustainable plant-forward menu that was launched throughout four different hospitals in the Sharp HealthCare system, in California, in 2020. Knowing that patients were served a menu I played a role in, gave me solace.
As part of the hospital food and nutrition team, I am grateful for the opportunity I have to work on a broader mission to address social determinants of health and seek opportunities to help the system work for our patients.
Public health communication has been lacking in the pandemic, but another bright light is that we were still the trusted messengers to our patients and our communities. I’m continually honored and humbled to be trusted with a whole family’s health.
Dr. Neison practices family medicine and culinary medicine at Sharp Rees-Stealy Medical Group in San Diego, and is cochair of climate and planetary health for SRS Medical Group. You can follow her on Instagram, LinkedIn, and Facebook @Flavors4WellnessMD.
Productively working together
Recently, some liberal colleagues urged a boycott of a conference in Orlando, Fla., because of various actions by its Republican state governor. At the same time, conservative colleagues advocated the boycott because business actions of Disney have become too leftist. Concerns about spreading COVID-19 at the national gathering have become small, compared with the desire to virtue-signal political viewpoints.
The 1960s in the United States were a time of social upheaval and polarization with many similarities to modern America. One difference is that, after a few years of social revolution, society emphasized bridging the differences. Politicians talked about reaching across the aisle. Religious groups sought ecumenical and interfaith ventures. Business and educational institutions promoted equal opportunity programs. The emphasis was finding common ground.
A half century later, the polarized work environment of medical organizations in 2022 has led to emphasis on cancel culture, litmus tests, and finding reasons not to work with others and to silence dissent. A professional working in a polarized environment faces frequent challenges that pit ethical and political principles against the pragmatic need to set and accomplish team goals that productively care for patients and support staff. One of the worst things societies can do for children’s health is to perpetuate the paralyzing divisiveness of modern politics.
As Justice Stephen Breyer nears retirement from the Supreme Court, I reflect back to 1994 when, on the day of his nomination to the court by President Clinton, Justice Breyer at a press conference said, “What [the law is] supposed to do seen as a whole is allow all people, all people, to live together in a society where they have so many different views, so many different needs, but to live together in a way that is more harmonious, that is better so that they can work productively together.”
I generally reject secondary boycotts and the hatred they spew. True inclusivity does not divide. True inclusivity is very messy. It rejects tyrants who insist on litmus tests to prove wokeness. Every red state has Democrats and every blue state has Republicans. If you are dedicated to loving your neighbor, I think it is necessary professionally to focus on who you will work with to improve the world. If woke extremism says you can only work with someone who echoes the same end of the blue or red political spectrum as yourself, that is not loving, not inclusive, and not productive.
My advice is to focus on the values, goals, and pathways you share with colleagues rather than using political or social differences to prejudice you against working with someone toward a common goal. The old adage is that politics makes strange bedfellows. People with diverse, divergent, and even opposed life views can work together to build schools and roads that benefit the community, contrary to the polarized examples that have flooded Washington, D.C., for the past 2 decades. (Generation Z: Take this as testimony from a Boomer who saw how politics used to work, especially in small towns.)
My other advice is to believe in free speech, but it requires a long civics lesson to understand what that means. Facebook promulgating unvetted posts as news feeds is not free speech. Facebook creating profiles so the app creates tailored echo chambers of misinformation is not free speech. President Obama ignoring the problem for 8 years as the iPhone became ubiquitous did not help. President Trump’s outreach to the masses via Twitter did not model responsible free speech. Surreptitiously promoting certain political viewpoints in math textbooks is not responsible behavior and has generated mistrust and the replacement of boards of education. Elon Musk wanting to buy Twitter is an unknown.
I won’t attempt to offer any pearls of wisdom on free speech in this column. It is a complex subject. I will suggest that doing a better job with free speech will save far more lives than eliminating crib bumpers.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
Recently, some liberal colleagues urged a boycott of a conference in Orlando, Fla., because of various actions by its Republican state governor. At the same time, conservative colleagues advocated the boycott because business actions of Disney have become too leftist. Concerns about spreading COVID-19 at the national gathering have become small, compared with the desire to virtue-signal political viewpoints.
The 1960s in the United States were a time of social upheaval and polarization with many similarities to modern America. One difference is that, after a few years of social revolution, society emphasized bridging the differences. Politicians talked about reaching across the aisle. Religious groups sought ecumenical and interfaith ventures. Business and educational institutions promoted equal opportunity programs. The emphasis was finding common ground.
A half century later, the polarized work environment of medical organizations in 2022 has led to emphasis on cancel culture, litmus tests, and finding reasons not to work with others and to silence dissent. A professional working in a polarized environment faces frequent challenges that pit ethical and political principles against the pragmatic need to set and accomplish team goals that productively care for patients and support staff. One of the worst things societies can do for children’s health is to perpetuate the paralyzing divisiveness of modern politics.
As Justice Stephen Breyer nears retirement from the Supreme Court, I reflect back to 1994 when, on the day of his nomination to the court by President Clinton, Justice Breyer at a press conference said, “What [the law is] supposed to do seen as a whole is allow all people, all people, to live together in a society where they have so many different views, so many different needs, but to live together in a way that is more harmonious, that is better so that they can work productively together.”
I generally reject secondary boycotts and the hatred they spew. True inclusivity does not divide. True inclusivity is very messy. It rejects tyrants who insist on litmus tests to prove wokeness. Every red state has Democrats and every blue state has Republicans. If you are dedicated to loving your neighbor, I think it is necessary professionally to focus on who you will work with to improve the world. If woke extremism says you can only work with someone who echoes the same end of the blue or red political spectrum as yourself, that is not loving, not inclusive, and not productive.
My advice is to focus on the values, goals, and pathways you share with colleagues rather than using political or social differences to prejudice you against working with someone toward a common goal. The old adage is that politics makes strange bedfellows. People with diverse, divergent, and even opposed life views can work together to build schools and roads that benefit the community, contrary to the polarized examples that have flooded Washington, D.C., for the past 2 decades. (Generation Z: Take this as testimony from a Boomer who saw how politics used to work, especially in small towns.)
My other advice is to believe in free speech, but it requires a long civics lesson to understand what that means. Facebook promulgating unvetted posts as news feeds is not free speech. Facebook creating profiles so the app creates tailored echo chambers of misinformation is not free speech. President Obama ignoring the problem for 8 years as the iPhone became ubiquitous did not help. President Trump’s outreach to the masses via Twitter did not model responsible free speech. Surreptitiously promoting certain political viewpoints in math textbooks is not responsible behavior and has generated mistrust and the replacement of boards of education. Elon Musk wanting to buy Twitter is an unknown.
I won’t attempt to offer any pearls of wisdom on free speech in this column. It is a complex subject. I will suggest that doing a better job with free speech will save far more lives than eliminating crib bumpers.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
Recently, some liberal colleagues urged a boycott of a conference in Orlando, Fla., because of various actions by its Republican state governor. At the same time, conservative colleagues advocated the boycott because business actions of Disney have become too leftist. Concerns about spreading COVID-19 at the national gathering have become small, compared with the desire to virtue-signal political viewpoints.
The 1960s in the United States were a time of social upheaval and polarization with many similarities to modern America. One difference is that, after a few years of social revolution, society emphasized bridging the differences. Politicians talked about reaching across the aisle. Religious groups sought ecumenical and interfaith ventures. Business and educational institutions promoted equal opportunity programs. The emphasis was finding common ground.
A half century later, the polarized work environment of medical organizations in 2022 has led to emphasis on cancel culture, litmus tests, and finding reasons not to work with others and to silence dissent. A professional working in a polarized environment faces frequent challenges that pit ethical and political principles against the pragmatic need to set and accomplish team goals that productively care for patients and support staff. One of the worst things societies can do for children’s health is to perpetuate the paralyzing divisiveness of modern politics.
As Justice Stephen Breyer nears retirement from the Supreme Court, I reflect back to 1994 when, on the day of his nomination to the court by President Clinton, Justice Breyer at a press conference said, “What [the law is] supposed to do seen as a whole is allow all people, all people, to live together in a society where they have so many different views, so many different needs, but to live together in a way that is more harmonious, that is better so that they can work productively together.”
I generally reject secondary boycotts and the hatred they spew. True inclusivity does not divide. True inclusivity is very messy. It rejects tyrants who insist on litmus tests to prove wokeness. Every red state has Democrats and every blue state has Republicans. If you are dedicated to loving your neighbor, I think it is necessary professionally to focus on who you will work with to improve the world. If woke extremism says you can only work with someone who echoes the same end of the blue or red political spectrum as yourself, that is not loving, not inclusive, and not productive.
My advice is to focus on the values, goals, and pathways you share with colleagues rather than using political or social differences to prejudice you against working with someone toward a common goal. The old adage is that politics makes strange bedfellows. People with diverse, divergent, and even opposed life views can work together to build schools and roads that benefit the community, contrary to the polarized examples that have flooded Washington, D.C., for the past 2 decades. (Generation Z: Take this as testimony from a Boomer who saw how politics used to work, especially in small towns.)
My other advice is to believe in free speech, but it requires a long civics lesson to understand what that means. Facebook promulgating unvetted posts as news feeds is not free speech. Facebook creating profiles so the app creates tailored echo chambers of misinformation is not free speech. President Obama ignoring the problem for 8 years as the iPhone became ubiquitous did not help. President Trump’s outreach to the masses via Twitter did not model responsible free speech. Surreptitiously promoting certain political viewpoints in math textbooks is not responsible behavior and has generated mistrust and the replacement of boards of education. Elon Musk wanting to buy Twitter is an unknown.
I won’t attempt to offer any pearls of wisdom on free speech in this column. It is a complex subject. I will suggest that doing a better job with free speech will save far more lives than eliminating crib bumpers.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
When burnout is moral injury
Several years have passed since I stood among a cohort of eager medical students wearing regalia that signaled a new beginning. Four years of grueling study culminated in a cacophony of unified voices, each reciting a pledge that I had longed to take since early adolescence. Together we celebrated, triumphant despite innumerable exams and various iterations of the Socratic method – all under the guise of assessing knowledge while in truth seeking to insidiously erode the crowd of prospective physicians. Yet our anxiety and uncertainty melted away as names were called, hands firmly clasped, and tassels transposed. For a moment in time, we stood on the precipice of victory, enthusiastic albeit oblivious of the tremendous obstacles that loomed ahead.
Wistfully I reminisce about the unequivocal joy that abounds within the protective shield of naiveté. Specifically, I think about that time when the edict of medicine and the art of being a physician felt congruent. Yet, reality is fickle and often supersedes expectation. Occasionally my thoughts drift to the early days of residency – a time during which the emotional weight of caring for vulnerable patients while learning to master my chosen specialty felt woefully insurmountable. I recall wading blindly through each rotation attempting to emulate the competent and compassionate care so effortlessly demonstrated by senior physicians as they moved through the health care system with apparent ease. They stepped fluidly, as I watched in awe through rose-tinted glasses.
As months passed into years, my perception cleared. What I initially viewed as graceful patient care belied a complex tapestry of health care workers often pressured into arduous decisions, not necessarily in service of a well-constructed treatment plan. Gradually, formidable barriers emerged, guidelines and restrictions embedded within a confining path that suffocated those who dared to cross it. As a result, a field built on the foundations of autonomy, benevolence, and nonmaleficence was slowly engulfed by a system fraught with contrivances. Amid such stressors, physical and psychological health grows tenuous. Classically, this overwhelming feeling of distress is recognized as burnout. Studies reformulated this malady to that which was first described in Vietnam war veterans, a condition known as “moral injury.”
The impact of burnout
To explain the development – and explore the complexities – of moral injury, we must return to 1975 when the term burnout was initially formulated by Herbert Freudenberger, PhD, a psychologist renowned for his work in substance use disorders, psychoanalysis, and clinical education.1 Dr. Freudenberger’s studies noted incidences of heightened emotional and physical distress in his colleagues working in substance abuse and other clinics. He sought to define these experiences as well as understand his own battle with malaise, apathy, and frustration.1 Ultimately, Dr. Freudenberger described burnout as “Becoming exhausted by making excessive demands on energy, strength, or resources in the workplace.”2 Although it characteristically overlaps with depression and anxiety, burnout is conceptualized as a separate entity specifically forged within a context of perfectionism, integrity, and self-sacrifice.2 Such qualities are integral in health care and, as a result, physicians are particularly vulnerable.
Since Dr. Freudenberger published “Burnout: The High Cost of Achievement” in 1980, immense research has assisted in not only identifying critical factors that contribute to its development but also the detrimental effects it has on physiological health.3 These include exhaustion from poor work conditions and extreme commitment to employee responsibilities that in turn precipitate mood destabilization and impaired work performance.3 Furthermore, research has also demonstrated that burnout triggers alterations in neural circuitry via the prefrontal cortex and the amygdala, structures critical for emotional regulation.4 To combat the ill effects of burnout while maintaining productivity and maximizing profit, several high-profile corporations instituted changes focusing on self-care, wellness, benefits, and incentives. Although these modifications are effective in decreasing the rate of employee turnover, such strategies are not easily transferable to health care. In fact, the rate of physician burnout has steadily increased over the past two decades as the business of medicine shifts towards longer hours, decreased reimbursement rates, and inexhaustible insurance stipulations.2,5 Consequently, occupational dissatisfaction increases the risk of cynicism, frustration with patients, internalization of failure, and likelihood of early retirement.5 Moreover, burnout may also fracture interpersonal relationships as well as precipitate errors, negative patient outcomes, malpractice, and development of severe mental health conditions associated with high morbidity and mortality.5,8
Although the concept of burnout is critical in understanding the side effects of stereotypical workplace culture, critics of the concept bemoan a suggestion of individual blame.6,8 In essence, they argue that burnout is explained as a side effect of toxic workplace conditions, but covertly represents a lack of resilience, motivation, and ambition to thrive in a physically or emotionally taxing occupational setting.6,8 Thus, the responsibility of acclimation lies upon the impacted individuals rather than the employer. For this reason, many strategies to ameliorate burnout are focused on the individual, including meditation, wellness retreats, creating or adjusting self-care regimens, or in some cases psychotherapy and psychopharmacology.6 Whereas burnout may respond (at least partially) to such interventions, without altering the causal factors, it is unlikely to remit. This is especially the case in health care, where systemic constraints lie beyond the control of an individual physician. Rather than promoting or specifically relying upon personal improvement and recovery, amendments are needed on multiple levels to affect meaningful change.
