| cognitive_dissonance | Cognitive Dissonance | WSMA_Reports | Shared_Content/News/Latest_News/2019/November/cognitive_dissonance | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Nov-Dec-2019-Reports-645x425px.jpg" class="pull-right" alt="WSMA Reports November/December 2019" /></div>
<h5>November 5, 2019</h5>
<h2>Cognitive Dissonance</h2>
<p>
</p>
<p>
By Pat Curry
</p>
<p>
For 10 years, Carl Berliner, MD, has been a solo family practitioner. He runs his practice out of a renovated house in Mt. Vernon, a community of 30,000 known for its annual tulip festival. His patients range in age from two days old to their late 90s. It brings him great joy, he says, to have delivered a third of them, many of whom call him "Dr. B."
</p>
<p>
Being a solo practitioner gives him what he calls "agency," the ability to control his day and his practice. A lot of physicians traded agency for better pay "and now they wish they hadn't," he says.
</p>
<p>
"It's just enormous, that ability to make extra time in your schedule and treat patients the way you think you should. … I always have this joke that I'm the last happy doctor in Washington. I live frugally enough that I weather these insanities. 'Cognitive dissonance' is the term I use."
</p>
<p>
The dissonance comes from trying to make enough money to keep the doors open.
</p>
<p>
"I don't like to talk about finances, but we are a business and have to pay bills and pay staff," he says. "We say we want healthy families, then make that almost impossible to happen. … Keeping up with the rules and fighting over every $14 charge is very discouraging. In the execution, you feel like you've been run over by a tractor."
</p>
<p>
And then there are the day-in and day-out challenges in getting approval from insurers to perform even the most standard levels of medical care.
</p>
<p>
"Prior authorization is an enormous time suck," he says, "and it's a reason why so many [physicians] are demoralized. At the end of the day, I don't leave with a smile because for six of the drugs I prescribed, I needed to click another radio button. I had a pregnant woman I prescribed prenatal vitamins for and the insurance company required prior authorization. On the form, I wrote, 'You are the worst insurance company ever.' "
</p>
<h3>Difficult decisions with few options</h3>
<p>
Without relief, some physicians have found that they have no choice but to shut down and go on someone else's payroll. In August, Cascade Family Medical Clinic in Centralia closed after more than 40 years.
</p>
<p>
Eric DeMun, MD, and Christopher Yarter, MD, posted on the clinic's website that the practice was "one of a shrinking group of small, independent primary care clinics that is suffering from increasing administrative burdens, rising costs of health care delivery, and a reimbursement system that has not kept pace with these costs. We have been unable to recruit physicians to partner with us in the face of these changes and have been unsuccessful in finding larger companies willing to buy the practice and keep it open."
</p>
<p>
Many physicians in small practices in Washington state face the same kind of gut-wrenching decisions. Eric Frankenfeld, MD, FACE, FACP, is an endocrinologist in solo practice in Bellingham, a physician-shortage area. This summer, he sweated out a lease renewal; the rent increase would determine if he stayed in business or retired. He negotiated a two-year lease instead of five years, enough for him to decide to keep at it a bit longer.
</p>
<p>
He's been aware for 25 years that it was "no way to make money," he says.
</p>
<p>
"I thought it was me, that I'm not enough of a hustler, not in a busy-enough practice, whatever," he says. "Then I talked to other colleagues over the years and found out they were doing worse than I was. You need a gimmick if you're going to make money in medicine. The gimmick is you perform a nice expensive procedure like endoscopy. Internists in general, and nonprocedural subspecialists without a gimmick, need to get themselves employed."
</p>
<p>
At 66, Dr. Frankenfeld says that as long as he can break even, fund his pension and his staff's pensions, he will continue to practice. He is ready to retire, though, from his second career as a hospitalist, which he has done half-time for 10 years.
</p>
<h3>The burden of fees and taxes</h3>
<p>
Working both as a solo practitioner and as a health system employee has been an eye-opener, he says, especially when it comes to state fees and taxes. With the state eyeing drastically increasing physician licensing fees, Dr. Frankenfeld wondered if it might be time for him to think about closing the doors on his private practice.
</p>
<p>
"This may be what does it for me," he says. "My reimbursements certainly haven't doubled in the last few years. How does a license become that valuable to me?"
</p>
<p>
He says the "biggest burr in my saddle" is the business and occupation, or B&amp;O, tax.
</p>
<p>
"I think that is the most unfriendly thing to small businesses," he says.
</p>
<p>
The B&amp;O tax, which is applied on a business' gross revenues, has been a long-standing point of contention for independent physicians, says Sean Graham, WSMA's director of government affairs. A bill passed last year added a 20 percent surcharge on certain industries with a significant number of highly educated workers, with the additional revenue going to higher education.
</p>
<p>
The fiscal impact of the tax increase on the physician community over the next two years is estimated at about $50 million, Graham says. Hospital systems were exempted from the tax surcharge as they are classified separately for the purposes of B&amp;O.
</p>
<p>
WSMA strenuously opposes the B&amp;O tax on all segments of health care and "vehemently" fought the surcharge, Graham says. Repealing the tax on physicians will be the "A-1 priority of WSMA for the 2020 legislative session," he says.
</p>
<p>
"It's simply a wrongheaded tax increase on a couple of levels, among them that it further increases the cost of health care," he says. "And it puts independent practices at a competitive disadvantage, jeopardizing access to care for patients in many communities."
</p>
<p>
The WSMA will be rolling out a broad advocacy campaign on repealing or ameliorating the B&amp;O tax in the next legislative session and will be asking our physician members for their help.
</p>
<p>
"We'll be working to raise awareness of the impact of the surcharge on patients and physicians, as well as to get physicians directly connected to their legislators," he said.
</p>
<p>
Mark T. Anderson, MD, a founding member of the independent Mill Creek Family Practice in Mill Creek, is one of the physicians who has volunteered to share his concerns with elected officials. His practice is "still doing OK," but faced with lower reimbursements, burdensome documentation and preauthorization requirements, and the B&amp;O tax increase, it's getting harder and harder to compete against hospital-based primary care clinics.
</p>
<p>
"We are one of the very few independent family practice clinics left," Dr. Anderson says. "We would like to continue to practice independently."
</p>
<p>
<em>Pat Curry is WSMA Reports' senior editor.</em>
</p>
<p>
<em>This article was featured in the November/December 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 11/5/2019 10:51:45 AM | 11/5/2019 10:49:42 AM | 11/5/2019 12:00:00 AM |
| do_no_harm | Do No Harm | WSMA_Reports | Shared_Content/News/Latest_News/2019/November/do_no_harm | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Nov-Dec-2019-Reports-645x425px.jpg" class="pull-right" alt="WSMA Reports November/December 2019" /></div>
<h5>November 5, 2019</h5>
<h2>Do No Harm</h2>
<p>
</p>
<p>
By Daniel Low, MD
</p>
<p>
In the midst of ever-increasing health care costs, we are obligated to think about and practice value-based care. What sadly is too often lost in this conversation, however, is the definition of "value." What are our values?
</p>
<p>
As physicians, we have all proclaimed via the Hippocratic Oath that we will "first, do no harm." Yet, current data seems to suggest that this theoretically unifying value reflects more of a distant ideal than a guiding principle.
</p>
<p>
By now, it is well known that black patients are less likely to be treated for pain in emergency departments, women are less likely to be treated for heart disease, immigrants are less likely to receive care, and those who are economically disadvantaged are more likely to suffer early morbidity and mortality.
</p>
<p>
While acknowledged as unfortunate, these disparities are generally viewed as inevitable, and thus, acceptable. This convention of normalcy must stop. Patients deserve health care providers who advocate for their best interests.
</p>
<p>
What might this look like? It means taking responsibility as physicians to not just organize to benefit ourselves financially—which has been the historic norm (e.g., the American Medical Association's partnership with the Sunbeam Corporation, the American Heart Association's exploitation of its heart logo for profit over health, the American Academy of Family Physicians' collaboration with Coca-Cola, etc.)—but rather to organize for our patients. Specifically, this would mean formally supporting campaigns targeting health inequities.
</p>
<p>
Fortunately, we don't have to look far for obvious opportunities. Study after study over the last 30 years has shown that income inequality drives poor health outcomes and may be one of the central causes of poor health in the United States. In Washington state, this is perpetuated by regressive tax systems—Washington ranks last in the country in disproportionately burdening low-income earnershelping guarantee the poor stay poor and continue enduring harm that we, as physicians, claim we will not do. We can instead follow the lead of groups like Washington Physicians for Social Responsibility, which advocates for cleaning up our tax code and enacting a capital gains tax.
</p>
<p>
As we discuss value-based care, we too often excuse rising health care costs as unrelated to our individual responsibility because physician salaries are not the cause for increasing costs. But such claims, while true, are red herrings. They distract us from the reality that increasing economic inequality is arguably the central force driving poor health outcomes in our communities, and economic inequality is something we can address.
</p>
<p>
Continuing business as usual—or trying to incrementally alter payment models in value-based care without addressing the structural violence enacted by our tax system—is a formula to ensure we continue harming disenfranchised individuals and communities. Ultimately, if our value is to do no harm, we must attack a system that guarantees unequal care to those who are different. We must organize, and we must support the redistribution of resources, putting our own pocketbooks on the table.