Moral injury
Similar to burnout, moral injury was not initially conceived within the scope of health care. In the 1990s Jonathan Shay, MD, PhD, identified veterans presenting with symptoms mimicking PTSD that failed to respond to standard, well established and efficacious treatments.9-11 With further analysis he determined that veterans who demonstrated minimal improvement reported similar histories of guilt, shame, and disgust following perceived injustices enacted or abetted by immoral leaders.10,11 Ultimately Shay identified three components of moral injury: 1. A betrayal of what is morally right; 2. By someone who holds legitimate priority; 3. In a high stakes situation.10
This definition was further modified in 2007 by Brett Linz, PhD, and colleagues as: “Perpetuating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”10,11 By expanding this description to include distress experienced by physicians and health care workers, Wendy Dean and Simon Talbot (in 2018 and 2019 respectively) explored how the health care system leads practitioners to deliver what they identify as substandard treatment.6-8 This results in disillusionment and lays the foundation for ethical and moral dilemmas in clinicians.
Themes of moral injury are repeatedly cited in various surveys and studies as a cause for occupational dissatisfaction. As physicians and other health care professionals reel from the aftermath of COVID-19, the effects of reconfiguring medicine into a business-oriented framework are glaringly conspicuous. Vast hospital nursing shortages, high patient census exacerbated by the political misuse and polarization of science, and insufficient availability of psychiatric beds, have culminated in a deluge of psychological strain in emergency medical physicians. Furthermore, pressure from administrators, mandated patient satisfaction measures, tedious electronic medical record systems, and copious licensing and certification requirements, contribute to physician distress as they attempt to navigate a system that challenges the vows which they swore to uphold.8 Because the cost of pursuing a medical degree frequently necessitates acquisition of loans that, without a physician income, may be difficult to repay,9 many doctors feel trapped within a seemingly endless cycle of misgiving that contributes to emotional exhaustion, pessimism, and low morale.
In my next series of The Myth of the Superdoctor columns, we will explore various factors that potentiate risk of moral injury. From medical school and residency training to corporate infrastructure and insurance obstacles, I will seek to discern and deliberate strategies for repair and rehabilitation. It is my hope that together we will illuminate the myriad complexities within the business of medicine, and become advocates and harbingers of change not only for physicians and health care workers but also for the sake of our patients and their families.
Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.
References
1. King N. When a Psychologist Succumbed to Stress, He Coined The Term Burnout. 2016 Dec 8. NPR: All Things Considered.
2. Maslach C and Leiter MP. World Psychiatry. 2016 Jun;15(2):103-11. doi: 10.1002/wps.20311.
3. InformedHealth.org and Institute for Quality and Efficiency in Health Care. Depression: What is burnout?. https://www.ncbi.nlm.nih.gov/books/NBK279286/.
4. Michel A. Burnout and the Brain. Observer. 2016 Jan 29. https://www.psychologicalscience.org/observer/burnout-and-the-brain.
5. Patel RS et al. Behav Sci. 2018;8(11):98. doi:10.3390/bs8110098.
6. Dean W and Talbot S. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat. 2018 Jul 26. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/.
7. Dean W and Talbot S. Moral injury and burnout in medicine: A year of lessons learned. Stat. 2019 Jul 26. https://www.statnews.com/2019/07/26/moral-injury-burnout-medicine-lessons-learned/.
8. Dean W et al. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep; 36(9):400-2. https://www.mdedge.com/fedprac/article/207458/mental-health/reframing-clinician-distress-moral-injury-not-burnout.
9. Bailey M. Beyond Burnout: Docs Decry ‘Moral Injury’ From Financial Pressures of Health Care. KHN. 2020 Feb 4. https://khn.org/news/beyond-burnout-docs-decry-moral-injury-from-financial-pressures-of-health-care/.
10. Litz B et al. Clin Psychol Rev. 2009 Dec;29(8):695-706. doi: 10.1016/j.cpr.2009.07.003.
11. Norman S and Maguen S. Moral Injury. PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp.
Several years have passed since I stood among a cohort of eager medical students wearing regalia that signaled a new beginning. Four years of grueling study culminated in a cacophony of unified voices, each reciting a pledge that I had longed to take since early adolescence. Together we celebrated, triumphant despite innumerable exams and various iterations of the Socratic method – all under the guise of assessing knowledge while in truth seeking to insidiously erode the crowd of prospective physicians. Yet our anxiety and uncertainty melted away as names were called, hands firmly clasped, and tassels transposed. For a moment in time, we stood on the precipice of victory, enthusiastic albeit oblivious of the tremendous obstacles that loomed ahead.
Wistfully I reminisce about the unequivocal joy that abounds within the protective shield of naiveté. Specifically, I think about that time when the edict of medicine and the art of being a physician felt congruent. Yet, reality is fickle and often supersedes expectation. Occasionally my thoughts drift to the early days of residency – a time during which the emotional weight of caring for vulnerable patients while learning to master my chosen specialty felt woefully insurmountable. I recall wading blindly through each rotation attempting to emulate the competent and compassionate care so effortlessly demonstrated by senior physicians as they moved through the health care system with apparent ease. They stepped fluidly, as I watched in awe through rose-tinted glasses.
As months passed into years, my perception cleared. What I initially viewed as graceful patient care belied a complex tapestry of health care workers often pressured into arduous decisions, not necessarily in service of a well-constructed treatment plan. Gradually, formidable barriers emerged, guidelines and restrictions embedded within a confining path that suffocated those who dared to cross it. As a result, a field built on the foundations of autonomy, benevolence, and nonmaleficence was slowly engulfed by a system fraught with contrivances. Amid such stressors, physical and psychological health grows tenuous. Classically, this overwhelming feeling of distress is recognized as burnout. Studies reformulated this malady to that which was first described in Vietnam war veterans, a condition known as “moral injury.”
The impact of burnout
To explain the development – and explore the complexities – of moral injury, we must return to 1975 when the term burnout was initially formulated by Herbert Freudenberger, PhD, a psychologist renowned for his work in substance use disorders, psychoanalysis, and clinical education.1 Dr. Freudenberger’s studies noted incidences of heightened emotional and physical distress in his colleagues working in substance abuse and other clinics. He sought to define these experiences as well as understand his own battle with malaise, apathy, and frustration.1 Ultimately, Dr. Freudenberger described burnout as “Becoming exhausted by making excessive demands on energy, strength, or resources in the workplace.”2 Although it characteristically overlaps with depression and anxiety, burnout is conceptualized as a separate entity specifically forged within a context of perfectionism, integrity, and self-sacrifice.2 Such qualities are integral in health care and, as a result, physicians are particularly vulnerable.
Since Dr. Freudenberger published “Burnout: The High Cost of Achievement” in 1980, immense research has assisted in not only identifying critical factors that contribute to its development but also the detrimental effects it has on physiological health.3 These include exhaustion from poor work conditions and extreme commitment to employee responsibilities that in turn precipitate mood destabilization and impaired work performance.3 Furthermore, research has also demonstrated that burnout triggers alterations in neural circuitry via the prefrontal cortex and the amygdala, structures critical for emotional regulation.4 To combat the ill effects of burnout while maintaining productivity and maximizing profit, several high-profile corporations instituted changes focusing on self-care, wellness, benefits, and incentives. Although these modifications are effective in decreasing the rate of employee turnover, such strategies are not easily transferable to health care. In fact, the rate of physician burnout has steadily increased over the past two decades as the business of medicine shifts towards longer hours, decreased reimbursement rates, and inexhaustible insurance stipulations.2,5 Consequently, occupational dissatisfaction increases the risk of cynicism, frustration with patients, internalization of failure, and likelihood of early retirement.5 Moreover, burnout may also fracture interpersonal relationships as well as precipitate errors, negative patient outcomes, malpractice, and development of severe mental health conditions associated with high morbidity and mortality.5,8
Although the concept of burnout is critical in understanding the side effects of stereotypical workplace culture, critics of the concept bemoan a suggestion of individual blame.6,8 In essence, they argue that burnout is explained as a side effect of toxic workplace conditions, but covertly represents a lack of resilience, motivation, and ambition to thrive in a physically or emotionally taxing occupational setting.6,8 Thus, the responsibility of acclimation lies upon the impacted individuals rather than the employer. For this reason, many strategies to ameliorate burnout are focused on the individual, including meditation, wellness retreats, creating or adjusting self-care regimens, or in some cases psychotherapy and psychopharmacology.6 Whereas burnout may respond (at least partially) to such interventions, without altering the causal factors, it is unlikely to remit. This is especially the case in health care, where systemic constraints lie beyond the control of an individual physician. Rather than promoting or specifically relying upon personal improvement and recovery, amendments are needed on multiple levels to affect meaningful change.
Moral injury
Similar to burnout, moral injury was not initially conceived within the scope of health care. In the 1990s Jonathan Shay, MD, PhD, identified veterans presenting with symptoms mimicking PTSD that failed to respond to standard, well established and efficacious treatments.9-11 With further analysis he determined that veterans who demonstrated minimal improvement reported similar histories of guilt, shame, and disgust following perceived injustices enacted or abetted by immoral leaders.10,11 Ultimately Shay identified three components of moral injury: 1. A betrayal of what is morally right; 2. By someone who holds legitimate priority; 3. In a high stakes situation.10
This definition was further modified in 2007 by Brett Linz, PhD, and colleagues as: “Perpetuating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”10,11 By expanding this description to include distress experienced by physicians and health care workers, Wendy Dean and Simon Talbot (in 2018 and 2019 respectively) explored how the health care system leads practitioners to deliver what they identify as substandard treatment.6-8 This results in disillusionment and lays the foundation for ethical and moral dilemmas in clinicians.
Themes of moral injury are repeatedly cited in various surveys and studies as a cause for occupational dissatisfaction. As physicians and other health care professionals reel from the aftermath of COVID-19, the effects of reconfiguring medicine into a business-oriented framework are glaringly conspicuous. Vast hospital nursing shortages, high patient census exacerbated by the political misuse and polarization of science, and insufficient availability of psychiatric beds, have culminated in a deluge of psychological strain in emergency medical physicians. Furthermore, pressure from administrators, mandated patient satisfaction measures, tedious electronic medical record systems, and copious licensing and certification requirements, contribute to physician distress as they attempt to navigate a system that challenges the vows which they swore to uphold.8 Because the cost of pursuing a medical degree frequently necessitates acquisition of loans that, without a physician income, may be difficult to repay,9 many doctors feel trapped within a seemingly endless cycle of misgiving that contributes to emotional exhaustion, pessimism, and low morale.
In my next series of The Myth of the Superdoctor columns, we will explore various factors that potentiate risk of moral injury. From medical school and residency training to corporate infrastructure and insurance obstacles, I will seek to discern and deliberate strategies for repair and rehabilitation. It is my hope that together we will illuminate the myriad complexities within the business of medicine, and become advocates and harbingers of change not only for physicians and health care workers but also for the sake of our patients and their families.
Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.
References
1. King N. When a Psychologist Succumbed to Stress, He Coined The Term Burnout. 2016 Dec 8. NPR: All Things Considered.
2. Maslach C and Leiter MP. World Psychiatry. 2016 Jun;15(2):103-11. doi: 10.1002/wps.20311.
3. InformedHealth.org and Institute for Quality and Efficiency in Health Care. Depression: What is burnout?. https://www.ncbi.nlm.nih.gov/books/NBK279286/.
4. Michel A. Burnout and the Brain. Observer. 2016 Jan 29. https://www.psychologicalscience.org/observer/burnout-and-the-brain.
5. Patel RS et al. Behav Sci. 2018;8(11):98. doi:10.3390/bs8110098.
6. Dean W and Talbot S. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat. 2018 Jul 26. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/.
7. Dean W and Talbot S. Moral injury and burnout in medicine: A year of lessons learned. Stat. 2019 Jul 26. https://www.statnews.com/2019/07/26/moral-injury-burnout-medicine-lessons-learned/.
8. Dean W et al. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep; 36(9):400-2. https://www.mdedge.com/fedprac/article/207458/mental-health/reframing-clinician-distress-moral-injury-not-burnout.
9. Bailey M. Beyond Burnout: Docs Decry ‘Moral Injury’ From Financial Pressures of Health Care. KHN. 2020 Feb 4. https://khn.org/news/beyond-burnout-docs-decry-moral-injury-from-financial-pressures-of-health-care/.
10. Litz B et al. Clin Psychol Rev. 2009 Dec;29(8):695-706. doi: 10.1016/j.cpr.2009.07.003.
11. Norman S and Maguen S. Moral Injury. PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp.
Several years have passed since I stood among a cohort of eager medical students wearing regalia that signaled a new beginning. Four years of grueling study culminated in a cacophony of unified voices, each reciting a pledge that I had longed to take since early adolescence. Together we celebrated, triumphant despite innumerable exams and various iterations of the Socratic method – all under the guise of assessing knowledge while in truth seeking to insidiously erode the crowd of prospective physicians. Yet our anxiety and uncertainty melted away as names were called, hands firmly clasped, and tassels transposed. For a moment in time, we stood on the precipice of victory, enthusiastic albeit oblivious of the tremendous obstacles that loomed ahead.
Wistfully I reminisce about the unequivocal joy that abounds within the protective shield of naiveté. Specifically, I think about that time when the edict of medicine and the art of being a physician felt congruent. Yet, reality is fickle and often supersedes expectation. Occasionally my thoughts drift to the early days of residency – a time during which the emotional weight of caring for vulnerable patients while learning to master my chosen specialty felt woefully insurmountable. I recall wading blindly through each rotation attempting to emulate the competent and compassionate care so effortlessly demonstrated by senior physicians as they moved through the health care system with apparent ease. They stepped fluidly, as I watched in awe through rose-tinted glasses.
As months passed into years, my perception cleared. What I initially viewed as graceful patient care belied a complex tapestry of health care workers often pressured into arduous decisions, not necessarily in service of a well-constructed treatment plan. Gradually, formidable barriers emerged, guidelines and restrictions embedded within a confining path that suffocated those who dared to cross it. As a result, a field built on the foundations of autonomy, benevolence, and nonmaleficence was slowly engulfed by a system fraught with contrivances. Amid such stressors, physical and psychological health grows tenuous. Classically, this overwhelming feeling of distress is recognized as burnout. Studies reformulated this malady to that which was first described in Vietnam war veterans, a condition known as “moral injury.”
The impact of burnout
To explain the development – and explore the complexities – of moral injury, we must return to 1975 when the term burnout was initially formulated by Herbert Freudenberger, PhD, a psychologist renowned for his work in substance use disorders, psychoanalysis, and clinical education.1 Dr. Freudenberger’s studies noted incidences of heightened emotional and physical distress in his colleagues working in substance abuse and other clinics. He sought to define these experiences as well as understand his own battle with malaise, apathy, and frustration.1 Ultimately, Dr. Freudenberger described burnout as “Becoming exhausted by making excessive demands on energy, strength, or resources in the workplace.”2 Although it characteristically overlaps with depression and anxiety, burnout is conceptualized as a separate entity specifically forged within a context of perfectionism, integrity, and self-sacrifice.2 Such qualities are integral in health care and, as a result, physicians are particularly vulnerable.
Since Dr. Freudenberger published “Burnout: The High Cost of Achievement” in 1980, immense research has assisted in not only identifying critical factors that contribute to its development but also the detrimental effects it has on physiological health.3 These include exhaustion from poor work conditions and extreme commitment to employee responsibilities that in turn precipitate mood destabilization and impaired work performance.3 Furthermore, research has also demonstrated that burnout triggers alterations in neural circuitry via the prefrontal cortex and the amygdala, structures critical for emotional regulation.4 To combat the ill effects of burnout while maintaining productivity and maximizing profit, several high-profile corporations instituted changes focusing on self-care, wellness, benefits, and incentives. Although these modifications are effective in decreasing the rate of employee turnover, such strategies are not easily transferable to health care. In fact, the rate of physician burnout has steadily increased over the past two decades as the business of medicine shifts towards longer hours, decreased reimbursement rates, and inexhaustible insurance stipulations.2,5 Consequently, occupational dissatisfaction increases the risk of cynicism, frustration with patients, internalization of failure, and likelihood of early retirement.5 Moreover, burnout may also fracture interpersonal relationships as well as precipitate errors, negative patient outcomes, malpractice, and development of severe mental health conditions associated with high morbidity and mortality.5,8
Although the concept of burnout is critical in understanding the side effects of stereotypical workplace culture, critics of the concept bemoan a suggestion of individual blame.6,8 In essence, they argue that burnout is explained as a side effect of toxic workplace conditions, but covertly represents a lack of resilience, motivation, and ambition to thrive in a physically or emotionally taxing occupational setting.6,8 Thus, the responsibility of acclimation lies upon the impacted individuals rather than the employer. For this reason, many strategies to ameliorate burnout are focused on the individual, including meditation, wellness retreats, creating or adjusting self-care regimens, or in some cases psychotherapy and psychopharmacology.6 Whereas burnout may respond (at least partially) to such interventions, without altering the causal factors, it is unlikely to remit. This is especially the case in health care, where systemic constraints lie beyond the control of an individual physician. Rather than promoting or specifically relying upon personal improvement and recovery, amendments are needed on multiple levels to affect meaningful change.
Moral injury
Similar to burnout, moral injury was not initially conceived within the scope of health care. In the 1990s Jonathan Shay, MD, PhD, identified veterans presenting with symptoms mimicking PTSD that failed to respond to standard, well established and efficacious treatments.9-11 With further analysis he determined that veterans who demonstrated minimal improvement reported similar histories of guilt, shame, and disgust following perceived injustices enacted or abetted by immoral leaders.10,11 Ultimately Shay identified three components of moral injury: 1. A betrayal of what is morally right; 2. By someone who holds legitimate priority; 3. In a high stakes situation.10
This definition was further modified in 2007 by Brett Linz, PhD, and colleagues as: “Perpetuating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”10,11 By expanding this description to include distress experienced by physicians and health care workers, Wendy Dean and Simon Talbot (in 2018 and 2019 respectively) explored how the health care system leads practitioners to deliver what they identify as substandard treatment.6-8 This results in disillusionment and lays the foundation for ethical and moral dilemmas in clinicians.
Themes of moral injury are repeatedly cited in various surveys and studies as a cause for occupational dissatisfaction. As physicians and other health care professionals reel from the aftermath of COVID-19, the effects of reconfiguring medicine into a business-oriented framework are glaringly conspicuous. Vast hospital nursing shortages, high patient census exacerbated by the political misuse and polarization of science, and insufficient availability of psychiatric beds, have culminated in a deluge of psychological strain in emergency medical physicians. Furthermore, pressure from administrators, mandated patient satisfaction measures, tedious electronic medical record systems, and copious licensing and certification requirements, contribute to physician distress as they attempt to navigate a system that challenges the vows which they swore to uphold.8 Because the cost of pursuing a medical degree frequently necessitates acquisition of loans that, without a physician income, may be difficult to repay,9 many doctors feel trapped within a seemingly endless cycle of misgiving that contributes to emotional exhaustion, pessimism, and low morale.
In my next series of The Myth of the Superdoctor columns, we will explore various factors that potentiate risk of moral injury. From medical school and residency training to corporate infrastructure and insurance obstacles, I will seek to discern and deliberate strategies for repair and rehabilitation. It is my hope that together we will illuminate the myriad complexities within the business of medicine, and become advocates and harbingers of change not only for physicians and health care workers but also for the sake of our patients and their families.
Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.
References
1. King N. When a Psychologist Succumbed to Stress, He Coined The Term Burnout. 2016 Dec 8. NPR: All Things Considered.
2. Maslach C and Leiter MP. World Psychiatry. 2016 Jun;15(2):103-11. doi: 10.1002/wps.20311.
3. InformedHealth.org and Institute for Quality and Efficiency in Health Care. Depression: What is burnout?. https://www.ncbi.nlm.nih.gov/books/NBK279286/.
4. Michel A. Burnout and the Brain. Observer. 2016 Jan 29. https://www.psychologicalscience.org/observer/burnout-and-the-brain.
5. Patel RS et al. Behav Sci. 2018;8(11):98. doi:10.3390/bs8110098.
6. Dean W and Talbot S. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat. 2018 Jul 26. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/.
7. Dean W and Talbot S. Moral injury and burnout in medicine: A year of lessons learned. Stat. 2019 Jul 26. https://www.statnews.com/2019/07/26/moral-injury-burnout-medicine-lessons-learned/.
8. Dean W et al. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep; 36(9):400-2. https://www.mdedge.com/fedprac/article/207458/mental-health/reframing-clinician-distress-moral-injury-not-burnout.
9. Bailey M. Beyond Burnout: Docs Decry ‘Moral Injury’ From Financial Pressures of Health Care. KHN. 2020 Feb 4. https://khn.org/news/beyond-burnout-docs-decry-moral-injury-from-financial-pressures-of-health-care/.
10. Litz B et al. Clin Psychol Rev. 2009 Dec;29(8):695-706. doi: 10.1016/j.cpr.2009.07.003.
11. Norman S and Maguen S. Moral Injury. PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp.
One weird trick to fight burnout
“Here and now is what counts. So, let’s go to work!” –Walter Orthmann, 100 years old
How long before you retire? If you know the answer in exact years, months, and days, you aren’t alone. For many good reasons, we doctors are more likely to be counting down the years until we retire rather than counting up the years since we started working. For me, if I’m to break the Guinness World Record, I have 69 more years, 3 months and 6 days left to go. That would surpass the current achievement for the longest career at one company, Mr. Walter Orthmann, who has been sitting at the same desk for 84 years. At 100 years old, Mr. Orthmann still shows up every Monday morning, as bright eyed and bushy tailed as a young squirrel. I’ll be 119 when I break his streak, which would also put me past Anthony Mancinelli, a New York barber who at 107 years of age was still brushing off his chair for the next customer. Unbelievable, I know! I wonder, what’s the one weird trick these guys are doing that keeps them going?
Of course, the job itself matters. Some jobs, like being a police officer, aren’t suitable for old people. Or are they? Officer L.C. “Buckshot” Smith was still keeping streets safe from his patrol car at 91 years old. After a bit of searching, I found pretty much any job you can think of has a very long-lasting Energizer Bunny story: A female surgeon who was operating at 90 years old, a 100-year-old rheumatologist who was still teaching at University of California, San Francisco, and a 105-year-old Japanese physician who was still seeing patients. There are plenty of geriatric lawyers, nurses, land surveyors, accountants, judges, you name it. So it seems it’s not the work, but the worker that matters. Why do some older workers recharge daily and carry on while many younger ones say the daily grind is burning them out? What makes the Greatest Generation so great?
We all know colleagues who hung up their white coats early. In my medical group, it’s often financially feasible to retire at 58 and many have chosen that option. Yet, we have loads of Partner Emeritus docs in their 70’s who still log on to EPIC and pitch in everyday.
“So, how do you keep going?” I asked my 105-year-old patient who still walks and manages his affairs. “Just stay healthy,” he advised. A circular argument, yet he’s right. You must both be lucky and also choose to be active mentally and physically. Mr. Mancinelli, who was barbering full time at 107 years old, had no aches and pains and all his teeth. He pruned his own bushes. The data are crystal clear that physical activity adds not only years of life, but also improves cognitive capabilities during those years.
As for beating burnout, it seems the one trick that these ultraworkers do is to focus only on the present. Mr. Orthmann’s pithy advice as quoted by NPR is, “You need to get busy with the present, not the past or the future.” These centenarian employees also frame their work not as stressful but rather as their daily series of problems to be solved.
When I asked my super-geriatric patient how he sleeps so well, he said, “I never worry when I get into bed, I just shut my eyes and sleep. I’ll think about tomorrow when I wake up.” Now if I can do that about 25,000 more times, I’ll have the record.
Dr. Jeff Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
“Here and now is what counts. So, let’s go to work!” –Walter Orthmann, 100 years old
How long before you retire? If you know the answer in exact years, months, and days, you aren’t alone. For many good reasons, we doctors are more likely to be counting down the years until we retire rather than counting up the years since we started working. For me, if I’m to break the Guinness World Record, I have 69 more years, 3 months and 6 days left to go. That would surpass the current achievement for the longest career at one company, Mr. Walter Orthmann, who has been sitting at the same desk for 84 years. At 100 years old, Mr. Orthmann still shows up every Monday morning, as bright eyed and bushy tailed as a young squirrel. I’ll be 119 when I break his streak, which would also put me past Anthony Mancinelli, a New York barber who at 107 years of age was still brushing off his chair for the next customer. Unbelievable, I know! I wonder, what’s the one weird trick these guys are doing that keeps them going?
Of course, the job itself matters. Some jobs, like being a police officer, aren’t suitable for old people. Or are they? Officer L.C. “Buckshot” Smith was still keeping streets safe from his patrol car at 91 years old. After a bit of searching, I found pretty much any job you can think of has a very long-lasting Energizer Bunny story: A female surgeon who was operating at 90 years old, a 100-year-old rheumatologist who was still teaching at University of California, San Francisco, and a 105-year-old Japanese physician who was still seeing patients. There are plenty of geriatric lawyers, nurses, land surveyors, accountants, judges, you name it. So it seems it’s not the work, but the worker that matters. Why do some older workers recharge daily and carry on while many younger ones say the daily grind is burning them out? What makes the Greatest Generation so great?
We all know colleagues who hung up their white coats early. In my medical group, it’s often financially feasible to retire at 58 and many have chosen that option. Yet, we have loads of Partner Emeritus docs in their 70’s who still log on to EPIC and pitch in everyday.
“So, how do you keep going?” I asked my 105-year-old patient who still walks and manages his affairs. “Just stay healthy,” he advised. A circular argument, yet he’s right. You must both be lucky and also choose to be active mentally and physically. Mr. Mancinelli, who was barbering full time at 107 years old, had no aches and pains and all his teeth. He pruned his own bushes. The data are crystal clear that physical activity adds not only years of life, but also improves cognitive capabilities during those years.
As for beating burnout, it seems the one trick that these ultraworkers do is to focus only on the present. Mr. Orthmann’s pithy advice as quoted by NPR is, “You need to get busy with the present, not the past or the future.” These centenarian employees also frame their work not as stressful but rather as their daily series of problems to be solved.
When I asked my super-geriatric patient how he sleeps so well, he said, “I never worry when I get into bed, I just shut my eyes and sleep. I’ll think about tomorrow when I wake up.” Now if I can do that about 25,000 more times, I’ll have the record.
Dr. Jeff Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
“Here and now is what counts. So, let’s go to work!” –Walter Orthmann, 100 years old
How long before you retire? If you know the answer in exact years, months, and days, you aren’t alone. For many good reasons, we doctors are more likely to be counting down the years until we retire rather than counting up the years since we started working. For me, if I’m to break the Guinness World Record, I have 69 more years, 3 months and 6 days left to go. That would surpass the current achievement for the longest career at one company, Mr. Walter Orthmann, who has been sitting at the same desk for 84 years. At 100 years old, Mr. Orthmann still shows up every Monday morning, as bright eyed and bushy tailed as a young squirrel. I’ll be 119 when I break his streak, which would also put me past Anthony Mancinelli, a New York barber who at 107 years of age was still brushing off his chair for the next customer. Unbelievable, I know! I wonder, what’s the one weird trick these guys are doing that keeps them going?
Of course, the job itself matters. Some jobs, like being a police officer, aren’t suitable for old people. Or are they? Officer L.C. “Buckshot” Smith was still keeping streets safe from his patrol car at 91 years old. After a bit of searching, I found pretty much any job you can think of has a very long-lasting Energizer Bunny story: A female surgeon who was operating at 90 years old, a 100-year-old rheumatologist who was still teaching at University of California, San Francisco, and a 105-year-old Japanese physician who was still seeing patients. There are plenty of geriatric lawyers, nurses, land surveyors, accountants, judges, you name it. So it seems it’s not the work, but the worker that matters. Why do some older workers recharge daily and carry on while many younger ones say the daily grind is burning them out? What makes the Greatest Generation so great?
We all know colleagues who hung up their white coats early. In my medical group, it’s often financially feasible to retire at 58 and many have chosen that option. Yet, we have loads of Partner Emeritus docs in their 70’s who still log on to EPIC and pitch in everyday.