</p>
<p>
<em>This opinion piece was submitted by Daniel Low, MD, a family medicine resident physician at Swedish Cherry Hill in Seattle and an alternate delegate from King County Medical Society to the WSMA House of Delegates.</em>
</p>
<p>
<em>This article was featured in the November/December 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 11/5/2019 10:47:02 AM | 11/5/2019 10:27:29 AM | 11/5/2019 12:00:00 AM |
| preparing_for_value_based_care | Preparing for Value-Based Care | WSMA_Reports | Shared_Content/News/Latest_News/2019/November/preparing_for_value_based_care | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Nov-Dec-2019-Reports-645x425px.jpg" class="pull-right" alt="WSMA Reports November/December 2019" /></div>
<h5>November 5, 2019</h5>
<h2>Preparing for Value-Based Care</h2>
<p>
</p>
<p>
By Rita Colorito
</p>
<p>
When a homeless cancer patient came to Northwest Cancer Clinic in Kennewick for radiotherapy, Sheila Rege, MD, a radiation oncologist and co-founder of the clinic, knew treatment would be challenging.
</p>
<p>
The patient's situation made maintaining hygiene difficult, and Dr. Rege worried it could cause her to develop skin infections during radiation. Plus, she had other chronic medical issues, including uncontrolled diabetes that once caused dangerously elevated blood pressure. Dr. Rege and her staff put systems in place to achieve the best outcome possible for the patient. They let her shower at the clinic and delivered food and warm clothing to the car she called home. They called her daily to remind her to take her medications.
</p>
<p>
When the patient needed more help, Dr. Rege's staff negotiated with a hotel to house her for the remainder of treatment. "There was a lot more time and care that we had to do for her," Dr. Rege says.
</p>
<p>
The patient is now doing well, a function of value-based care being applied across the clinic's patient population, Dr. Rege says.
</p>
<p>
"We really try and not highlight who is on a risk-based contract. We focus on keeping people out of the emergency room," she says. "So, we're going to accept a risk-based contract, but we're really going to bring everyone else to that level."
</p>
<p>
As public and private payers undergo a major transition to value-based care (VBC) models, Dr. Rege hopes physicians can continue to care for this type of vulnerable patient, and those with treatment challenges, without the patient or the practice getting short shrift.
</p>
<p>
"All of us want to do better for our patients; everyone is trying to reduce what I call the hassle factor in medicine," Dr. Rege says. "But as we're going through these dramatic changes in how we pay for care, we have to make sure the vulnerable people, the people having a harder time either accessing care or tolerating treatment, don't suffer. We also have to make sure incentives are aligned to allow physicians to care for them."
</p>
<h3>A dramatic shift in focus</h3>
<p>
It seems like only a few years ago that VBC entered the lexicon of health care buzzwords. This reimbursement model rewards physicians for meeting agreed-upon quality metrics. It can also penalize them when those metrics aren't met.
</p>
<p>
If you've been sitting on the fence about VBC, you may no longer have the option of waiting, says Micah Thorp, DO, a nephrologist and clinical researcher with Northwest Permanente.
</p>
<p>
"Value-based is going to be the primary form of payment in the not-too-distant future. It's coming pretty fast and you've got to get ready for it," says Dr. Thorp, who also serves as vice president of business strategy for Kaiser Permanente.
</p>
<p>
At the state level, the Health Care Authority's Healthier Washington initiative plans to drive 90 percent of state-financed health care—more than 2 million people on Medicaid and those who receive public employee, state school employee, and retiree benefits—to value-based payment by 2021. At the federal level, the Centers for Medicare &amp; Medicaid Services has rolled out eight value-based care models since 2018, with the triple aim of better care for individuals, better care for populations, and lower cost.
</p>
<p>
The aim of VBC models is to allow physicians to concentrate on taking care of patients. "For value-based care to work, it's important for providers to free up their PCPs. They can really drive savings in other areas," says Mark Mantei, CEO of Vancouver Clinic. "This isn't a model built on seeing 30 patients a day. This is a model that takes up more time, but we're rewarded for that because your patients don't end up in the ER or hospital."
</p>
<p>
Vancouver Clinic began transitioning to VBC for its Medicare population six years ago, after realizing traditional Medicare was no longer sustainable. Earlier this year, it partnered with Humana to open a dedicated primary care clinic in Southwest Washington designed to serve Medicare Advantage beneficiaries and those on Dual Eligible Special Needs Plan (those who qualify for both Medicare and Medicaid); it also accepts commercial insurance.
</p>
<p>
The clinic's integrated care team includes doctors, nurses, nutritionists, and health coaches. Representatives from both Humana and the Agency on Aging and Disabilities of Southwest Washington hold office hours several days a week to help patients navigate their benefits and manage outside factors that affect health outcomes, such as housing, transportation, mental health, and home care.
</p>
<p>
Despite a 40 percent higher-than-average risk adjustment factor for the clinic's Medicare population, it's had some amazing successes already that speak to the power of value-based care, Mantei says. "We saw patients that were in the hospital 16 times last year before that clinic was implemented. And since then, they've only been in the hospital once."
</p>
<h3>Despite challenges, smaller practices and specialties can benefit</h3>
<p>Dr. Thorp oversees contracting with external providers in areas where Kaiser Permanente lacks a local specialty presence. These physician groups often struggle with transitioning from an efficiency mindset to a utilization mindset, the latter of which is central to value-based care, he says.
</p>
<p>
"Fee-for-service drives great efficiency. It also does terrible things to utilization," he says. "The value-based model basically says, 'Let's treat people with what they actually need' rather than just treating them with a lot of stuff they don't need, but doing it very efficiently."
</p>
<p>
Having enough high-quality baseline data is another issue physicians struggle with in negotiating and implementing VBC contracts, Dr. Thorp says. "You need to have a good idea of where you are starting from to gauge progress," he says, adding that electronic medical records can provide a wealth of information to track clinical quality, population data, and other metrics. Robust patient data, he says, also safeguards against a common criticism of VBC—that physicians will take a lump-sum payment and withhold services to meet metrics.
</p>
<p>
To position her practice to best take advantage of VBC models, Dr. Rege entered into a joint venture and management contract with 21st Century Oncology, a large national physician-owned oncology group.
</p>
<p>
"Value-based and risk-based only work if you can provide data that shows you are improving outcomes and being more efficient," which is something Dr. Rege says her clinic lacked. It made sense to partner with 21st Century Oncology, she says, because they have experience managing risk-based contracts and could provide the necessary investments to train her team and conduct financial reporting.
</p>
<p>
To better serve patients, it's important to be able to access a patient's health records in a HIPAA-compliant manner in and outside the office, says Dr. Rege. Northwest Cancer Clinic also benefited from 21st Century's more advanced medical records capabilities. "We were on the same system, but they were able to beef it up," she says. "[And] they already had an existing contract with an electronic medical record provider to generate all those reports that would be needed by the insurance companies."
</p>
<p>
Risk adjustment is another major concern when transitioning to a capitated payment system. It's even more so with cancer treatment, says Dr. Rege.
</p>
<p>
"We don't know what causes someone to do great with cancer treatment and what causes some people to end up in the ICU," she says. "In a value-based system, we have to figure out a way that sicker patients aren't left out. And so far, no insurance company knows who's going to do okay on treatment and who is going to have trouble."
</p>
<p>
Northwest Cancer Clinic's VBC contracting has flexibility to account for that uncertainty, Dr. Rege says. The corporate office of 21st Century Oncology acts as a "shadow team," she says, that helps her staff assist patients who are struggling with treatment by acting as an intermediary with insurers.
</p>
<p>
She warns physicians and practices against entering into VBC systems with rigid metrics. "If a patient is an outlier, it's important to have the flexibility with insurance providers to discuss next steps," she says. An open dialogue with insurers allows Dr. Rege to manage costs while providing patients the best care possible.
</p>
<p>
As Medicare is driving the larger health care space toward VBC, Dr. Rege expects it to drive oncology reimbursement as well. For now, Northwest Cancer Clinic's VBC contracts are in the commercial insurance space. Medicare oncology care model (OCM) pilot projects are only a few years old. "While quality and cost performance results across OCM practices continue to improve, only 33 percent of practices have earned a performance-based payment so far," Dr. Rege says. As these models evolve, she remains hopeful Medicare and Medicaid will keep the health of both the patient and the physician practice in mind.
</p>
<p>
Despite some of the challenges faced by smaller clinics, Dr. Thorp says he's seen some of the biggest benefits of VBC among smaller physician practices. "You're getting a guaranteed per-patient, per-month money. It can stabilize cash flow," he says.
</p>
<p>
One of the biggest rewards for Northwest Cancer Clinic's VBC contracting has been eliminating prior authorization for evidence-based treatment, a huge time saver for both physicians and patients, Dr. Rege says. The clinic receives capitated payments specific to each cancer type, with care decisions following established clinical guidelines.
</p>
<p>
"You have to reduce the cost for the practice in some way," Dr. Rege says.
</p>
<p>
"If a bunch of your staff is doing prior authorizations and documentation, that's time the staff could've spent on the patient. So when a patient comes in, we can say, 'This is what you need.' If they say, 'Can we start now? ', we can say, 'Yes, we can.' "
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care.</em></p>
<p>
<em>This article was featured in the November/December 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 11/5/2019 10:49:30 AM | 11/5/2019 10:47:33 AM | 11/5/2019 12:00:00 AM |
| lead_is_still_a_public_health_culprit | Lead is Still a Public Health Culprit | WSMA_Reports | Shared_Content/News/Latest_News/2019/September/lead_is_still_a_public_health_culprit | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA-Reports-S-O_Website-Graphic_645px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>September 10, 2019</h5>
<h2>Lead is Still a Public Health Culprit</h2>
<p>
</p>
<p>
By Amish Dave, MD, MPH
</p>
<p>
At a recent meeting of the Somali Health Board in Seattle, concerned parents raised questions about the prevalence of lead in their communities. They wondered if their children's low birth weights and hyperactive behavior might be associated with the age of their apartments, paint on the walls, or what they were eating.
</p>
<p>
Even though lead-based paint was banned by 1978, lead remains an issue today. Lead is everywhere, from older plumbing fixtures, soil, imported medicines, and ceramics. It is found adjacent to highways and via occupational exposures. Even more concerning, the attorney general's office in Washington recently found lead in children's school products. Further, many of Washington's counties have a high percentage of homes with lead paint, lead piping, and environmental lead exposures.
</p>
<p>
There is no safe level of lead in the human body. Even low blood lead levels (&lt;5 micrograms/deciliter) can harm a child’s ability to learn and increase behavior problems. Research shows an association of childhood lead exposure and later risk of poorer educational attainment and incarceration.
</p>
<p>
Lead has also been causally linked with attentiondeficit hyperactivity disorder diagnosis. Most children exposed to lead remain asymptomatic, as longterm effects of lead exposure manifest later in life. Importantly, pregnant mothers with elevated lead levels can transfer lead from their blood to the fetus.
</p>
<p>
Massachusetts and New York are leading the way in screening for lead and conducting blood testing in 50 percent of their children. By comparison, in Washington, we test fewer than 5 percent of our children, making this state one of the five worst in the country for that metric. In King County, we estimate more than 6,000 children are likely lead poisoned, are not tested, and don’t receive services that could support their development.
</p>
<p>
Besides the personal toll on affected children, there are hard costs as well. One study estimates that for children born in 2014, with lead exposure, they would experience a total loss of $195 million in lifetime earnings and 393,000 healthy years lived. When long-term lead-exposure effects (hypertension, organ damage, reproductive problems, behavioral impacts) are factored over a five-year period, the costs expand to $1 billion in financial loss and 2 million healthy years lost.
</p>
<p>
</p>
<p>
We have a responsibility to advocate for the health and well-being of vulnerable children. For the past two years, Public Health – Seattle &amp; King County and the King County Medical Society Board of Trustees partnered with the Washington Chapter of the American Academy of Pediatrics, the Washington State Department of Health, the Washington Poison Center, and the Northwest Pediatric Environmental Health Specialty Unit to highlight the seriousness of lead poisoning. We introduced a comprehensive resolution at the 2018 WSMA Annual Meeting to increase awareness about lead poisoning, which was adopted by delegates and is now association policy (<a href="http://bit.ly/wsma-lead">bit.ly/wsma-lead</a>).
</p>
<p>
But we need to do more. To get involved, contact Salem Adisu at <a href="mailto:sadisu@kcmsociety.org">sadisu@kcmsociety.org</a>.
</p>
<p>
<em><strong>Amish Dave, MD, MPH</strong>, is a rheumatologist with Virginia Mason Medical Center in Seattle, in addition to being chair of the Public Health Committee for King County Medical Society and a delegate to the WSMA House of Delegates.</em>
</p>
<p>
<em>This article was featured in the September/October 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 9/16/2019 3:48:03 PM | 9/10/2019 3:16:22 PM | 9/10/2019 12:00:00 AM |
| ending_death_by_a_million_clicks | Ending Death by a Million Clicks | WSMA_Reports | Shared_Content/News/Latest_News/2019/September/ending_death_by_a_million_clicks | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA-Reports-S-O_Website-Graphic_645px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>September&nbsp;6, 2019</h5>
<h2>Ending Death by a Million Clicks</h2>
<p>
By John Gallagher
</p>
<p>
Every physician knows the problem: an additional box to check in the EMR, a flurry of prescription refills, lab results that arrive after the patient's visit. Individually, each item may require just a few minutes. But collectively, the minutes add up to hours that rob physicians of time with patients and contribute to the epidemic of burnout.
</p>
<p>
The WSMA has been working on this problem for more than four years with its Healthy Doctors, Healthier Patients initiative. Because of Washington state's role in the forefront of addressing the issue, the WSMA was one of just three medical associations in the nation awarded a grant from the Physicians Foundation to work with the American Medical Association to test potential projects to improve physician wellness. (New Jersey and North Carolina are the other states participating in the grant.)
</p>
<p>
"We know a lot about the degree of burnout, the drivers, and the impact, but there's been little research on interventions," says Jessica Martinson, director of clinical education and professional development at the WSMA Foundation for Health Care Improvement.
</p>
<p>
Eight organizations in Washington are participating in the project. The grant covers four subject areas—pre-visit planning, pre-visit labs, synchronized prescription renewal, and implementing team-based care—with participants in Washington tackling the first three. (Implementing team-based care presents unique challenges for a time-limited grant, including the need for additional staff.)
</p>
<p>
The interventions will run for one year, with results to be shared nationally. To test the effectiveness of the interventions, the participating organizations conducted baseline surveys of physician burnout at the clinics where the interventions are implemented, with a follow-up survey once the intervention is completed. Organizations also are frequently pairing the intervention site with a control clinic. Each organization has a team that is composed of both physicians and administrators working on its project.
</p>
<p>
The grant builds upon the AMA's STEPS Forward program, which offers a free collection of interactive educational modules developed by physicians to help address common practice challenges. Each module offers real-world solutions, practical steps for implementation, case studies, and downloadable resources for anyone to use.
</p>
<h3>An ongoing struggle with serious consequences</h3>
<p>
The need for the interventions is obvious; 43 percent of Washington's physicians are experiencing burnout, according to a recent physician and advanced practitioner wellness survey conducted by Stanford University's The Risk Authority (TRA) and commissioned by the WSMA and the Washington State Hospital Association. (For comparison, the TRA national benchmark is 36 percent.)
</p>
<p>
Moreover, studies have found that the impact extends to patient care; doctors suffering from burnout have poorer patient outcomes.
</p>
<p>
"We're struggling to meet the demands of modern medicine," says Scott Itano, MD, a family medicine physician at Washington Permanente Medical Group. "Regardless of the model you're in, people are having a tough time. We are the most highly trained clerical workers in the country. It's death by a million clicks."
</p>
<p>
Dr. Itano and other leaders testing interventions attended a boot camp hosted by the AMA in April. What they learned there was that 80 percent of burnout was related to the way the health care system affects doctors in their work.
</p>
<p>
"I thought burnout was pretty touchy-feely and that you just needed to get tougher," Dr. Itano acknowledges. "But when you see the data and see how widespread the epidemic is, you realize that no matter who you are, it affects your day-to-day life."
</p>
<p>
The AMA research aims to make small but impactful improvements to the system; Dr. Itano is part of the team at Kaiser Permanente working on pre-visit labs. "We wanted to focus on something simple that we could execute in a year," he says. "We want to show that whatever staffing model you have, this is something you can do."
</p>
<p>
Having a patient get lab tests before a visit gives physicians the opportunity to discuss the results during the visit, instead of reviewing results afterward and then coordinating follow-up care. Something as simple as scheduling a patient's next set of labs at the end of each visit can save precious time. So can empowering staff to manage a physician's inbox. Even these small changes can have a big impact, according to AMA calculations.
</p>
<p>
"I was really surprised that pre-visit labs increase patient satisfaction, decrease cost by $26 per visit, and decrease the number of calls a clinic receives," says Dr. Itano.
</p>
<p>
In planning its project, the Kaiser Permanente team realized that physicians don't need to do many of the tasks of pre-visit labs. "My medical center manager and medical assistants are going to be doing the bulk of the work because we will be shifting a lot of day-to-day work from physicians to staff," Dr. Itano says.
</p>
<h3>Small changes yield big time savings</h3>
<p>
Labs aren't the only pre-visit intervention being tested. Four organizations, including The Everett Clinic, are testing ways to improve pre-visit planning so that visits themselves are more productive and don't add time to the doctor's day.
</p>
<p>
"We're doing a small checklist to have in the exam room for orders," says Michael Rohrenbach, DO, associate medical director of clinician engagement at The Everett Clinic. "When we're done with the visit, we can check off what we want the medical assistant to do with follow-up labs, visits, and referrals."
</p>
<p>
The assistant—not the physician—will then enter that information into the computer. "We'll sign the checklist at the bottom, and they'll be able to order for themselves," says Rohrenbach. "They will scan the orders into the EMR." Dr. Rohrenbach estimates this one change will save physicians 15 minutes a day, or about 91 hours in a year.
</p>
<p>
Even something as straightforward as a having a checklist required a significant amount of work, a sign of the challenges inherent in the system.