“So, how do you keep going?” I asked my 105-year-old patient who still walks and manages his affairs. “Just stay healthy,” he advised. A circular argument, yet he’s right. You must both be lucky and also choose to be active mentally and physically. Mr. Mancinelli, who was barbering full time at 107 years old, had no aches and pains and all his teeth. He pruned his own bushes. The data are crystal clear that physical activity adds not only years of life, but also improves cognitive capabilities during those years.
As for beating burnout, it seems the one trick that these ultraworkers do is to focus only on the present. Mr. Orthmann’s pithy advice as quoted by NPR is, “You need to get busy with the present, not the past or the future.” These centenarian employees also frame their work not as stressful but rather as their daily series of problems to be solved.
When I asked my super-geriatric patient how he sleeps so well, he said, “I never worry when I get into bed, I just shut my eyes and sleep. I’ll think about tomorrow when I wake up.” Now if I can do that about 25,000 more times, I’ll have the record.
Dr. Jeff Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Lost keys, missed appointments: The struggle of treating executive dysfunction
Maybe you know some of these patients: They may come late or not show up at all. They may have little to say and minimize their difficulties, often because they are ashamed of how much effort it takes to meet ordinary obligations. They may struggle to complete assignments, fail classes, or lose jobs. And being in the right place at the right time can feel monumental to them: They forget appointments, double book themselves, or sometimes sleep through important events.
It’s not just appointments. They lose their keys and valuables, forget to pay bills, and may not answer calls, texts, or emails. Their voicemail may be full and people are often frustrated with them. These are all characteristics of executive dysfunction, which together can make the routine responsibilities of life very difficult.
Treatments include stimulants, and because of their potential for abuse, these medications are more strictly regulated when it comes to prescribing. The FDA does not allow them to be phoned into a pharmacy or refills to be added to prescriptions. Patients must wait until right before they are due to run out to get the next prescription, and this can present a problem if the patient travels or takes long vacations.
And although it is not the patient’s fault that stimulants can’t be ordered with refills, this adds to the burden of treating patients who take them. It’s hard to imagine that these restrictions on stimulants and opiates (but not on benzodiazepines) do much to deter abuse or diversion.
I trained at a time when ADD and ADHD were disorders of childhood, and as an adult psychiatrist, I was not exposed to patients on these medications. Occasionally, a stimulant was prescribed in a low dose to help activate a very depressed patient, but it was thought that children outgrow issues of attention and focus, and I have never felt fully confident in the more nuanced use of these medications with adults. Most of the patients I now treat with ADD have come to me on stable doses of the medications or at least with a history that directs care.
With others, the tip-off to look for the disorder is their disorganization in the absence of a substance use or active mood disorder. Medications help, sometimes remarkably, yet patients still struggle with organization and planning, and sometimes I find myself frustrated when patients forget their appointments or the issues around prescribing stimulants become time-consuming.
David W. Goodman, MD, director of the Adult Attention Deficit Center of Maryland, Lutherville, currently treats hundreds of patients with ADD and has written and spoken extensively about treating this disorder in adults.
“There are three things that make it difficult to manage patients with ADD,” Dr. Goodman noted, referring specifically to administrative issues. “You can’t write for refills, but with e-prescribing you can write a sequence of prescriptions with ‘fill-after’ dates. Or some patients are able to get a 90-day supply from mail-order pharmacies. Still, it’s a hassle if the patient moves around, as college students often do, and there are inventory shortages when some pharmacies can’t get the medications.”
“The second issue,” he adds, “is that it’s the nature of this disorder that patients struggle with organizational issues. Yelling at someone with ADD to pay attention is like yelling at a blind person not to run into furniture when they are in a new room. They go through life with people being impatient that they can’t do the things an ordinary person can do easily.”
Finally, Dr. Goodman noted that the clinicians who treat patients with ADD may have counter-transference issues.
“You have to understand that this is a disability and be sympathetic to it. They often have comorbid disorders, including personality disorders, and this can all bleed over to cause frustrations in their care. Psychiatrists who treat patients with ADD need to know they can deal with them compassionately.”
“I am occasionally contacted by patients who already have an ADHD diagnosis and are on stimulants, and who seem like they just want to get their prescriptions filled and aren’t interested in working on their issues,” says Douglas Beech, MD, a psychiatrist in private practice in Worthington, Ohio. “The doctor in this situation can feel like they are functioning as a sort of drug dealer. There are logistical matters that are structurally inherent in trying to assist these patients, from both a regulatory perspective and from a functional perspective. Dr. Beech feels that it’s helpful to acknowledge these issues when seeing patients with ADHD, so that he is prepared when problems do arise.
“It can almost feel cruel to charge a patient for a “no-show,” when difficulty keeping appointments may be a symptom of their illness, Dr. Beech adds. But he does believe it’s important to apply any fee policy equitably to all patients. “I don’t apply the ‘missed appointment’ policy differently to a person with an ADHD diagnosis versus any other diagnosis.” Though for their first missed appointment, he does give patients a “mulligan.”
“I don’t charge, but it puts both patient and doctor on notice,” he says.
And when his patients do miss an appointment, he offers to send a reminder for the next time, which is he says is effective. “With electronic messaging, this is a quick and easy way to prevent missed appointments and the complications that arise with prescriptions and rescheduling,” says Dr. Beech.
Dr. Goodman speaks about manging a large caseload of patients, many of whom have organizational issues.
“I have a full-time office manager who handles a lot of the logistics of scheduling and prescribing. Patients are sent multiple reminders, and I charge a nominal administrative fee if prescriptions need to be sent outside of appointments. This is not to make money, but to encourage patients to consider the administrative time.”
“I charge for appointments that are not canceled 48 hours in advance, and for patients who have missed appointments, a credit card is kept on file,” he says.
In a practice similar to Dr. Beech, Dr. Goodman notes that he shows some flexibility for new patients when they miss an appointment the first time. “By the second time, they know this is the policy. Having ADHD can be financially costly.”
He notes that about 10% of his patients, roughly one a day, cancel late or don’t show up for scheduled appointments: “We keep a waitlist, and if someone cancels before the appointment, we can often fill the time with another patient in need on our waitlist.”
Dr. Goodman noted repeatedly that the clinician needs to be able to empathize with the patient’s condition and how they suffer. “This is not something people choose to have. The trap is that people think that if you’re successful you can’t have ADHD, and that’s not true. Often people with this condition work harder, are brighter, and find ways to compensate.”
If a practice is set up to accommodate the needs of patients with attention and organizational issues, treating them can be very gratifying. In settings without administrative support, the psychiatrist needs to stay cognizant of this invisible disability and the frustration that may come with this disorder, not just for the patient, but also for the family, friends, and employers, and even for the psychiatrist.
Dr. Dinah Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, Baltimore. Dr. Miller has no conflicts of interest.
A version of this article first appeared on Medscape.com.
Maybe you know some of these patients: They may come late or not show up at all. They may have little to say and minimize their difficulties, often because they are ashamed of how much effort it takes to meet ordinary obligations. They may struggle to complete assignments, fail classes, or lose jobs. And being in the right place at the right time can feel monumental to them: They forget appointments, double book themselves, or sometimes sleep through important events.
It’s not just appointments. They lose their keys and valuables, forget to pay bills, and may not answer calls, texts, or emails. Their voicemail may be full and people are often frustrated with them. These are all characteristics of executive dysfunction, which together can make the routine responsibilities of life very difficult.
Treatments include stimulants, and because of their potential for abuse, these medications are more strictly regulated when it comes to prescribing. The FDA does not allow them to be phoned into a pharmacy or refills to be added to prescriptions. Patients must wait until right before they are due to run out to get the next prescription, and this can present a problem if the patient travels or takes long vacations.
And although it is not the patient’s fault that stimulants can’t be ordered with refills, this adds to the burden of treating patients who take them. It’s hard to imagine that these restrictions on stimulants and opiates (but not on benzodiazepines) do much to deter abuse or diversion.
I trained at a time when ADD and ADHD were disorders of childhood, and as an adult psychiatrist, I was not exposed to patients on these medications. Occasionally, a stimulant was prescribed in a low dose to help activate a very depressed patient, but it was thought that children outgrow issues of attention and focus, and I have never felt fully confident in the more nuanced use of these medications with adults. Most of the patients I now treat with ADD have come to me on stable doses of the medications or at least with a history that directs care.
With others, the tip-off to look for the disorder is their disorganization in the absence of a substance use or active mood disorder. Medications help, sometimes remarkably, yet patients still struggle with organization and planning, and sometimes I find myself frustrated when patients forget their appointments or the issues around prescribing stimulants become time-consuming.
David W. Goodman, MD, director of the Adult Attention Deficit Center of Maryland, Lutherville, currently treats hundreds of patients with ADD and has written and spoken extensively about treating this disorder in adults.
“There are three things that make it difficult to manage patients with ADD,” Dr. Goodman noted, referring specifically to administrative issues. “You can’t write for refills, but with e-prescribing you can write a sequence of prescriptions with ‘fill-after’ dates. Or some patients are able to get a 90-day supply from mail-order pharmacies. Still, it’s a hassle if the patient moves around, as college students often do, and there are inventory shortages when some pharmacies can’t get the medications.”
“The second issue,” he adds, “is that it’s the nature of this disorder that patients struggle with organizational issues. Yelling at someone with ADD to pay attention is like yelling at a blind person not to run into furniture when they are in a new room. They go through life with people being impatient that they can’t do the things an ordinary person can do easily.”
Finally, Dr. Goodman noted that the clinicians who treat patients with ADD may have counter-transference issues.
“You have to understand that this is a disability and be sympathetic to it. They often have comorbid disorders, including personality disorders, and this can all bleed over to cause frustrations in their care. Psychiatrists who treat patients with ADD need to know they can deal with them compassionately.”
“I am occasionally contacted by patients who already have an ADHD diagnosis and are on stimulants, and who seem like they just want to get their prescriptions filled and aren’t interested in working on their issues,” says Douglas Beech, MD, a psychiatrist in private practice in Worthington, Ohio. “The doctor in this situation can feel like they are functioning as a sort of drug dealer. There are logistical matters that are structurally inherent in trying to assist these patients, from both a regulatory perspective and from a functional perspective. Dr. Beech feels that it’s helpful to acknowledge these issues when seeing patients with ADHD, so that he is prepared when problems do arise.
“It can almost feel cruel to charge a patient for a “no-show,” when difficulty keeping appointments may be a symptom of their illness, Dr. Beech adds. But he does believe it’s important to apply any fee policy equitably to all patients. “I don’t apply the ‘missed appointment’ policy differently to a person with an ADHD diagnosis versus any other diagnosis.” Though for their first missed appointment, he does give patients a “mulligan.”
“I don’t charge, but it puts both patient and doctor on notice,” he says.
And when his patients do miss an appointment, he offers to send a reminder for the next time, which is he says is effective. “With electronic messaging, this is a quick and easy way to prevent missed appointments and the complications that arise with prescriptions and rescheduling,” says Dr. Beech.
Dr. Goodman speaks about manging a large caseload of patients, many of whom have organizational issues.
“I have a full-time office manager who handles a lot of the logistics of scheduling and prescribing. Patients are sent multiple reminders, and I charge a nominal administrative fee if prescriptions need to be sent outside of appointments. This is not to make money, but to encourage patients to consider the administrative time.”
“I charge for appointments that are not canceled 48 hours in advance, and for patients who have missed appointments, a credit card is kept on file,” he says.
In a practice similar to Dr. Beech, Dr. Goodman notes that he shows some flexibility for new patients when they miss an appointment the first time. “By the second time, they know this is the policy. Having ADHD can be financially costly.”
He notes that about 10% of his patients, roughly one a day, cancel late or don’t show up for scheduled appointments: “We keep a waitlist, and if someone cancels before the appointment, we can often fill the time with another patient in need on our waitlist.”
Dr. Goodman noted repeatedly that the clinician needs to be able to empathize with the patient’s condition and how they suffer. “This is not something people choose to have. The trap is that people think that if you’re successful you can’t have ADHD, and that’s not true. Often people with this condition work harder, are brighter, and find ways to compensate.”
If a practice is set up to accommodate the needs of patients with attention and organizational issues, treating them can be very gratifying. In settings without administrative support, the psychiatrist needs to stay cognizant of this invisible disability and the frustration that may come with this disorder, not just for the patient, but also for the family, friends, and employers, and even for the psychiatrist.
Dr. Dinah Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, Baltimore. Dr. Miller has no conflicts of interest.
A version of this article first appeared on Medscape.com.
Maybe you know some of these patients: They may come late or not show up at all. They may have little to say and minimize their difficulties, often because they are ashamed of how much effort it takes to meet ordinary obligations. They may struggle to complete assignments, fail classes, or lose jobs. And being in the right place at the right time can feel monumental to them: They forget appointments, double book themselves, or sometimes sleep through important events.
It’s not just appointments. They lose their keys and valuables, forget to pay bills, and may not answer calls, texts, or emails. Their voicemail may be full and people are often frustrated with them. These are all characteristics of executive dysfunction, which together can make the routine responsibilities of life very difficult.
Treatments include stimulants, and because of their potential for abuse, these medications are more strictly regulated when it comes to prescribing. The FDA does not allow them to be phoned into a pharmacy or refills to be added to prescriptions. Patients must wait until right before they are due to run out to get the next prescription, and this can present a problem if the patient travels or takes long vacations.
And although it is not the patient’s fault that stimulants can’t be ordered with refills, this adds to the burden of treating patients who take them. It’s hard to imagine that these restrictions on stimulants and opiates (but not on benzodiazepines) do much to deter abuse or diversion.
I trained at a time when ADD and ADHD were disorders of childhood, and as an adult psychiatrist, I was not exposed to patients on these medications. Occasionally, a stimulant was prescribed in a low dose to help activate a very depressed patient, but it was thought that children outgrow issues of attention and focus, and I have never felt fully confident in the more nuanced use of these medications with adults. Most of the patients I now treat with ADD have come to me on stable doses of the medications or at least with a history that directs care.
With others, the tip-off to look for the disorder is their disorganization in the absence of a substance use or active mood disorder. Medications help, sometimes remarkably, yet patients still struggle with organization and planning, and sometimes I find myself frustrated when patients forget their appointments or the issues around prescribing stimulants become time-consuming.