</p>
<p>
"It has been no small undertaking," Dr. Rohrenbach says. "We had to get corporate compliance to buy off on this. We had to get the Epic team to make changes so medical assistants could do the ordering. We had to get quite a few people in the room to change processes."
</p>
<p>
Synchronizing prescription refills presents its own problems, as the team at UW Valley Medical Center knows.
</p>
<p>
"It sounds simple, but it's a challenge," says Michele Despreaux, MD, medical director of senior care and internal medicine clinics at UW Valley Medical Center. "We're trying to reduce phone calls and frustration for the clinicians, staff, and patients, so that patients get their meds and we get way fewer messages."
</p>
<p>
Dr. Despreaux and her colleagues are trying to tackle three issues. The first is relatively straightforward: getting doctors to renew all of a patient's stable medications for the maximum duration period. The other issues are thornier.
</p>
<p>
"It's ingrained in many medical office cultures and in many patients that the refill is contingent on them having an appointment," Dr. Despreaux says.
</p>
<p>
But patients often don't realize that their prescription needs renewal until they are almost out of their medication. That leads to a stopgap request for a 30-day refill until they can get in for an appointment—all of which takes time.
</p>
<p>
The actual synchronization is the most difficult problem to solve. The AMA estimates that if 1,000 patients taking five meds call their doctor twice a year for each medication, with a call lasting just two minutes each time, the doctor and staff spend more than 330 hours a year on refills alone.
</p>
<p>
Theoretically, patients taking multiple medications for chronic conditions should be able to have their refills on the same schedule. But insurance and pharmacy issues make it hard to line up refill times.
</p>
<h3>Physicians need to lead the process</h3>
<p>
Each of the areas of intervention in the grant share a common thread: the importance of having physicians at the table to make the changes that improve their work lives. Many of the systemic problems affecting physician wellness—especially the additional work EMRs require—are the result of changes made without input from the doctors who would have to live with them.
</p>
<p>
It can feel like a losing battle at times. "Someone comes up with great idea, but they don't realize the downstream effect on the workflow for the clinical teams," says Dr. Rohrenbach, who in his role is responsible for physician engagement and satisfaction. "We don't realize how much that does to the teams working on the front line doing clinical care."
</p>
<p>
The grant participants are optimistic that the interventions can reduce burnout rates and increase satisfaction.
</p>
<p>
"My hope is that when our teams look back, they can say it took effort, but was well worth it," says Martinson. "The hope is really in physicians reclaiming their role as decision-makers within health care organizations."
</p>
<p>
Besides, doing nothing to improve physician wellness is no longer an option.
</p>
<p>
"This is probably one of the biggest crises in the health care profession," Dr. Itano says. "I see physicians leaving their jobs because they're just burned out. It's almost akin to climate change. We have to be aggressive now to prevent those downstream effects from occurring.".
</p>
<p>
<em>John Gallagher is a Washington state-based freelance writer who specializes in covering health care.</em>
</p>
<p>
<em>This article was featured in the September/October 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 9/16/2019 3:48:27 PM | 9/6/2019 10:44:15 AM | 9/6/2019 12:00:00 AM |
| prioritizing_wellness | Prioritizing Wellness | WSMA_Reports | Shared_Content/News/Latest_News/2019/September/prioritizing_wellness | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA-Reports-S-O_Website-Graphic_645px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>September&nbsp;6, 2019</h5>
<h2>Prioritizing Wellness</h2>
<p>
By Kim Moore, MD and Kent Hu, MD, MPH
</p>
<p>
Physician and advanced practitioner wellness have always been priorities for the members of the Medical Officer Collaborative. We have worked over the years to address issues that contribute to burnout and overwhelm because we see the harmful effects to our colleagues on a daily basis. Now, Healthy Doctors, Healthier Patients - the WSMA physician wellness and administrative simplification initiative - joins Better Prescribing, Better Treatment, Honoring Choices® Pacific Northwest, and Partnership for Patients as one of our "Call to Action" initiatives, making it a central element of our work as physician leaders.
</p>
<p>
Call to Action initiatives are health care quality and safety initiatives that aim to improve patient care, health care delivery, and ultimately the health of our communities. The members of our collaborative have robust discussions about developing statewide strategies and implementation plans to advance improvements in these areas.
</p>
<p>
The word "statewide" is key. As a joint initiative of the WSMA and the Washington State Hospital Association, the Medical Officer Collaborative provides physician leaders from hospitals and medical groups throughout the state the opportunity to work collaboratively to improve care and make Washington known for its achievements in safety and quality.
</p>
<p>
Adding Healthy Doctors, Healthier Patients to our Call to Action initiatives recognizes the importance of this issue; a 2003 study published in JAMA ("Confronting Depression and Suicide in Physicians") estimated 300 physicians die by suicide in the U.S. each year. Wellness demands our ongoing attention, and we will build on our discussions of this important topic at every meeting.
</p>
<p>
The recent data from our physician and advanced practitioner wellness survey, based on Stanford WellMD's model of burnout and fulfillment, gave us valuable insights into what physicians in our state are experiencing and what is driving burnout. Being able to compare our health care organizations and our state with the rest of the country was very meaningful. With these results in hand, many of us are taking action.
</p>
<p>
That change is palpable. We now are moving from a conversation about burnout to pursuing a series of small, medium, and large initiatives to address the systemic issues that can improve wellness.
</p>
<h3>Open and honest dialogue</h3>
<p>
Our Medical Officer Collaborative Safe Tables are regularly scheduled events at which physician leaders can have open, honest dialogue on key issues and how they affect their staff, patients, and their health care organizations. It's clear from our meetings that health systems are continually looking for ways to support the wellness of their physicians, whether it's by providing scribes, reducing the number of clicks needed to reach information in EMRs, or handling physicians' laundry and grocery shopping.
</p>
<p>
At a Safe Table meeting earlier this year, we heard about health systems that:
</p>
<ul>
<li>Restructured employee contracts to promote wellness.</li>
<li>Addressed workplace inefficiencies using Kaizen and Lean principles so that physicians could finish documentation faster and leave work on time.</li>
<li>Changed the name and focus of the Impaired Physician Committee to a Wellness Committee.</li>
<li>Offered peer mentorship with young, up-and-coming leaders.</li>
<li>Provided peer-support volunteers to distressed physicians.</li>
</ul>
<h3>A history of effectiveness</h3>
<p>
A prime example of the effectiveness of the work of the Medical Officer Collaborative is its success in addressing the opioid epidemic. We have been monitoring opioid safety for many years. Members of the collaborative encouraged increased access to the state's prescription monitoring program and supported the creation of metrics, as well as guidelines, policies, and procedures. We collaborated to implement an overdose notification process that now is being rolled out across the state.
</p>
<p>
We now hope to achieve the same kind of success with addressing wellness. The Safe Table is a place where we can openly discuss what works and what doesn't. Knowing that we all have similar issues and concerns, we learn from organizations that are finding new and innovative ways to help support physicians in their daily work..
</p>
<p>
<em><strong>Kim Moore, MD</strong>, is associate chief medical officer at CHI Franciscan. <strong>Kent Hu, MD</strong>, is associate medical director at The Everett Clinic. They serve as chair and chair-elect, respectively, of the Medical Officer Collaborative.</em>
</p>
<p>
<em>This article was featured in the September/October 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 9/16/2019 3:48:34 PM | 9/6/2019 10:33:28 AM | 9/6/2019 12:00:00 AM |
| health_at_risk | Health at Risk | WSMA_Reports | Shared_Content/News/Latest_News/2019/July/health_at_risk | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/July-Aug-Reports-Article-Graphic-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2019</h5>
<h2>Health at Risk</h2>
<p>
By Rita Colorito
</p>
<p>
Every spring and summer, Tony Butruille, MD, a family physician in Leavenworth, deals with the impact of what the World Health Organization says is the "greatest public health threat in the 21st century" - climate change. Throughout Washington state, wildfires are the front-and-center concern, with the highest number of fires on record in 2018.
</p>
<p>
Leavenworth, a Bavarian-style city of some 2,000 people in the foothills east of the Cascade Mountains, has the state's greatest exposure to wildfires, according to the U.S. Forest Service Pacific Northwest office. At times last August, the air quality in Washington was the worst in the world, with Seattle experiencing several consecutive days of unhealthy air.
</p>
<p>
August has become a shut-in period for many of Dr. Butruille's patients as they try to avoid the smoke.
</p>
<p>
"Respiratory issues, asthma, COPD, and allergies all spike when you have drier conditions and more smoke and allergens in the air," says Dr. Butruille. "Those exacerbations are not only much more frequent, but can also be much more severe."
</p>
<h3>The dangers of wildfire smoke</h3>
<p>
According to the 4th National Climate Assessment, rising temperatures worldwide, driven by skyrocketing greenhouse gases, have led to a cascade of increasingly frequent and severe heat events, drought, and flooding, as well as sea level rise and spread of disease-carrying insects that impact the environmental and societal determinants of public health—clean air and water, sufficient food, and safe shelter.
</p>
<p>
Washington's Department of Natural Resources predicts 2019 will experience hotter, drier temperatures and an earlier and longer fire season— and it's not just the drier eastern half of the state. Some 40 percent of last year's 1,850 fires, and 49 of 50 unseasonal wildfires that occurred by the end of March, struck west of the Cascades.
</p>
<p>
Wildfire smoke poses the greatest risk to young children, pregnant women, the elderly, and those with asthma, allergies, and heart and lung problems.
</p>
<p>
"The more smoke and air pollution we have in our environment, the more cardiovascular, cerebrovascular, and pulmonary diseases we can expect to see," says Jeffrey Duchin, MD, a physician and health officer for Public Health – Seattle &amp; King County.
</p>
<p>
Also impacted are those with kidney problems, says Annemarie Dooley, MD, a nephrologist in Bellevue.
</p>
<p>
"Your kidneys act as a giant sieve," says Dr. Dooley. "Small particulate matter, under 2.5 micrometers, penetrates very deeply into lung tissue, is absorbed through the bloodstream, circulates to the heart, and the kidneys get 20 percent of what's filtered through the heart every second."
</p>
<p>
Researchers are still determining other developmental and long-term effects of wildfire smoke on children, who breathe more air per pound of body weight than adults because their metabolism runs faster, says Chris Covert-Bowlds, MD, a family physician in Seattle.
</p>
<p>
"The concern is that their lung development may never reach its full potential," he says.
</p>
<h3>The cascading effects of heat</h3>
<p>
Climate change means another new normal for Washington—increased temperatures and extreme heat events. A report from the University of Washington Climate Impacts Group (CIG) finds climate change is likely to increase heat-related illness, including heat exhaustion and stroke. Nationwide, extreme heat kills more Americans than any other form of severe weather.
</p>
<p>
Between 1990 and 2010, King County saw a 10 percent increase in deaths on "extreme heat days," according to the National Climate Assessment. Recent heat waves have seen a significant increase in hospitalizations, especially for the elderly, says Dr. Duchin.
</p>
<p>
Increased temperatures play a major role in ground-level ozone and fine particulate matter (PM2.5), both widespread air pollutants in Washington that increase the risk of cardiovascular disease and death, including death from lung cancer. With high concentrations of these pollutants, Yakima and the greater Spokane area received failing grades from the American Lung Association's most recent air quality report.
</p>
<p>
Renal health also should be on everyone's radar, says Dr. Dooley. Heat stress can impact those with existing renal injury or at an increased renal risk, such
as those with diabetes, as well as people whose kidneys are otherwise healthy.
"You can form kidney stones just by being dehydrated without having any kidney injury, by working or even playing out in hot weather," she says.
</p>
<p>
Carbon dioxide in the atmosphere not only makes the trees produce more pollen, but the warmer weather and reduced rainfall is causing the pollen season to start earlier, last longer, and become more severe. "People are having asthma symptoms earlier and worse than ever before," says Dr. Covert- Bowlds, whose son has asthma.
</p>
<p>
The result is also more severe allergy flares, says Markus Boos, MD, a pediatric dermatologist with Seattle Children's. "We have clinics where it's wall-to-wall kids with atopic dermatitis," he says.
</p>
<h3>Vector-borne and infectious diseases</h3>
<p>
Warmer year-round temperatures worldwide are also driving the population of disease-carrying mosquitoes and ticks. In the United States, vector-borne disease cases tripled from 2004 to 2016, according to the Centers for Disease Control and Prevention. Washington state is home to more than 40 species of mosquitoes, many of them capable of spreading disease.
</p>
<p>
Higher temperatures have led to an earlier onset of the potentially fatal West Nile virus-carrying mosquitoes, according to the Washington State Department of Health's vector surveillance program. Since the first three human cases of West Nile reported in Washington in 2006, there have been an additional 92 endemic cases. King County had its first reported case of West Nile last summer.
</p>
<p>
The few reported cases of Zika virus were acquired elsewhere. The fear nationwide is that it's only a matter of time before the two types of mosquitoes that cause Zika move northward.
</p>
<p>
Warming sea temperatures and increasing ocean acidity fuel harmful algal blooms that can contaminate recreational water and shellfish. Warming waters are also becoming more hospitable to disease-causing pathogens such as vibrio, says Dr. Duchin. "Vibrio cases have risen dramatically in recent years; it's a disease that grows where a lot of our shellfish are farmed," he said. "People get nasty gastroenteritis— vomiting, diarrhea—from vibrio. And it also has a real economic impact."
</p>
<h3>Vulnerable communities</h3>
<p>
Communities of color, those with lower incomes, and indigenous people face the greatest and disproportionate climate risks, a CIG study found. These marginalized communities often lack the resources needed to manage their health or get the medical help they need, says Heidi Roop, a CIG climate change and equity researcher.
</p>
<p>
In Washington's agricultural sector, some 79 percent of outdoor farm workers experience a heat-related illness during summertime harvest. Those workers are vulnerable to heat-stress nephropathy, says Dr. Dooley. It's the leading killer of men under age 45 in Central America, where the majority of the population works outdoors.
</p>
<p>
Exacerbating the health of many outdoor workers during periods of high heat or wildfire smoke is that they often don't seek medical help for fear of losing their job, says Russell Maier, MD, a family physician in Yakima, and physician advisor to the dean of Pacific Northwest University of Health Sciences. "If they
do come in, what we're seeing is more advanced respiratory illness. It's hitting them when they can least afford it."
</p>
<p>
In Seattle, and other highly populated cities, the air quality is always worse in lower-income communities, which often sit near major highways, says Dr. Covert- Bowlds. These communities often lack air conditioning necessary to deal with heat waves or times of wildfire smoke.
</p>
<p>
"Polar bears dying is sad, but kids in South Seattle struggling to breathe is the current face of climate change and air pollution," he says. "That human suffering is what drives us to keep at it."
</p>
<p>
Smoke and air quality aren't the only climate change-related health concerns, says Roop. "If people live in flood plains and in coastal areas with sea level rise, those all have impacts on people's health and their ability to live in a clean home absent mold and contaminated drinking water," she says.
</p>
<p>
The impact of climate change goes beyond the physical. Mental health issues are often not discussed, but are a significant burden of climate change, says Dr. Duchin. "Extreme weather events, like heat waves and floods and windstorms all have significant mental health effects, particularly post- traumatic stress disorder, anxiety, and depression."
</p>
<h3>Physicians must speak out</h3>
<p>
Physicians are in a unique position to advance the dialogue on climate change, but public health systems face a steep hurdle when it comes to addressing climate change.
</p>
<p>
"We don't have the resources in place to adequately track the health consequences of climate change," says Dr. Duchin. "It lends to this complacency and helps people to minimize the fact that this is the single largest health threat facing us and will be for centuries unless we get our act together quickly."
</p>
<p>
"Sometimes doctors get too focused on treating the disease without asking, 'What are people going to do to solve the causes?'" Dr. Dooley says. "We should be screaming red [alert] in the summer to get vehicles off the road. The problem is not only particulate matter from wildfire smoke, but from diesel emissions."
</p>
<p>
Every physician has a responsibility to get involved, Dr. Butruille says. "We are seeing the public health effects of climate change now," he says. "We're going to see more of them in the future and shame on us if we don't do what we can to both prepare for and mitigate the results."
</p>
<p>
<em>Rita Colorito is a freelance journalist who specializes in writing about health care.</em>
</p>
<p>
<em>This article was featured in the July/August 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 9/16/2019 3:46:56 PM | 7/2/2019 2:36:29 PM | 7/2/2019 12:00:00 AM |
| taking_a_stand | Taking a Stand | WSMA_Reports | Shared_Content/News/Latest_News/2019/July/taking_a_stand | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/July-Aug-Reports-Article-Graphic-645x425px.jpg" class="pull-right" /></div>
<h5>July 2, 2019</h5>
<h2>Taking a Stand</h2>
<p>
</p>
<p>
By Pat Curry
</p>
<p>
Several Washington state hospital systems have been recognized for their efforts to reduce their effect on climate change. WSMA Reports talked to the sustainability managers at three health care organizations about the steps they have taken and asked them to suggest small steps individual physicians can take.
</p>
<h3>Virginia Mason Medical Center</h3>
<p>
Since 2011, Virginia Mason's energy conservation efforts have saved more than 4.5 million kilowatt hours per year, and water conservation efforts have saved around 7 million gallons of water annually. The hospital's food and nutrition department purchases nearly 40 percent locally or sustainably, and the hospital's recycling and composting efforts achieved a 48 percent rate.
</p>
<p>
"Our footprint is giant as an industry," says John Leigh, director of sustainability for Virginia Mason. "We are in the business of human well-being. Knowing climate change will have negative effects on the health of human beings, it would be unconscionable to not doing something about it as soon as possible."
</p>
<p>
An ad hoc green team at Virginia Mason focuses on recycling, looking at ways to improve signage and locate recycling bins. Every effort is important because hospitals generate so much waste through single-use or disposable items for infection control.
</p>
<p>
"Patient safety will always trump waste generation," he says. "It always will—and it should."
</p>
<p>
The health care industry is responsible for 10 percent of the nation's total emissions in greenhouse gases, including the use of anesthetic gases. One of the biggest impacts of the efforts at Virginia Mason is a radical reduction in the use of desflurane. The available options are more sustainable and less expensive.
</p>
<p>
"One doctor got behind this work here with my predecessor," Leigh says. "It just takes one champion to start asking questions in their department and pushing those who are reluctant to give it a try and see it can be done. ... That was one thing we could do without a lot of difficulty or fanfare."