David W. Goodman, MD, director of the Adult Attention Deficit Center of Maryland, Lutherville, currently treats hundreds of patients with ADD and has written and spoken extensively about treating this disorder in adults.
“There are three things that make it difficult to manage patients with ADD,” Dr. Goodman noted, referring specifically to administrative issues. “You can’t write for refills, but with e-prescribing you can write a sequence of prescriptions with ‘fill-after’ dates. Or some patients are able to get a 90-day supply from mail-order pharmacies. Still, it’s a hassle if the patient moves around, as college students often do, and there are inventory shortages when some pharmacies can’t get the medications.”
“The second issue,” he adds, “is that it’s the nature of this disorder that patients struggle with organizational issues. Yelling at someone with ADD to pay attention is like yelling at a blind person not to run into furniture when they are in a new room. They go through life with people being impatient that they can’t do the things an ordinary person can do easily.”
Finally, Dr. Goodman noted that the clinicians who treat patients with ADD may have counter-transference issues.
“You have to understand that this is a disability and be sympathetic to it. They often have comorbid disorders, including personality disorders, and this can all bleed over to cause frustrations in their care. Psychiatrists who treat patients with ADD need to know they can deal with them compassionately.”
“I am occasionally contacted by patients who already have an ADHD diagnosis and are on stimulants, and who seem like they just want to get their prescriptions filled and aren’t interested in working on their issues,” says Douglas Beech, MD, a psychiatrist in private practice in Worthington, Ohio. “The doctor in this situation can feel like they are functioning as a sort of drug dealer. There are logistical matters that are structurally inherent in trying to assist these patients, from both a regulatory perspective and from a functional perspective. Dr. Beech feels that it’s helpful to acknowledge these issues when seeing patients with ADHD, so that he is prepared when problems do arise.
“It can almost feel cruel to charge a patient for a “no-show,” when difficulty keeping appointments may be a symptom of their illness, Dr. Beech adds. But he does believe it’s important to apply any fee policy equitably to all patients. “I don’t apply the ‘missed appointment’ policy differently to a person with an ADHD diagnosis versus any other diagnosis.” Though for their first missed appointment, he does give patients a “mulligan.”
“I don’t charge, but it puts both patient and doctor on notice,” he says.
And when his patients do miss an appointment, he offers to send a reminder for the next time, which is he says is effective. “With electronic messaging, this is a quick and easy way to prevent missed appointments and the complications that arise with prescriptions and rescheduling,” says Dr. Beech.
Dr. Goodman speaks about manging a large caseload of patients, many of whom have organizational issues.
“I have a full-time office manager who handles a lot of the logistics of scheduling and prescribing. Patients are sent multiple reminders, and I charge a nominal administrative fee if prescriptions need to be sent outside of appointments. This is not to make money, but to encourage patients to consider the administrative time.”
“I charge for appointments that are not canceled 48 hours in advance, and for patients who have missed appointments, a credit card is kept on file,” he says.
In a practice similar to Dr. Beech, Dr. Goodman notes that he shows some flexibility for new patients when they miss an appointment the first time. “By the second time, they know this is the policy. Having ADHD can be financially costly.”
He notes that about 10% of his patients, roughly one a day, cancel late or don’t show up for scheduled appointments: “We keep a waitlist, and if someone cancels before the appointment, we can often fill the time with another patient in need on our waitlist.”
Dr. Goodman noted repeatedly that the clinician needs to be able to empathize with the patient’s condition and how they suffer. “This is not something people choose to have. The trap is that people think that if you’re successful you can’t have ADHD, and that’s not true. Often people with this condition work harder, are brighter, and find ways to compensate.”
If a practice is set up to accommodate the needs of patients with attention and organizational issues, treating them can be very gratifying. In settings without administrative support, the psychiatrist needs to stay cognizant of this invisible disability and the frustration that may come with this disorder, not just for the patient, but also for the family, friends, and employers, and even for the psychiatrist.
Dr. Dinah Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, Baltimore. Dr. Miller has no conflicts of interest.
A version of this article first appeared on Medscape.com.
Student loan forgiveness plans exclude physicians
In the run up to the midterm elections in November, President Biden has warmed to student loan forgiveness. However, before even being proposed,
What was the plan?
During the 2020 election, student loan forgiveness was a hot topic as the COVID epidemic raged. The CARES Act has placed all federal student loans in forbearance, with no payments made and the interest rate set to 0% to prevent further accrual. While this was tremendously useful to 45 million borrowers around the country (including the author), nothing material was done to deal with the loans.
The Biden Administration’s approach at that time was multi-tiered and chaotic. Plans were put forward that either expanded Public Service Loan Forgiveness (PSLF) or capped it. Plans were put forward that either extended free undergraduate or severely limited it through Pell Grants. Unfortunately, that duality continues today, with current plans not having a clear goal or a target group of beneficiaries.
Necessary CARES Act extensions
The Biden Administration has attempted repeatedly to turn the student loan apparatus back on, restarting payments en masse. However, each time, they are beset by challenges, ranging from repeat COVID spikes to servicer withdrawals or macroeconomic indicators of a recession.
At each step, the administration has had little choice but to extend the CARES Act forbearance, lest they suffer retribution for hastily resuming payments for 45 million borrowers without the apparatus to do so. Two years ago, the major federal servicers laid off hundreds, if not thousands, of staffers responsible for payment processing, accounting, customer care, and taxation. Hiring, training, and staffing these positions is nontrivial.
The administration has been out of step with servicers such that three of the largest have chosen not to renew their contracts: Navient, MyFedLoan, and Granite State Management and Resources. This has left 15 million borrowers in the lurch, not knowing who their servicer is – and, even worse, losing track of qualifying payments toward programs like PSLF.
Avenues of forgiveness
There are two major pathways to forgiveness. It is widely believed that the executive branch has the authority to broadly forgive student loans under executive order and managed through the U.S. Department of Education.
The alternative is through congressional action, voting on forgiveness as an economic stimulus plan. There is little appetite in Congress for forgiveness, and prominent congresspeople like Senator Warren and Senator Schumer have both pushed the executive branch for forgiveness in recognition of this.
What has been proposed?
First, it’s important to state that as headline-grabbing as it is to see that $50,000 of forgiveness has been proposed, the reality is that President Biden has repeatedly stated that he will not be in favor of that level of forgiveness. Instead, the number most commonly being discussed is $10,000. This would represent an unprecedented amount of support, alleviating 35% of borrowers of all student debt.
The impact of proposed forgiveness plans for physicians
For the medical community, sadly, this doesn’t represent a significant amount of forgiveness. At graduation, the average MD has $203,000 in debt, and the average DO has $258,000 in debt. These numbers grow during residency for years before any meaningful payments are made.
Further weakening forgiveness plans for physicians has been two caps proposed by the administration in recent days. The first is an income cap of $125,000. While this would maintain forgiveness for nearly all residents and fellows, this would exclude nearly every practicing physician. The alternative to an income cap is specific exclusion of certain careers seen to be high-earning: doctors and lawyers.
The bottom line
Physicians are unlikely to be included in any forgiveness plans being proposed recently by the Biden Administration. If they are considered, it will be for exclusion from any forgiveness offered.
For physicians no longer eligible for PSLF, this exclusion needs to be considered in managing the student loan debt associated with becoming a doctor.
Dr. Palmer is a part-time instructor, department of pediatrics, Harvard Medical School, Boston, and staff physician, department of medical critical care, Boston Children’s Hospital. He disclosed that he serves as director for Panacea Financial.
A version of this article first appeared on Medscape.com.
In the run up to the midterm elections in November, President Biden has warmed to student loan forgiveness. However, before even being proposed,
What was the plan?
During the 2020 election, student loan forgiveness was a hot topic as the COVID epidemic raged. The CARES Act has placed all federal student loans in forbearance, with no payments made and the interest rate set to 0% to prevent further accrual. While this was tremendously useful to 45 million borrowers around the country (including the author), nothing material was done to deal with the loans.
The Biden Administration’s approach at that time was multi-tiered and chaotic. Plans were put forward that either expanded Public Service Loan Forgiveness (PSLF) or capped it. Plans were put forward that either extended free undergraduate or severely limited it through Pell Grants. Unfortunately, that duality continues today, with current plans not having a clear goal or a target group of beneficiaries.
Necessary CARES Act extensions
The Biden Administration has attempted repeatedly to turn the student loan apparatus back on, restarting payments en masse. However, each time, they are beset by challenges, ranging from repeat COVID spikes to servicer withdrawals or macroeconomic indicators of a recession.
At each step, the administration has had little choice but to extend the CARES Act forbearance, lest they suffer retribution for hastily resuming payments for 45 million borrowers without the apparatus to do so. Two years ago, the major federal servicers laid off hundreds, if not thousands, of staffers responsible for payment processing, accounting, customer care, and taxation. Hiring, training, and staffing these positions is nontrivial.
The administration has been out of step with servicers such that three of the largest have chosen not to renew their contracts: Navient, MyFedLoan, and Granite State Management and Resources. This has left 15 million borrowers in the lurch, not knowing who their servicer is – and, even worse, losing track of qualifying payments toward programs like PSLF.
Avenues of forgiveness
There are two major pathways to forgiveness. It is widely believed that the executive branch has the authority to broadly forgive student loans under executive order and managed through the U.S. Department of Education.
The alternative is through congressional action, voting on forgiveness as an economic stimulus plan. There is little appetite in Congress for forgiveness, and prominent congresspeople like Senator Warren and Senator Schumer have both pushed the executive branch for forgiveness in recognition of this.
What has been proposed?
First, it’s important to state that as headline-grabbing as it is to see that $50,000 of forgiveness has been proposed, the reality is that President Biden has repeatedly stated that he will not be in favor of that level of forgiveness. Instead, the number most commonly being discussed is $10,000. This would represent an unprecedented amount of support, alleviating 35% of borrowers of all student debt.
The impact of proposed forgiveness plans for physicians
For the medical community, sadly, this doesn’t represent a significant amount of forgiveness. At graduation, the average MD has $203,000 in debt, and the average DO has $258,000 in debt. These numbers grow during residency for years before any meaningful payments are made.
Further weakening forgiveness plans for physicians has been two caps proposed by the administration in recent days. The first is an income cap of $125,000. While this would maintain forgiveness for nearly all residents and fellows, this would exclude nearly every practicing physician. The alternative to an income cap is specific exclusion of certain careers seen to be high-earning: doctors and lawyers.
The bottom line
Physicians are unlikely to be included in any forgiveness plans being proposed recently by the Biden Administration. If they are considered, it will be for exclusion from any forgiveness offered.
For physicians no longer eligible for PSLF, this exclusion needs to be considered in managing the student loan debt associated with becoming a doctor.
Dr. Palmer is a part-time instructor, department of pediatrics, Harvard Medical School, Boston, and staff physician, department of medical critical care, Boston Children’s Hospital. He disclosed that he serves as director for Panacea Financial.
A version of this article first appeared on Medscape.com.
In the run up to the midterm elections in November, President Biden has warmed to student loan forgiveness. However, before even being proposed,
What was the plan?
During the 2020 election, student loan forgiveness was a hot topic as the COVID epidemic raged. The CARES Act has placed all federal student loans in forbearance, with no payments made and the interest rate set to 0% to prevent further accrual. While this was tremendously useful to 45 million borrowers around the country (including the author), nothing material was done to deal with the loans.
The Biden Administration’s approach at that time was multi-tiered and chaotic. Plans were put forward that either expanded Public Service Loan Forgiveness (PSLF) or capped it. Plans were put forward that either extended free undergraduate or severely limited it through Pell Grants. Unfortunately, that duality continues today, with current plans not having a clear goal or a target group of beneficiaries.
Necessary CARES Act extensions
The Biden Administration has attempted repeatedly to turn the student loan apparatus back on, restarting payments en masse. However, each time, they are beset by challenges, ranging from repeat COVID spikes to servicer withdrawals or macroeconomic indicators of a recession.
At each step, the administration has had little choice but to extend the CARES Act forbearance, lest they suffer retribution for hastily resuming payments for 45 million borrowers without the apparatus to do so. Two years ago, the major federal servicers laid off hundreds, if not thousands, of staffers responsible for payment processing, accounting, customer care, and taxation. Hiring, training, and staffing these positions is nontrivial.
The administration has been out of step with servicers such that three of the largest have chosen not to renew their contracts: Navient, MyFedLoan, and Granite State Management and Resources. This has left 15 million borrowers in the lurch, not knowing who their servicer is – and, even worse, losing track of qualifying payments toward programs like PSLF.
Avenues of forgiveness
There are two major pathways to forgiveness. It is widely believed that the executive branch has the authority to broadly forgive student loans under executive order and managed through the U.S. Department of Education.
The alternative is through congressional action, voting on forgiveness as an economic stimulus plan. There is little appetite in Congress for forgiveness, and prominent congresspeople like Senator Warren and Senator Schumer have both pushed the executive branch for forgiveness in recognition of this.
What has been proposed?
First, it’s important to state that as headline-grabbing as it is to see that $50,000 of forgiveness has been proposed, the reality is that President Biden has repeatedly stated that he will not be in favor of that level of forgiveness. Instead, the number most commonly being discussed is $10,000. This would represent an unprecedented amount of support, alleviating 35% of borrowers of all student debt.
The impact of proposed forgiveness plans for physicians
For the medical community, sadly, this doesn’t represent a significant amount of forgiveness. At graduation, the average MD has $203,000 in debt, and the average DO has $258,000 in debt. These numbers grow during residency for years before any meaningful payments are made.
Further weakening forgiveness plans for physicians has been two caps proposed by the administration in recent days. The first is an income cap of $125,000. While this would maintain forgiveness for nearly all residents and fellows, this would exclude nearly every practicing physician. The alternative to an income cap is specific exclusion of certain careers seen to be high-earning: doctors and lawyers.
The bottom line
Physicians are unlikely to be included in any forgiveness plans being proposed recently by the Biden Administration. If they are considered, it will be for exclusion from any forgiveness offered.
For physicians no longer eligible for PSLF, this exclusion needs to be considered in managing the student loan debt associated with becoming a doctor.
Dr. Palmer is a part-time instructor, department of pediatrics, Harvard Medical School, Boston, and staff physician, department of medical critical care, Boston Children’s Hospital. He disclosed that he serves as director for Panacea Financial.
A version of this article first appeared on Medscape.com.
More practice merger options
The continuing than larger ones. While there are some smaller offices offering unique services that may be able to remain small, most small general practices will be forced to at least consider a larger alternative. Recently, I discussed one option – merging individual practices into a larger one – but others are available.
One alternate strategy is to form a cooperative group. If you look around your area of practice, you will likely find other small practices in similar situations that might be willing to collaborate with you for the purpose of pooling your billing and purchasing resources. This allows each participant to maintain independence, yet share office overhead expenses and employee salaries for mutual benefit. If that arrangement works, and remains satisfactory for all participants, you can consider expanding your sharing of expenditures, such as collective purchasing of supplies and equipment, and centralizing appointment scheduling. Such an arrangement might be particularly attractive to physicians in later stages of their careers who need to alleviate financial burdens but don’t wish to close up shop just yet.
After more time has passed, if everyone remains happy with the arrangement, an outright merger can be considered, allowing the group to negotiate higher insurance remunerations and even lower overhead costs. Obviously, projects of this size and scope require careful planning and implementation, and should not be undertaken without the help of competent legal counsel and an experienced business consultant.
Another option is to join an independent practice association (IPA), if one is operating in your area. IPAs are physician-directed legal entities, formed to provide the same advantages enjoyed by large group practices while allowing individual members to remain independent. IPAs have greater purchasing power, allowing members to cut costs on medical and office supplies. They can also negotiate more favorable contracts with insurance companies and other payers.
Before joining such an organization, examine its legal status carefully. Some IPAs have been charged with antitrust violations because their member practices are, in reality, competitors. Make certain that any IPA you consider joining abides by antitrust and price fixing laws. Look carefully at its financial solvency as well, as IPAs have also been known to fail, leaving former members to pick up the tab.
An alternative to the IPA is the accountable care organization (ACO), a relatively new entity created as part of the Affordable Care Act. Like an IPA, an ACO’s basic purpose is to limit unnecessary spending; but ACOs are typically limited to Medicare and Medicaid recipients, and involve a larger network of doctors and hospitals sharing financial and medical responsibility for patient care. Criteria for limits on spending are established by the Centers for Medicare & Medicaid Services (CMS).
ACOs offer financial incentives to cooperate, and to save money by avoiding unnecessary tests and procedures. A key component is the sharing of information. Providers who save money while also meeting quality targets are theoretically entitled to a portion of the savings. According to federal data, ACOs saved Medicare $4.1 billion in 2020). As of January 2022, 483 ACOs were participating in the Medicare Shared Savings Program. A similar entity designed for private-sector patients is the clinically integrated network (CIN), created by the Federal Trade Commission to serve the commercial or self-insured market, while ACOs treat Medicare and Medicaid patients. Like ACOs, the idea is to work together to improve care and reduce costs by sharing records and tracking data.
When joining any group, read the agreement carefully for any clauses that might infringe on your clinical judgment. In particular, be sure that there are no restrictions on patient treatment or physician referral options for your patients. You should also negotiate an escape clause, allowing you to opt out if you become unhappy with the arrangement.
Clearly, the price of remaining autonomous is significant, and many private practitioners are unwilling to pay it. In 2019, the American Medical Association reported that for the first time, there were fewer physician owners (45.9%) than employees (47.4%).
But as I have written many times, those of us who remain committed to independence will find ways to preserve it. In medicine, as in life, those most responsive to change will survive and flourish.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
The continuing than larger ones. While there are some smaller offices offering unique services that may be able to remain small, most small general practices will be forced to at least consider a larger alternative. Recently, I discussed one option – merging individual practices into a larger one – but others are available.
One alternate strategy is to form a cooperative group. If you look around your area of practice, you will likely find other small practices in similar situations that might be willing to collaborate with you for the purpose of pooling your billing and purchasing resources. This allows each participant to maintain independence, yet share office overhead expenses and employee salaries for mutual benefit. If that arrangement works, and remains satisfactory for all participants, you can consider expanding your sharing of expenditures, such as collective purchasing of supplies and equipment, and centralizing appointment scheduling. Such an arrangement might be particularly attractive to physicians in later stages of their careers who need to alleviate financial burdens but don’t wish to close up shop just yet.
After more time has passed, if everyone remains happy with the arrangement, an outright merger can be considered, allowing the group to negotiate higher insurance remunerations and even lower overhead costs. Obviously, projects of this size and scope require careful planning and implementation, and should not be undertaken without the help of competent legal counsel and an experienced business consultant.
Another option is to join an independent practice association (IPA), if one is operating in your area. IPAs are physician-directed legal entities, formed to provide the same advantages enjoyed by large group practices while allowing individual members to remain independent. IPAs have greater purchasing power, allowing members to cut costs on medical and office supplies. They can also negotiate more favorable contracts with insurance companies and other payers.
Before joining such an organization, examine its legal status carefully. Some IPAs have been charged with antitrust violations because their member practices are, in reality, competitors. Make certain that any IPA you consider joining abides by antitrust and price fixing laws. Look carefully at its financial solvency as well, as IPAs have also been known to fail, leaving former members to pick up the tab.
An alternative to the IPA is the accountable care organization (ACO), a relatively new entity created as part of the Affordable Care Act. Like an IPA, an ACO’s basic purpose is to limit unnecessary spending; but ACOs are typically limited to Medicare and Medicaid recipients, and involve a larger network of doctors and hospitals sharing financial and medical responsibility for patient care. Criteria for limits on spending are established by the Centers for Medicare & Medicaid Services (CMS).
ACOs offer financial incentives to cooperate, and to save money by avoiding unnecessary tests and procedures. A key component is the sharing of information. Providers who save money while also meeting quality targets are theoretically entitled to a portion of the savings. According to federal data, ACOs saved Medicare $4.1 billion in 2020). As of January 2022, 483 ACOs were participating in the Medicare Shared Savings Program. A similar entity designed for private-sector patients is the clinically integrated network (CIN), created by the Federal Trade Commission to serve the commercial or self-insured market, while ACOs treat Medicare and Medicaid patients. Like ACOs, the idea is to work together to improve care and reduce costs by sharing records and tracking data.
When joining any group, read the agreement carefully for any clauses that might infringe on your clinical judgment. In particular, be sure that there are no restrictions on patient treatment or physician referral options for your patients. You should also negotiate an escape clause, allowing you to opt out if you become unhappy with the arrangement.
Clearly, the price of remaining autonomous is significant, and many private practitioners are unwilling to pay it. In 2019, the American Medical Association reported that for the first time, there were fewer physician owners (45.9%) than employees (47.4%).
But as I have written many times, those of us who remain committed to independence will find ways to preserve it. In medicine, as in life, those most responsive to change will survive and flourish.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
The continuing than larger ones. While there are some smaller offices offering unique services that may be able to remain small, most small general practices will be forced to at least consider a larger alternative. Recently, I discussed one option – merging individual practices into a larger one – but others are available.
One alternate strategy is to form a cooperative group. If you look around your area of practice, you will likely find other small practices in similar situations that might be willing to collaborate with you for the purpose of pooling your billing and purchasing resources. This allows each participant to maintain independence, yet share office overhead expenses and employee salaries for mutual benefit. If that arrangement works, and remains satisfactory for all participants, you can consider expanding your sharing of expenditures, such as collective purchasing of supplies and equipment, and centralizing appointment scheduling. Such an arrangement might be particularly attractive to physicians in later stages of their careers who need to alleviate financial burdens but don’t wish to close up shop just yet.
After more time has passed, if everyone remains happy with the arrangement, an outright merger can be considered, allowing the group to negotiate higher insurance remunerations and even lower overhead costs. Obviously, projects of this size and scope require careful planning and implementation, and should not be undertaken without the help of competent legal counsel and an experienced business consultant.
Another option is to join an independent practice association (IPA), if one is operating in your area. IPAs are physician-directed legal entities, formed to provide the same advantages enjoyed by large group practices while allowing individual members to remain independent. IPAs have greater purchasing power, allowing members to cut costs on medical and office supplies. They can also negotiate more favorable contracts with insurance companies and other payers.
Before joining such an organization, examine its legal status carefully. Some IPAs have been charged with antitrust violations because their member practices are, in reality, competitors. Make certain that any IPA you consider joining abides by antitrust and price fixing laws. Look carefully at its financial solvency as well, as IPAs have also been known to fail, leaving former members to pick up the tab.
An alternative to the IPA is the accountable care organization (ACO), a relatively new entity created as part of the Affordable Care Act. Like an IPA, an ACO’s basic purpose is to limit unnecessary spending; but ACOs are typically limited to Medicare and Medicaid recipients, and involve a larger network of doctors and hospitals sharing financial and medical responsibility for patient care. Criteria for limits on spending are established by the Centers for Medicare & Medicaid Services (CMS).
ACOs offer financial incentives to cooperate, and to save money by avoiding unnecessary tests and procedures. A key component is the sharing of information. Providers who save money while also meeting quality targets are theoretically entitled to a portion of the savings. According to federal data, ACOs saved Medicare $4.1 billion in 2020). As of January 2022, 483 ACOs were participating in the Medicare Shared Savings Program. A similar entity designed for private-sector patients is the clinically integrated network (CIN), created by the Federal Trade Commission to serve the commercial or self-insured market, while ACOs treat Medicare and Medicaid patients. Like ACOs, the idea is to work together to improve care and reduce costs by sharing records and tracking data.
When joining any group, read the agreement carefully for any clauses that might infringe on your clinical judgment. In particular, be sure that there are no restrictions on patient treatment or physician referral options for your patients. You should also negotiate an escape clause, allowing you to opt out if you become unhappy with the arrangement.
Clearly, the price of remaining autonomous is significant, and many private practitioners are unwilling to pay it. In 2019, the American Medical Association reported that for the first time, there were fewer physician owners (45.9%) than employees (47.4%).
But as I have written many times, those of us who remain committed to independence will find ways to preserve it. In medicine, as in life, those most responsive to change will survive and flourish.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
Measles outbreaks: Protecting your patients during international travel
The U.S. immunization program is one of the best public health success stories. Physicians who provide care for children are familiar with the routine childhood immunization schedule and administer a measles-containing vaccine at age-appropriate times. Thanks to its rigorous implementation and acceptance, endemic measles (absence of continuous virus transmission for > 1 year) was eliminated in the U.S. in 2000. Loss of this status was in jeopardy in 2019 when 22 measles outbreaks occurred in 17 states (7 were multistate outbreaks). That year, 1,163 cases were reported.1 Most cases occurred in unvaccinated persons (89%) and 81 cases were imported of which 54 were in U.S. citizens returning from international travel. All outbreaks were linked to travel. Fortunately, the outbreaks were controlled prior to the elimination deadline, or the United States would have lost its measles elimination status. Restrictions on travel because of COVID-19 have relaxed significantly since the introduction of COVID-19 vaccines, resulting in increased regional and international travel. Multiple countries, including the United States noted a decline in routine immunizations rates during the last 2 years. Recent U.S. data for the 2020-2021 school year indicates that MMR immunizations rates (two doses) for kindergarteners declined to 93.9% (range 78.9% to > 98.9%), while the overall percentage of those students with an exemption remained low at 2.2%. Vaccine coverage greater than 95% was reported in only 16 states. Coverage of less than 90% was reported in seven states and the District of Columbia (Georgia, Idaho, Kentucky, Maryland, Minnesota, Ohio, and Wisconsin).2 Vaccine coverage should be 95% or higher to maintain herd immunity and control outbreaks.
Why is measles prevention so important? Many physicians practicing in the United States today have never seen a case or know its potential complications. I saw my first case as a resident in an immigrant child. It took our training director to point out the subtle signs and symptoms. It was the first time I saw Kolpik spots. Measles is transmitted person to person via large respiratory droplets and less often by airborne spread. It is highly contagious for susceptible individuals with an attack rate of 90%. In this case, a medical student on the team developed symptoms about 10 days later. Six years would pass before I diagnosed my next case of measles. An HIV patient acquired it after close contact with someone who was in the prodromal stage. He presented with the 3 C’s: Cough, coryza, and conjunctivitis, in addition to fever and an erythematous rash. He did not recover from complications of the disease.
Prior to the routine administration of a measles vaccine, 3-4 million cases with almost 500 deaths occurred annually in the United States. Worldwide, 35 million cases and more than 6 million deaths occurred each year. Here, most patients recover completely; however, complications including otitis media, pneumonia, croup, and encephalitis can develop. Complications commonly occur in immunocompromised individuals and young children. Groups with the highest fatality rates include children aged less than 5 years, immunocompromised persons, and pregnant women. Worldwide, fatality rates are dependent on the patients underlying nutritional and health status in addition to the quality of health care available.3
Measles vaccine was licensed in 1963 and cases began to decline (Figure 1). There was a resurgence in 1989 but it was not limited to the United States. The cause of the U.S. resurgence was multifactorial: Widespread viral transmission among unvaccinated preschool-age children residing in inner cities, outbreaks in vaccinated school-age children, outbreaks in students and personnel on college campuses, and primary vaccine failure (2%-5% of recipients failed to have an adequate response). In 1989, to help prevent future outbreaks, the United States recommended a two-dose schedule for measles and in 1993, the Vaccines for Children Program, a federally funded program, was established to improve access to vaccines for all children.
What is going on internationally?
Figure 2 lists the top 10 countries with current measles outbreaks.
Most countries on the list may not be typical travel destinations for tourists; however, they are common destinations for individuals visiting friends and relatives after immigrating to the United States. In contrast to the United States, most countries with limited resources and infrastructure have mass-vaccination campaigns to ensure vaccine administration to large segments of the population. They too have been affected by the COVID-19 pandemic. By report, at least 41 countries delayed implementation of their measles campaign in 2020 and 2021, thus, leading to the potential for even larger outbreaks.4
Progress toward the global elimination of measles is evidenced by the following: All 194 countries now include one dose of measles in their routine schedules; between 2000 and 2019 coverage of one dose of measles increased from 72% to 85% and countries with more than 90% coverage increased from 45% to 63%. Finally, the number of countries offering two doses of measles increased from 50% to 91% and vaccine coverage increased from 18% to 71% over the same time period.3
What can you do for your patients and their parents before they travel abroad?
- Inform all staff that the MMR vaccine can be administered to children as young as 6 months and at times other than those listed on the routine immunization schedule. This will help avoid parents seeking vaccine being denied an appointment.