</p>
<p>
Leigh says his "grand plan" is for Virginia Mason to achieve carbon neutrality, which means taking action to remove as much carbon dioxide from the atmosphere as you put into it. That means spending money on upgrading equipment. Justifying the expense can be tough at a health care facility, he says.
</p>
<p>
"This is an industry with not a lot of surplus capital to perform important facility upgrades like this," he says. "We tend to lose out on internal competition for capital improvements. It's hard to compete against an MRI or another important piece of equipment."
</p>
<p>
A quick win for individual physicians is to "green up" the supplies; use less
in the first place wherever possible, and then challenge manufacturers and suppliers to find ways to move toward environmentally preferable products and packaging.
</p>
<p>
They can also look at whether any items in their clinics expire before they are used.
</p>
<p>
"Focusing on reducing waste can have a lot of environmental benefit," he says. "Reducing 5 percent is pretty doable from my observation."
</p>
<h3>MultiCare Health Systems</h3>
<p>
MultiCare has been focused on sustainability for at least a decade, and is the parent company to Washington state's first green hospital, Good Samaritan Hospital Dally Tower in Puyallup. The system recently hired Tony Garcia, who ran the sustainability program at the Disneyland Resort for 10 years.
</p>
<p>
His early efforts are focusing on establishing task forces looking at technology, waste management, and water conservation. A sustainability committee of senior leaders steers the direction of the program.
</p>
<p>
The big wins in sustainability occur when senior executives see saving energy, water, and solid waste as a revenue stream, Garcia says.
</p>
<p>
"If you save costs on utilities, it's the same as generating revenue," he explained. "Cost cutting is nothing new in health care; this is a painless way to cut costs because you're not affecting your service level, you're reducing what you spend on a utility."
</p>
<p>
The easiest way to reduce energy and water consumption, he says, is through technology and automation.
</p>
<p>
"Sometimes the hardest part is getting authorization to invest in technologies, but there is a lot of proven technology out there we can leverage," he says.
</p>
<p>
For example, sensors help reduce energy use because they "don't require someone to turn something on or off, so there's no training required," Garcia says. Software ensures air handlers work efficiently, filters are clean, and the system is sequenced accurately and calibrated for the use of each space.
</p>
<p>
Small changes can add up as well. LED lights use less energy, require far less maintenance, and provide better light quality than incandescent or fluorescent bulbs. Ultra-low-flow toilets reduce the water usage rate per fixture; if automatic flush vales are used, careful calibration could reduce the amount of false flushes.
</p>
<p>
One area that can make a big difference is space management, says Ron Fues, project director with construction engineering firm McKinstry, which works with MultiCare.
</p>
<p>
"Your space changes all the time; an office could have once been a storage room or a waiting room," he says. "What often gets overlooked is the HVAC system that supports that space. ... In some cases, spaces need to be adjusted for more or less air flow."
</p>
<p>
If physicians lease a building, they should "be the squeaky wheel," Fues says. "If you see that things are automatically on at weird hours, put in a work order. That's an easy fix. If you own your own building, the EPA has a utility bill benchmarking tool (<a href="https://portfoliomanager.energystar.gov">portfoliomanager.energystar.gov</a>). You should be benchmarking your building to see how your building compares on a per square foot basis versus other similar buildings."
</p>
<h3>Seattle Children's Hospital</h3>
<p>
A 2019 winner of the Practice Greenhealth Environmental Excellence Award, Seattle Children's Hospital set several environmental goals in 2017 and achieved them within a year. Water use for irrigation was reduced by about a million gallons.
</p>
<p>
The hospital also increased a daily pay incentive to $4.50 to employees
to carpool, bike, walk, or take public transit. Staff members who carpool or vanpool can park on campus. A shuttle is provided from the Link light rail station to the hospital.
</p>
<p>
"Asthma is always in our top 5 in admissions," says Colleen Groll, manager of Seattle Children's sustainability program. "When we get more staff out of their cars, we're reducing pollution because in Seattle, transportation is the Number 1 emission."
</p>
<p>
Pulmonologist Jonathan Cogen, MD, noted that many of his patients drive long distances to see him. He could help with that.
</p>
<p>
"[One] morning, four of my five patients came over from Yakima for a half-hour visit," he says. "If I went out there, it would have cut those drives."
</p>
<p>
Reducing waste reduces carbon emissions, so dermatologist Markus Boos, MD, changed the way he has his staff set up his trays for skin biopsies. "The nurses are great and they would set up these beautiful trays," he says. "I would use half of it and the rest was thrown away. I had them put on the bare minimum and then hand me whatever else is needed."
</p>
<p>
Physicians can help the environment and save money for their practices by properly disposing of medical waste.
</p>
<p>
"Some people think a piece of gauze with a little blood on it needs to go in the red waste bag," he says. "Those bags are actually for things that are soaked with waste that can be expressed. Those items are a lot more involved to dispose of."
</p>
<p>
Whether physicians have their own prac- tices or work in a group or a hospital system, they can make a difference by speaking up.
</p>
<p>
"Sometimes, as physicians, we are afraid of talking about controversial issues," he says. "There's nothing controversial about this; the world is getting warmer. We should care about the children in front of us. That is a way to talk about it without getting on our high horse or use terms that are off putting. When I hear about climate change, it can feel overwhelming. What can I do as one person? As a society, everybody's voice matters."
</p>
<p>
<em>Pat Curry is WSMA Reports' senior editor.</em>
</p>
<p>
<em>This article was featured in the July/August 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
</div> | 9/16/2019 3:47:29 PM | 7/2/2019 2:35:48 PM | 7/2/2019 12:00:00 AM |
| ai_and_the_next_generation_of_physicians | AI and the Next Generation of Physicians | WSMA_Reports | Shared_Content/News/Latest_News/2019/June/ai_and_the_next_generation_of_physicians | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMA_MayJune-Reports-Cover-Article-Image-645x425px.jpg" class="pull-right" /></div>
<h5>June 21, 2019</h5>
<h2>AI and the Next Generation of Physicians</h2>
<p>
By Pat Curry</p>
<p>Seventeen thousand genes.</p>
<p>
Five driver events of cancer progression: gene expression, mutations, copy number, methylation, and known regulators of gene expression.
</p>
<p>
Fifty-three chemotherapeutic drugs that are FDA-approved and reasonably effective. Every tumor is different. Which drug will work best to fight each one?
</p>
<p>
"Our gut said the gene expression was affecting the drug sensitivity resistance...if we could figure out what those genes were," says Pamela Becker, MD, PhD, professor of medicine in the UW School of Medicine Division of Hematology and a member in the Clinical Research Division of the Fred Hutchinson Cancer Research Center.
</p>
<p>
But there were just too many variables to consider to achieve any degree of accuracy.
</p>
<p>
"To correlate 17,000 things with 50 things doesn't work," Dr. Becker says. "We needed another method; machine learning, also known as AI, is the method that can do that."
</p>
<p>
Dr. Becker is part of a research team at the University of Washington that is applying a combination of machine learning and big data to improve outcomes for cancer patients. The team—from UW Medicine, the Paul G. Allen School of Computer Science and Engineering, and the UW Department of Genome Sciences—developed MERGE, a new algorithm integrating five criteria impacting genes' contribution to cancer development. Using MERGE (short for "Mutation, Expression hubs, known Regulators, Genomic CNV, and mEthylation"), the team narrowed down the group of genes that would be sensitive or resistant to chemotherapeutic drugs from 17,000 to about three dozen.
</p>
<p>
"The higher or lower expression of those genes seems to be related to sensitivity of the entire class of agents," Dr. Becker says. "It reassured us we were on the right track. This was a huge first step to find the genes that seem to be related to drug sensitivity or resistance. That would help us figure out the best drugs for each patient."
</p>
<p>
The MERGE project is just one example of the ways Washington state's medical schools are using AI to advance health care for the next generation of physicians. This type of research is happening in every area of medicine, Dr. Becker says. Patient genetic profiles will be readily available to help customize treatment.
</p>
<p>
"Therapeutic information, drug dosing, this will get more and more sophisticated," she says. "For [medical] students, it's important to know that this is happening. Our tools will be better, more defined, and more able to recognize all these differences between people."
</p>
<h3>A tool for bringing specialties to rural areas</h3>
<p>
Robert Sorrells, PhD, associate dean for pre-clinical education and associate professor of anatomy at Pacific Northwest University of Health Sciences, was a cognitive science specialist for the University of Georgia's Artificial Intelligence Group before joining the faculty at PNWU. With a research focus on neural and computer modeling of knowledge representation and learning, Dr. Sorrells has written on artificial intelligence and the future of health care.
</p>
<p>
For PNWU, whose mission is to increase access to health care in rural areas, AI offers some intriguing possibilities for reaching rural areas that are underserved by specialties such as radiology and pathology.
</p>
<p>
"AI isn't going to replace those specialties," Sorrells says. "They aren't there in those rural areas. AI can be an interface between the physician and patient to deliver health care. When we can't get into rural areas, we can train the students to use the interface. Those are huge initiatives we want to equip our students for. With electronic medical records, algorithms can see patterns the primary care physician doesn't have the time or the bandwidth to put together. We want to train our students to use them before they're even available to the nascent population."