- Children 6-11 months need 1 dose of MMR. Two additional doses will still need to be administered at the routine time.
- Children 12 months or older need 2 doses of MMR at least 4 weeks apart.
- If yellow fever vaccine is needed, coordinate administration with a travel medicine clinic since both are live vaccines and must be given on the same day.
- Any person born after 1956 should have 2 doses of MMR at least 4 weeks apart if they have no evidence of immunity.
- Encourage parents to always inform you and your staff of any international travel plans.
Moving forward, remember this increased global activity and the presence of inadequately vaccinated individuals/communities keeps the United States at continued risk for measles outbreaks. The source of the next outbreak may only be one plane ride away.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
This article was updated 6/29/22.
References
1. Patel M et al. MMWR. 2019 Oct 11; 68(40):893-6.
2. Seither R et al. MMWR. 2022 Apr 22;71(16):561-8.
3. Gastañaduy PA et al. J Infect Dis. 2021 Sep 30;224(12 Suppl 2):S420-8. doi: 10.1093/infdis/jiaa793.
4. Centers for Disease Control and Prevention. Measles (Rubeola). http://www.CDC.gov/Measles.
The U.S. immunization program is one of the best public health success stories. Physicians who provide care for children are familiar with the routine childhood immunization schedule and administer a measles-containing vaccine at age-appropriate times. Thanks to its rigorous implementation and acceptance, endemic measles (absence of continuous virus transmission for > 1 year) was eliminated in the U.S. in 2000. Loss of this status was in jeopardy in 2019 when 22 measles outbreaks occurred in 17 states (7 were multistate outbreaks). That year, 1,163 cases were reported.1 Most cases occurred in unvaccinated persons (89%) and 81 cases were imported of which 54 were in U.S. citizens returning from international travel. All outbreaks were linked to travel. Fortunately, the outbreaks were controlled prior to the elimination deadline, or the United States would have lost its measles elimination status. Restrictions on travel because of COVID-19 have relaxed significantly since the introduction of COVID-19 vaccines, resulting in increased regional and international travel. Multiple countries, including the United States noted a decline in routine immunizations rates during the last 2 years. Recent U.S. data for the 2020-2021 school year indicates that MMR immunizations rates (two doses) for kindergarteners declined to 93.9% (range 78.9% to > 98.9%), while the overall percentage of those students with an exemption remained low at 2.2%. Vaccine coverage greater than 95% was reported in only 16 states. Coverage of less than 90% was reported in seven states and the District of Columbia (Georgia, Idaho, Kentucky, Maryland, Minnesota, Ohio, and Wisconsin).2 Vaccine coverage should be 95% or higher to maintain herd immunity and control outbreaks.
Why is measles prevention so important? Many physicians practicing in the United States today have never seen a case or know its potential complications. I saw my first case as a resident in an immigrant child. It took our training director to point out the subtle signs and symptoms. It was the first time I saw Kolpik spots. Measles is transmitted person to person via large respiratory droplets and less often by airborne spread. It is highly contagious for susceptible individuals with an attack rate of 90%. In this case, a medical student on the team developed symptoms about 10 days later. Six years would pass before I diagnosed my next case of measles. An HIV patient acquired it after close contact with someone who was in the prodromal stage. He presented with the 3 C’s: Cough, coryza, and conjunctivitis, in addition to fever and an erythematous rash. He did not recover from complications of the disease.
Prior to the routine administration of a measles vaccine, 3-4 million cases with almost 500 deaths occurred annually in the United States. Worldwide, 35 million cases and more than 6 million deaths occurred each year. Here, most patients recover completely; however, complications including otitis media, pneumonia, croup, and encephalitis can develop. Complications commonly occur in immunocompromised individuals and young children. Groups with the highest fatality rates include children aged less than 5 years, immunocompromised persons, and pregnant women. Worldwide, fatality rates are dependent on the patients underlying nutritional and health status in addition to the quality of health care available.3
Measles vaccine was licensed in 1963 and cases began to decline (Figure 1). There was a resurgence in 1989 but it was not limited to the United States. The cause of the U.S. resurgence was multifactorial: Widespread viral transmission among unvaccinated preschool-age children residing in inner cities, outbreaks in vaccinated school-age children, outbreaks in students and personnel on college campuses, and primary vaccine failure (2%-5% of recipients failed to have an adequate response). In 1989, to help prevent future outbreaks, the United States recommended a two-dose schedule for measles and in 1993, the Vaccines for Children Program, a federally funded program, was established to improve access to vaccines for all children.
What is going on internationally?
Figure 2 lists the top 10 countries with current measles outbreaks.
Most countries on the list may not be typical travel destinations for tourists; however, they are common destinations for individuals visiting friends and relatives after immigrating to the United States. In contrast to the United States, most countries with limited resources and infrastructure have mass-vaccination campaigns to ensure vaccine administration to large segments of the population. They too have been affected by the COVID-19 pandemic. By report, at least 41 countries delayed implementation of their measles campaign in 2020 and 2021, thus, leading to the potential for even larger outbreaks.4
Progress toward the global elimination of measles is evidenced by the following: All 194 countries now include one dose of measles in their routine schedules; between 2000 and 2019 coverage of one dose of measles increased from 72% to 85% and countries with more than 90% coverage increased from 45% to 63%. Finally, the number of countries offering two doses of measles increased from 50% to 91% and vaccine coverage increased from 18% to 71% over the same time period.3
What can you do for your patients and their parents before they travel abroad?
- Inform all staff that the MMR vaccine can be administered to children as young as 6 months and at times other than those listed on the routine immunization schedule. This will help avoid parents seeking vaccine being denied an appointment.
- Children 6-11 months need 1 dose of MMR. Two additional doses will still need to be administered at the routine time.
- Children 12 months or older need 2 doses of MMR at least 4 weeks apart.
- If yellow fever vaccine is needed, coordinate administration with a travel medicine clinic since both are live vaccines and must be given on the same day.
- Any person born after 1956 should have 2 doses of MMR at least 4 weeks apart if they have no evidence of immunity.
- Encourage parents to always inform you and your staff of any international travel plans.
Moving forward, remember this increased global activity and the presence of inadequately vaccinated individuals/communities keeps the United States at continued risk for measles outbreaks. The source of the next outbreak may only be one plane ride away.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
This article was updated 6/29/22.
References
1. Patel M et al. MMWR. 2019 Oct 11; 68(40):893-6.
2. Seither R et al. MMWR. 2022 Apr 22;71(16):561-8.
3. Gastañaduy PA et al. J Infect Dis. 2021 Sep 30;224(12 Suppl 2):S420-8. doi: 10.1093/infdis/jiaa793.
4. Centers for Disease Control and Prevention. Measles (Rubeola). http://www.CDC.gov/Measles.
The U.S. immunization program is one of the best public health success stories. Physicians who provide care for children are familiar with the routine childhood immunization schedule and administer a measles-containing vaccine at age-appropriate times. Thanks to its rigorous implementation and acceptance, endemic measles (absence of continuous virus transmission for > 1 year) was eliminated in the U.S. in 2000. Loss of this status was in jeopardy in 2019 when 22 measles outbreaks occurred in 17 states (7 were multistate outbreaks). That year, 1,163 cases were reported.1 Most cases occurred in unvaccinated persons (89%) and 81 cases were imported of which 54 were in U.S. citizens returning from international travel. All outbreaks were linked to travel. Fortunately, the outbreaks were controlled prior to the elimination deadline, or the United States would have lost its measles elimination status. Restrictions on travel because of COVID-19 have relaxed significantly since the introduction of COVID-19 vaccines, resulting in increased regional and international travel. Multiple countries, including the United States noted a decline in routine immunizations rates during the last 2 years. Recent U.S. data for the 2020-2021 school year indicates that MMR immunizations rates (two doses) for kindergarteners declined to 93.9% (range 78.9% to > 98.9%), while the overall percentage of those students with an exemption remained low at 2.2%. Vaccine coverage greater than 95% was reported in only 16 states. Coverage of less than 90% was reported in seven states and the District of Columbia (Georgia, Idaho, Kentucky, Maryland, Minnesota, Ohio, and Wisconsin).2 Vaccine coverage should be 95% or higher to maintain herd immunity and control outbreaks.
Why is measles prevention so important? Many physicians practicing in the United States today have never seen a case or know its potential complications. I saw my first case as a resident in an immigrant child. It took our training director to point out the subtle signs and symptoms. It was the first time I saw Kolpik spots. Measles is transmitted person to person via large respiratory droplets and less often by airborne spread. It is highly contagious for susceptible individuals with an attack rate of 90%. In this case, a medical student on the team developed symptoms about 10 days later. Six years would pass before I diagnosed my next case of measles. An HIV patient acquired it after close contact with someone who was in the prodromal stage. He presented with the 3 C’s: Cough, coryza, and conjunctivitis, in addition to fever and an erythematous rash. He did not recover from complications of the disease.
Prior to the routine administration of a measles vaccine, 3-4 million cases with almost 500 deaths occurred annually in the United States. Worldwide, 35 million cases and more than 6 million deaths occurred each year. Here, most patients recover completely; however, complications including otitis media, pneumonia, croup, and encephalitis can develop. Complications commonly occur in immunocompromised individuals and young children. Groups with the highest fatality rates include children aged less than 5 years, immunocompromised persons, and pregnant women. Worldwide, fatality rates are dependent on the patients underlying nutritional and health status in addition to the quality of health care available.3
Measles vaccine was licensed in 1963 and cases began to decline (Figure 1). There was a resurgence in 1989 but it was not limited to the United States. The cause of the U.S. resurgence was multifactorial: Widespread viral transmission among unvaccinated preschool-age children residing in inner cities, outbreaks in vaccinated school-age children, outbreaks in students and personnel on college campuses, and primary vaccine failure (2%-5% of recipients failed to have an adequate response). In 1989, to help prevent future outbreaks, the United States recommended a two-dose schedule for measles and in 1993, the Vaccines for Children Program, a federally funded program, was established to improve access to vaccines for all children.
What is going on internationally?
Figure 2 lists the top 10 countries with current measles outbreaks.
Most countries on the list may not be typical travel destinations for tourists; however, they are common destinations for individuals visiting friends and relatives after immigrating to the United States. In contrast to the United States, most countries with limited resources and infrastructure have mass-vaccination campaigns to ensure vaccine administration to large segments of the population. They too have been affected by the COVID-19 pandemic. By report, at least 41 countries delayed implementation of their measles campaign in 2020 and 2021, thus, leading to the potential for even larger outbreaks.4
Progress toward the global elimination of measles is evidenced by the following: All 194 countries now include one dose of measles in their routine schedules; between 2000 and 2019 coverage of one dose of measles increased from 72% to 85% and countries with more than 90% coverage increased from 45% to 63%. Finally, the number of countries offering two doses of measles increased from 50% to 91% and vaccine coverage increased from 18% to 71% over the same time period.3
What can you do for your patients and their parents before they travel abroad?
- Inform all staff that the MMR vaccine can be administered to children as young as 6 months and at times other than those listed on the routine immunization schedule. This will help avoid parents seeking vaccine being denied an appointment.
- Children 6-11 months need 1 dose of MMR. Two additional doses will still need to be administered at the routine time.
- Children 12 months or older need 2 doses of MMR at least 4 weeks apart.
- If yellow fever vaccine is needed, coordinate administration with a travel medicine clinic since both are live vaccines and must be given on the same day.
- Any person born after 1956 should have 2 doses of MMR at least 4 weeks apart if they have no evidence of immunity.
- Encourage parents to always inform you and your staff of any international travel plans.
Moving forward, remember this increased global activity and the presence of inadequately vaccinated individuals/communities keeps the United States at continued risk for measles outbreaks. The source of the next outbreak may only be one plane ride away.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.
This article was updated 6/29/22.
References
1. Patel M et al. MMWR. 2019 Oct 11; 68(40):893-6.
2. Seither R et al. MMWR. 2022 Apr 22;71(16):561-8.
3. Gastañaduy PA et al. J Infect Dis. 2021 Sep 30;224(12 Suppl 2):S420-8. doi: 10.1093/infdis/jiaa793.
4. Centers for Disease Control and Prevention. Measles (Rubeola). http://www.CDC.gov/Measles.
A 64-year-old woman presents with a history of asymptomatic erythematous grouped papules on the right breast
. Recurrences may occur. Rarely, lymph nodes, the gastrointestinal system, lung, bone and bone marrow may be involved as extracutaneous sites.
Primary cutaneous B-cell lymphomas account for approximately 25% of all cutaneous lymphomas. Clinically, patients present with either solitary or multiple papules or plaques, typically on the upper extremities or trunk.
Histopathology is vital for the correct diagnosis. In this patient, the histologic report was written as follows: “The findings are those of a well-differentiated but atypical diffuse mixed small lymphocytic infiltrate representing a mixture of T-cells and B-cells. The minor component of the infiltrate is of T-cell lineage, whereby the cells do not show any phenotypic abnormalities. The background cell population is interpreted as reactive. However, the dominant cell population is in fact of B-cell lineage. It is extensively highlighted by CD20. Only a minor component of the B cell infiltrate appeared to be in the context of representing germinal centers as characterized by small foci of centrocytic and centroblastic infiltration highlighted by BCL6 and CD10. The overwhelming B-cell component is a non–germinal center small B cell that does demonstrate BCL2 positivity and significant immunoreactivity for CD23. This small lymphocytic infiltrate obscures the germinal centers. There are only a few plasma cells; they do not show light chain restriction.”
The pathologist remarked that “this type of morphology of a diffuse small B-cell lymphocytic infiltrate that is without any evidence of light chain restriction amidst plasma cells, whereby the B cell component is dominant over the T-cell component would in fact be consistent with a unique variant of marginal zone lymphoma derived from a naive mantle zone.”
PCMZL has an excellent prognosis. When limited to the skin, local radiation or excision are effective treatments. Intravenous rituximab has been used to treat multifocal PCMZL. This patient was found to have no extracutaneous involvement and was treated with radiation.
This case and photo were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
Virmani P et al. JAAD Case Rep. 2017 Jun 14;3(4):269-72.
Magro CM and Olson LC. Ann Diagn Pathol. 2018 Jun;34:116-21.