</p>
<p>
Today's medical students, who were born in the digital age and are extremely comfortable with technology, seem open and accepting of the new tools they will have at their disposal. Electronic stethoscopes can find a heart murmur that can't be heard by the human ear and provide a preliminary diagnosis.
</p>
<p>
Ultrasounds that connect to smartphones or tablets will be the "next huge thing in primary care," he says. "You can get this information without having to send a patient off to the city," he says. "When these tools hit the market, our students will already know how to use them."
</p>
<p>
Will AI change the coursework at medical school? Somewhat, Dr. Sorrells says, but only to the extent that it changes the tools.
</p>
<p>
"We still teach science," he says. "A doctor needs to be able to think through her science. When there isn't an iPhone or a stethoscope available, what kind of data do I need? We won't ever replace having very knowledgeable doctors who can reason through what can't be dealt with algorithmically."
</p>
<p>
One role of medical schools, he says, is to help address not only the technical advances provided by AI, but the ethical and cultural ones that physicians face every day.
</p>
<p>
"We need to train AI about cultural distinctions and teach them to respect and embrace those differences," he says.
</p>
<h3>An incubator for innovation</h3>
<p>The state's newest medical school, Washington State University's Elson S. Floyd College of Medicine, has taken the approach of creating a technology incubator, which is in the planning stages. The goal of the incubator will be to develop tools, technology, processes, and innovations to address health care problems in rural and underserved care and population health. It stands to reason that many of these initiatives will involve some aspect of AI.
</p>
<p>
The medical school also does a "wonderful job of providing an environment for students and faculty
to explore applications of emergent technology in all aspects of medicine," says Chris Martin, director of the medical school's simulation-based training.
</p>
<p>
Martin, whose department focuses on the use of virtual reality for medical training, notes that many of the devices his students use—Bluetooth-enabled blood pressure cuffs and glucometers, for example— download the results to a computer.
</p>
<p>
"We are finding is we have plenty of data," he says. "The vast amounts of data are difficult for a single person or a team to synthesize to understand what's going on with a patient or a disease process."
</p>
<p>
That, he says, is where AI can be extremely helpful.
</p>
<p>
"It won't replace the role of a physician, but will be able to augment their practice to provide better outcomes," he says. "It's just another example of how technology can better a practice rather than alter the trajectory of a profession. AI is great, but it still needs a teacher."
</p>
<p>
<em>This article was featured in the May/June 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
<p>
<em>Pat Curry is WSMA Reports' senior editor.</em>
</p>
</div> | 9/16/2019 3:47:45 PM | 6/21/2019 10:34:14 AM | 6/21/2019 12:00:00 AM |
| algorithms_as_partners_not_practitioners | Algorithms as Partners, Not Practitioners | WSMA_Reports | Shared_Content/News/Latest_News/2019/June/algorithms_as_partners_not_practitioners | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMA_MayJune-Reports-Cover-Article-Image-645x425px.jpg" class="pull-right" /></div>
<h5>June 21, 2019</h5>
<h2>Algorithms as Partners, Not Practitioners</h2>
<p><em>Members only, sign-in required</em></p>
<p>
By John Gallagher
</p>
<p>
Physicians can't escape the buzz around artificial intelligence in medicine, or the concerns that it raises: visions of robots in white coats practicing medicine by algorithm. If that's not bad enough, many suspect that AI might actually add to their workload instead of relieving it.
</p>
<p>
It's true that AI has the potential to change the way physicians practice. But that change can be for the better.
</p>
<p>
</p>
<p>
Properly done, AI could help with differential diagnoses, pick up on patterns that might otherwise escape detection, and identify roadblocks to better care. In fact, it is already doing these very things. To expand this achievement even further, the emphasis needs to be on how humans and computers can work
together to do better than either can do alone.
</p>
<p>
"You have to realize that it's a tool, just as a stethoscope is a tool," says Michael Anderson,
MD, chief medical officer at CHI Franciscan and a WSMA member. "There will never be a substitute for hands-on care of patients."
</p>
<p>
AI might be able to identify patterns in data to provide decision support for clinicians, says Lara Mangravite, president of Sage Bionetworks, a Seattle-based nonprofit focused on open practices for large-scale collaborative biomedical research. That would provide clinicians with more time to focus on "the human part of the job."
</p>
<h3>Harnessing big data</h3>
<p>
Measured by dollars alone, AI is a force to be reckoned with in health care. According to a December 2018 report from ReportLinker, investment in health care AI is expected to grow at an astonishing compounded growth rate of 50 percent between now and 2025, reaching more than $36 billion.
</p>
<p>
As with any emerging technology, AI has been the subject of sweeping rhetoric about its potential, both as a disruptor and a panacea. "Data science is really cool and a really hot topic," says Sean Mooney, PhD, chief research information officer of UW Medicine. "It is transforming fields."
</p>
<p>
Mooney acknowledges that as a phrase, AI is subject to shifting meanings. "Isn't it funny how the big- picture words are the hardest to define?" he notes. "I think of AI as learning something from data and using that to inform things." [For a glossary of terms, see facing page.]
</p>
<p>
Indeed, AI can help sort through reams of data to discover information that might otherwise be overlooked. WSMA President Thomas Schaaf, MD, a geriatrician and hospice care physician,
says that to him, the value of AI-type systems is the ability to see patterns that could potentially be missed by a human being in analyzing large data sets.
</p>
<p>
"It also brings the ability to suggest alternative diagnosis and treatments based on sufficient data about the patient and their case," he says.
</p>
<p>
Medicine offers no shortage of data from which to draw. But what AI relies upon is good data. That may be rarer than many think.
</p>
<p>
"We like to say, we have EHRs, we have big data, end of story," says David Haynor, MD, a neuroradiologist at UW Medicine, "but it's nowhere near that simple."
</p>
<p>
Indeed, getting data that is reliable and comparable is a challenge uniquely suited to the capabilities of AI systems. Haynor notes that a doctor may treat 1,000 patients for sore throat. "By the time he narrows it down, he's only got 152 patients with a reasonable amount of data: one lab test, a physical exam, and a follow up," he says. "That's not big data. That's tiny data."
</p>
<p>
Creating an algorithm for AI isn't necessarily difficult. Mooney recalls a colleague at Notre Dame who designed a predictive analysis on anonymized claims data using the kind of algorithm Netflix employs to suggest movies you might like.
</p>
<p>
Getting algorithms to be specific and sensitive is another matter. The patterns an algorithm picks out may be legitimate, but not important. Schaaf notes that one analysis determined that "the most reliable marker for a skin cancer lesion is the presence of a ruler next to the lesion."
</p>
<p>
That's why data scientists consider the input of physicians pivotal in creating AI that truly advances patient care.
</p>
<p>
"Data scientists may be using AI to solve problems that clinicians don't need solved; that's a problem that I think might become a real issue," Mangrative says. "Just because clinicians don't know how to manage a 50-terabyte file doesn't mean they aren't exquisitely talented about those things they do know about. We need to take both sets of expertise into account as we design systems."
</p>
<h3>Teaching AI to learn</h3>
<p>
Not surprisingly, imaging is a field ripe for AI, and radiology is one specialty where AI has already made significant inroads. Routine imaging, such as mammograms, creates a treasure trove of data that lends itself to computer analysis.
</p>
<p>
A recent study of the performance of AI algorithms in interpreting mammogram results showed that AI is fulfilling its promise—to a degree. "The results were as good or better as the average radiologist's," Haynor says, "but not as good as the best radiologist's."
</p>
<p>
However, algorithms can learn, just as people do. As algorithms have more data to work with, they can become more adept at flagging what truly matters with ever greater accuracy. This machine learning, as it is called, is key to advancing AI and creating systems that provide physicians with information they need to make decisions.
</p>
<p>
For example, Haynor cites the recommended chest CTs that smokers should get every few years. AI could correlate certain features, such as the size of a nodule, with past scans and determine if it warrants the radiologist's further attention.
</p>
<p>
"The ideal model would be something that functions as a radiologist's assistant," he says, "a tireless guy who looks at every study, working in the middle of the night and on Sundays, telling you, 'Look at this particular slice and tell me if that is of concern."
</p>
<h3>Involving physicians in the process</h3>
<p>
Even primary care is beginning to feel the impact of AI. Providence St. Joseph Health has created an AI-powered chatbot called Grace to make sure patients can navigate more smoothly through the system. Sunitra Mishra, MD, chief executive of the Express Care program at Providence, says her clinical team worked closely with the tech team to create the logic to determine when patients should be seen at one venue versus another.
</p>
<p>
As a primary care provider, Dr. Mishra says she can see the opportunities AI offers. It could potentially reduce some of the administrative burdens for physicians, giving them more time for patient care and reducing the risk of burnout.
</p>
<p>
Of course, to do so, AI needs to be integrated into the workflow in such a way that it does not make more work. "I'm like all doctors," Dr. Haynor says. "If it takes me more time, and it doesn't make my work easier, why should I do it?"
</p>
<p>
In addition, AI will have to earn the confidence of physicians through rigorous study of how it performs. "It's really important to invest in research around the performance of data science methods in practice and whether they achieve the outcomes we want them to achieve," Mooney says. If AI is able to fulfill all of these goals, it will prove extraordinarily useful in the practice of medicine.