. Recurrences may occur. Rarely, lymph nodes, the gastrointestinal system, lung, bone and bone marrow may be involved as extracutaneous sites.
Primary cutaneous B-cell lymphomas account for approximately 25% of all cutaneous lymphomas. Clinically, patients present with either solitary or multiple papules or plaques, typically on the upper extremities or trunk.
Histopathology is vital for the correct diagnosis. In this patient, the histologic report was written as follows: “The findings are those of a well-differentiated but atypical diffuse mixed small lymphocytic infiltrate representing a mixture of T-cells and B-cells. The minor component of the infiltrate is of T-cell lineage, whereby the cells do not show any phenotypic abnormalities. The background cell population is interpreted as reactive. However, the dominant cell population is in fact of B-cell lineage. It is extensively highlighted by CD20. Only a minor component of the B cell infiltrate appeared to be in the context of representing germinal centers as characterized by small foci of centrocytic and centroblastic infiltration highlighted by BCL6 and CD10. The overwhelming B-cell component is a non–germinal center small B cell that does demonstrate BCL2 positivity and significant immunoreactivity for CD23. This small lymphocytic infiltrate obscures the germinal centers. There are only a few plasma cells; they do not show light chain restriction.”
The pathologist remarked that “this type of morphology of a diffuse small B-cell lymphocytic infiltrate that is without any evidence of light chain restriction amidst plasma cells, whereby the B cell component is dominant over the T-cell component would in fact be consistent with a unique variant of marginal zone lymphoma derived from a naive mantle zone.”
PCMZL has an excellent prognosis. When limited to the skin, local radiation or excision are effective treatments. Intravenous rituximab has been used to treat multifocal PCMZL. This patient was found to have no extracutaneous involvement and was treated with radiation.
This case and photo were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
Virmani P et al. JAAD Case Rep. 2017 Jun 14;3(4):269-72.
Magro CM and Olson LC. Ann Diagn Pathol. 2018 Jun;34:116-21.
. Recurrences may occur. Rarely, lymph nodes, the gastrointestinal system, lung, bone and bone marrow may be involved as extracutaneous sites.
Primary cutaneous B-cell lymphomas account for approximately 25% of all cutaneous lymphomas. Clinically, patients present with either solitary or multiple papules or plaques, typically on the upper extremities or trunk.
Histopathology is vital for the correct diagnosis. In this patient, the histologic report was written as follows: “The findings are those of a well-differentiated but atypical diffuse mixed small lymphocytic infiltrate representing a mixture of T-cells and B-cells. The minor component of the infiltrate is of T-cell lineage, whereby the cells do not show any phenotypic abnormalities. The background cell population is interpreted as reactive. However, the dominant cell population is in fact of B-cell lineage. It is extensively highlighted by CD20. Only a minor component of the B cell infiltrate appeared to be in the context of representing germinal centers as characterized by small foci of centrocytic and centroblastic infiltration highlighted by BCL6 and CD10. The overwhelming B-cell component is a non–germinal center small B cell that does demonstrate BCL2 positivity and significant immunoreactivity for CD23. This small lymphocytic infiltrate obscures the germinal centers. There are only a few plasma cells; they do not show light chain restriction.”
The pathologist remarked that “this type of morphology of a diffuse small B-cell lymphocytic infiltrate that is without any evidence of light chain restriction amidst plasma cells, whereby the B cell component is dominant over the T-cell component would in fact be consistent with a unique variant of marginal zone lymphoma derived from a naive mantle zone.”
PCMZL has an excellent prognosis. When limited to the skin, local radiation or excision are effective treatments. Intravenous rituximab has been used to treat multifocal PCMZL. This patient was found to have no extracutaneous involvement and was treated with radiation.
This case and photo were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.
References
Virmani P et al. JAAD Case Rep. 2017 Jun 14;3(4):269-72.
Magro CM and Olson LC. Ann Diagn Pathol. 2018 Jun;34:116-21.
Nurses under fire: The stress of medical malpractice
Just because nurses are sued less often than doctors doesn’t mean that their actions aren’t a focus of a large number of medical malpractice lawsuits. A condition known as medical malpractice stress syndrome (MMSS) is increasingly being recognized as affecting medical professionals who are subjected to litigation.
According to a 2019 report by CRICO, the risk management arm of Harvard’s medical facilities, nursing was a “primary service” in 34% of cases with a high-severity injury and in 44% of cases that were closed with a payment. And even though nurses were named as defendants only 14% of the time, likely because many nurses don’t have their own personal malpractice coverage, their hospitals or facilities were sued in most of these cases – making the nurses important witnesses for the defense.
We have every reason to believe that things have gotten worse since the CRICO study was published. Chronic nursing shortages were exacerbated during the COVID pandemic, and we have seen a large number of nurses leave the workforce altogether. In a recent survey of nurses by Hospital IQ, 90% of respondents said they were considering leaving the nursing profession in the next year, with 71% of nurses who have more than 15 years of nursing experience thinking about leaving within the next few months.
Those remaining are faced with increased workloads and extra shifts – often mandated – and working with too little sleep. Their commitment to their mission is heroic, but they are only human; it’s hard to imagine the number of errors, the number of bad outcomes, and the number of lawsuits going anywhere but up.
And of course, the entire profession has been fixated on the recent case of the Tennessee nurse who was prosecuted criminally and convicted in connection with a fatal medication error.
These are all reasons to expect that an increasing number of nurses are going to be trying to cope with symptoms of MMSS. Too many of them will initially be viewed by lawyers or claims professionals as simply defensive, arrogant, or difficult to work with. In fact, it’s impossible to know how many cases are settled just to avoid the risk of such a “difficult client” being deposed.
These caring, hard-working, and committed individuals have had their lives shaken in ways that they never expected. Nurses with MMSS need support, but traditional psychotherapy, with a diffuse focus and long-time horizon, is not the most effective option. What’s necessary is practical support that is short term, goal oriented, and tailored to the specifics of the pending litigation process.
Most important, they need to know that they are not experiencing this alone, that MMSS is a common phenomenon, and that a productive coaching relationship can be highly effective.
When approached and supported effectively, nurses – and indeed all medical professionals – can regain their confidence and focus, continue having productive professional and personal lives, and reduce the likelihood of a downhill spiral. And it makes it more likely that they’ll remain in the profession rather than becoming just another statistic in the ever-worsening shortage of nurses in the United States.
Signs of MMSS in nurses
Mixed with their feelings of anxiety and depression, nurses with MMSS often have thoughts such as:
- Am I going to lose my license?
- Am I going to lose my job?
- Will my reputation be destroyed? Will I ever be able to work as a nurse again?
- What am I going to do for a living?
- If I lose everything, will my spouse divorce me? Will I lose my kids?
- I don’t think I did anything wrong, but what if I’m still found to be at fault?
- Did I miss something? Did I make a mistake? Was there something more that I should have done?
- What’s going to happen next? What else could go wrong?
- Are there more people out there who are going to sue me?
- Everything feels overwhelming and out of control.
- My entire identity is now in question.
- How do I get this case out of my head? I can’t focus on anything else.
- I’m developing medical problems of my own.
- I’m having difficulty focusing at work and relating to patients; how do I know who’s going to sue me next?
- I wish that I could escape it all; I feel like killing myself.
Gail Fiore is president of The Winning Focus, which works with physicians and other professionals involved in litigation who are having difficulty coping with stress, anxiety, and other emotional issues. A version of this article first appeared on Medscape.com.
Just because nurses are sued less often than doctors doesn’t mean that their actions aren’t a focus of a large number of medical malpractice lawsuits. A condition known as medical malpractice stress syndrome (MMSS) is increasingly being recognized as affecting medical professionals who are subjected to litigation.
According to a 2019 report by CRICO, the risk management arm of Harvard’s medical facilities, nursing was a “primary service” in 34% of cases with a high-severity injury and in 44% of cases that were closed with a payment. And even though nurses were named as defendants only 14% of the time, likely because many nurses don’t have their own personal malpractice coverage, their hospitals or facilities were sued in most of these cases – making the nurses important witnesses for the defense.
We have every reason to believe that things have gotten worse since the CRICO study was published. Chronic nursing shortages were exacerbated during the COVID pandemic, and we have seen a large number of nurses leave the workforce altogether. In a recent survey of nurses by Hospital IQ, 90% of respondents said they were considering leaving the nursing profession in the next year, with 71% of nurses who have more than 15 years of nursing experience thinking about leaving within the next few months.
Those remaining are faced with increased workloads and extra shifts – often mandated – and working with too little sleep. Their commitment to their mission is heroic, but they are only human; it’s hard to imagine the number of errors, the number of bad outcomes, and the number of lawsuits going anywhere but up.
And of course, the entire profession has been fixated on the recent case of the Tennessee nurse who was prosecuted criminally and convicted in connection with a fatal medication error.
These are all reasons to expect that an increasing number of nurses are going to be trying to cope with symptoms of MMSS. Too many of them will initially be viewed by lawyers or claims professionals as simply defensive, arrogant, or difficult to work with. In fact, it’s impossible to know how many cases are settled just to avoid the risk of such a “difficult client” being deposed.
These caring, hard-working, and committed individuals have had their lives shaken in ways that they never expected. Nurses with MMSS need support, but traditional psychotherapy, with a diffuse focus and long-time horizon, is not the most effective option. What’s necessary is practical support that is short term, goal oriented, and tailored to the specifics of the pending litigation process.
Most important, they need to know that they are not experiencing this alone, that MMSS is a common phenomenon, and that a productive coaching relationship can be highly effective.
When approached and supported effectively, nurses – and indeed all medical professionals – can regain their confidence and focus, continue having productive professional and personal lives, and reduce the likelihood of a downhill spiral. And it makes it more likely that they’ll remain in the profession rather than becoming just another statistic in the ever-worsening shortage of nurses in the United States.
Signs of MMSS in nurses
Mixed with their feelings of anxiety and depression, nurses with MMSS often have thoughts such as:
- Am I going to lose my license?
- Am I going to lose my job?
- Will my reputation be destroyed? Will I ever be able to work as a nurse again?
- What am I going to do for a living?
- If I lose everything, will my spouse divorce me? Will I lose my kids?
- I don’t think I did anything wrong, but what if I’m still found to be at fault?
- Did I miss something? Did I make a mistake? Was there something more that I should have done?
- What’s going to happen next? What else could go wrong?
- Are there more people out there who are going to sue me?
- Everything feels overwhelming and out of control.
- My entire identity is now in question.
- How do I get this case out of my head? I can’t focus on anything else.
- I’m developing medical problems of my own.
- I’m having difficulty focusing at work and relating to patients; how do I know who’s going to sue me next?
- I wish that I could escape it all; I feel like killing myself.
Gail Fiore is president of The Winning Focus, which works with physicians and other professionals involved in litigation who are having difficulty coping with stress, anxiety, and other emotional issues. A version of this article first appeared on Medscape.com.
Just because nurses are sued less often than doctors doesn’t mean that their actions aren’t a focus of a large number of medical malpractice lawsuits. A condition known as medical malpractice stress syndrome (MMSS) is increasingly being recognized as affecting medical professionals who are subjected to litigation.
According to a 2019 report by CRICO, the risk management arm of Harvard’s medical facilities, nursing was a “primary service” in 34% of cases with a high-severity injury and in 44% of cases that were closed with a payment. And even though nurses were named as defendants only 14% of the time, likely because many nurses don’t have their own personal malpractice coverage, their hospitals or facilities were sued in most of these cases – making the nurses important witnesses for the defense.
We have every reason to believe that things have gotten worse since the CRICO study was published. Chronic nursing shortages were exacerbated during the COVID pandemic, and we have seen a large number of nurses leave the workforce altogether. In a recent survey of nurses by Hospital IQ, 90% of respondents said they were considering leaving the nursing profession in the next year, with 71% of nurses who have more than 15 years of nursing experience thinking about leaving within the next few months.
Those remaining are faced with increased workloads and extra shifts – often mandated – and working with too little sleep. Their commitment to their mission is heroic, but they are only human; it’s hard to imagine the number of errors, the number of bad outcomes, and the number of lawsuits going anywhere but up.
And of course, the entire profession has been fixated on the recent case of the Tennessee nurse who was prosecuted criminally and convicted in connection with a fatal medication error.
These are all reasons to expect that an increasing number of nurses are going to be trying to cope with symptoms of MMSS. Too many of them will initially be viewed by lawyers or claims professionals as simply defensive, arrogant, or difficult to work with. In fact, it’s impossible to know how many cases are settled just to avoid the risk of such a “difficult client” being deposed.
These caring, hard-working, and committed individuals have had their lives shaken in ways that they never expected. Nurses with MMSS need support, but traditional psychotherapy, with a diffuse focus and long-time horizon, is not the most effective option. What’s necessary is practical support that is short term, goal oriented, and tailored to the specifics of the pending litigation process.
Most important, they need to know that they are not experiencing this alone, that MMSS is a common phenomenon, and that a productive coaching relationship can be highly effective.
When approached and supported effectively, nurses – and indeed all medical professionals – can regain their confidence and focus, continue having productive professional and personal lives, and reduce the likelihood of a downhill spiral. And it makes it more likely that they’ll remain in the profession rather than becoming just another statistic in the ever-worsening shortage of nurses in the United States.
Signs of MMSS in nurses
Mixed with their feelings of anxiety and depression, nurses with MMSS often have thoughts such as:
- Am I going to lose my license?
- Am I going to lose my job?
- Will my reputation be destroyed? Will I ever be able to work as a nurse again?
- What am I going to do for a living?
- If I lose everything, will my spouse divorce me? Will I lose my kids?
- I don’t think I did anything wrong, but what if I’m still found to be at fault?
- Did I miss something? Did I make a mistake? Was there something more that I should have done?
- What’s going to happen next? What else could go wrong?
- Are there more people out there who are going to sue me?
- Everything feels overwhelming and out of control.
- My entire identity is now in question.
- How do I get this case out of my head? I can’t focus on anything else.
- I’m developing medical problems of my own.
- I’m having difficulty focusing at work and relating to patients; how do I know who’s going to sue me next?
- I wish that I could escape it all; I feel like killing myself.
Gail Fiore is president of The Winning Focus, which works with physicians and other professionals involved in litigation who are having difficulty coping with stress, anxiety, and other emotional issues. A version of this article first appeared on Medscape.com.