</p>
<p>
What it won't do is supersede the physician-patient relationship.
</p>
<p>
"Whether a patient improves or not depends on whether patients trust their physician and feel listened to,"
says WSMA member Jessica Schlicher, MD, MBA, medical director for care transformation for CHI Franciscan. "Caring for our people with compassion, coupling the experience with clinical expertise—that's where the power of the physician is. I don't ever see a world where AI can replace that."
</p>
<p>
<em>This article was featured in the May/June 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
<p>
<em>John Gallagher is a Washington-based freelance writer who specializes in covering health care and health care policy topics.</em>
</p>
</div> | 9/16/2019 3:48:35 PM | 6/21/2019 10:41:43 AM | 6/21/2019 12:00:00 AM |
| keeping_physicians_engaged | Keeping Physicians Engaged | WSMA_Reports | Shared_Content/News/Latest_News/2019/March/keeping_physicians_engaged | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/Reports-Mar-April-Website-645x425.jpg" class="pull-right" /></div>
<h5>March 12, 2019</h5>
<h2>Keeping Physicians Engaged</h2>
<p>
By Pat Curry
</p>
<p>
When a longtime patient of Bruce Nitsche, MD, made a donation to the Virginia Mason Foundation, the patient asked if Dr. Nitsche could be involved in how to use the funds. A study from the Mayo Clinic found that sharing a meal helped with physician engagement; the foundation used some of the donated funds to try it.
</p>
<p>
"I called up the head of nutrition services and said, 'Do you think you could get the chefs to cater a lunch in the doctor's dining room once a month?'" Dr. Nitsche said.
</p>
<p>
They started with Cinco de Mayo, complete with Mexican music, mocktails, and handmade tortillas; it was a tremendous success.
</p>
<p>
"It was just fun," Dr. Nitsche said. "I remember sitting at a table with a longtime urologist and one of the newer internal medicine doctors. They had shared a lot of the same patients, but they had never met, and they introduced themselves to each other."
</p>
<p>
The lunches are just one way Virginia Mason, MultiCare Health System, Allegro Pediatrics, and other systems are addressing issues presented in Stanford Medicine's 2018 Physician and Advanced Practitioner Wellness Survey, commissioned by WSMA and the Washington State Hospital Association. Notably, the survey found that 42 percent of the surveyed physicians were moderately or highly likely to leave their organization within two years.
</p>
<p>
"It costs $500,000 to $1 million to replace a doctor who leaves, quits, or cuts down on their practice," Dr. Nitsche said. "It's a huge financial burden on the organization."
</p>
<p>
And it's not going to go away, said Scott Hansen, MD, who heads up Virginia Mason's psychiatry consultation service and professional staff engagement.
</p>
<p>
"What younger physicians will accept as working conditions is different than what physicians would accept several decades ago," Dr. Hansen said. "They aren't willing to spend 120 hours a week in a hospital."
</p>
<p>
Dr. Hansen noted that research very clearly shows what physicians believe to be important in their practice experience. Physicians want an electronic health record system that supports both good care and reduces time spent on activity that doesn't feel meaningful. They seek a sense of community and want to understand that they have the support of their supervisors.
</p>
<p>
"Developing frontline leaders is critical; it has so much to do with the experience of physicians over time," Dr. Hansen said.
</p>
<h3>Giving physicians more flexibility</h3>
<p>
Physician-owned Allegro Pediatrics, which has about 100 physicians working in eight locations, began studying physician burnout about three years ago. A physician survey focused on scheduling, how long physicians had with their patients, what their day looked like, and what was getting in their way of doing their jobs.
</p>
<p>
"The providers were saying they needed more support," said Tiffany Spanier, MD, who works in Allegro's Bellevue location. "It was very clear this was something we needed to address."
</p>
<p>
The results led to discussions about choice, flexibility, and autonomy, Dr. Spanier said. Physicians can pursue a partner track, a locums position, or a time-limited contract. Senior physicians have the choice of decreasing their call nights and weekend shifts, which lets them feel less burdened.
</p>
<p>
New physicians receive an extensive orientation and a mentor, and all physicians know that if they need to be out of the office for a family emergency, "the coverage is there immediately," she said. "That support is a huge sense of relief."
</p>
<p>
The practice also offers three-month paid sabbaticals to let physicians recharge and refresh. "A lot of them use that time to do research; others travel," she said. "We have a lot of part-time providers working in endeavors outside our practice: travel medicine, research; I'm teaching mindfulness. We're finding ways to give them the opportunity to pursue their passions."
</p>
<p>
Allegro continues to survey its physicians and encourages them to talk to clinic leadership. Dr. Spanier said she's going into clinics and starting conversations with physicians to "give them the framework to speak up even more.
</p>
<p>
"A lot of times, providers think the responsibility for burnout is going to land on their shoulders, and we don't want that," she said. "We don't want this on their shoulders. We want to continue to address it systemwide; we want them to know they're not alone."
</p>
<h3>Finding better workflow</h3>
<p>
It's not uncommon to hear physicians say they're being offered personal solutions, such as resilience training, to tackle systemic problems. MultiCare Health System is addressing that point with its Provider Wellness Team. The two-pronged approach offers free, confidential counseling and practice optimization consulting to address the pain points in a physician's practice.
</p>
<p>
"Eighty percent of burnout is the result of the workplace environment," said MultiCare practice optimization consultant Ellie Rajcevich. "Being able to provide that support has been a cornerstone of our program."
</p>
<p>
Most often, physicians contact the team because they're frustrated with some aspect of how their practice is running. For example, an internal medicine physician called because she had reduced her FTE from full time to .8 "to keep her head above water," Rajcevich said. "Even then, she was using days off to work. If the problem is all this work, reducing the FTE doesn't address the root of the problem."
</p>
<p>
To find solutions, the team starts by shadowing the physician.
</p>
<p>
"We look at the processes and what that physician's time and the team's
time looks like," Rajcevich said. "The teams we work with don't have the chance to step away from all the things they have to do every day. Having someone come in and say, 'This is what your work could look like' is an interesting experience for them."
</p>
<p>
Sometimes, dictation software or a medical scribe proves helpful. Other times, the consulting team identifies a task that is unnecessary or could be completed by someone other than the physician, such as responding to MyChart patient messages.
</p>
<p>
Quite often, part of the solution involves dealing with the Epic electronic records software. That's such a big part of a physician's workload that the consulting team is adding dedicated Epic trainers "so they can access what they need accurately and quickly."
</p>
<h3>Small steps toward a solution</h3>
<p>
All these efforts help, but they just scratch the surface of addressing what makes so many physicians consider leaving their jobs, Dr. Nitsche said.
</p>
<p>
"What needs to be done is make the job require less resilience to survive it," he said. "The whole health care system is troubled. It's like living in a dysfunctional family; you need to fix that. But you can also make people feel better along the way."
</p>
<p>
<em>This article was featured in the March/April 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
<p>
<em>Pat Curry is WSMA Reports' senior editor.</em>
</p>
</div> | 9/16/2019 3:47:41 PM | 3/12/2019 3:59:58 PM | 3/12/2019 12:00:00 AM |
| at_higher_risk | At Higher Risk | WSMA_Reports | Shared_Content/News/Latest_News/2019/March/at_higher_risk | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/Reports-Mar-April-Website-645x425.jpg" class="pull-right" /></div>
<h5>March 8, 2019</h5>
<h2>At Higher Risk</h2>
<p>
By Marcia Frellick
</p>
<p><em>Members only, sign-in required</em></p>
<p>
Jessica Bloom, MD, a family physician in Bellingham, knows the dark corners of burnout and knows when she's getting near them. Sensing those danger zones is part of an ongoing self-care strategy forged during a five-year time period when the "good Midwestern girl who is always fine" actually wasn't.
</p>
<p>
Dr. Bloom, now 45, looks back at that time when, in addition to practicing medicine, she was the wife of a family physician, the mother of three children under the age of 10, and the sole caregiver for her aging father.
</p>
<p>
She describes feeling empty. She forgot to attend some of her kids' events. She got angry when someone at work told her she hadn't completed her charts. She asked her husband why he stayed with her when she wasn't so sure, in his shoes, if she could.
</p>
<p>
"I felt so tired," she said. "All I wanted for my birthday was to be alone."
</p>
<p>
Bloom said her patient care never wavered, though she admits she may have been less engaged with some. But she felt torn about whether she should spend more time at work, where she was handling things well, or more time with her family.
</p>
<p>
Safety nets are easier to build when certain numbers of physicians meet the definition of burnout, she said, but what the numbers don't reveal are that many physicians are "just a 'something' away from a crisis"—a patient's bad outcome, a fight with a spouse, a death in the family, or a personal illness.
</p>
<p>
Experiences like Dr. Bloom's spurred the WSMA and the Washington State Hospital Association to commission Stanford Medicine's WellMD Center to survey physicians and advanced practitioners about burnout and professional fulfillment. The report found that 43 percent of Washington's physicians and advanced practitioners are experiencing burnout, compared with the national benchmark of 36 percent. Additionally, 34 percent reported they are fulfilled professionally, lower than the national average of 41 percent.
</p>
<h3>No health care organization beat both benchmarks</h3>
<p>
Jennifer Hanscom, WSMA's chief executive officer, said that the most surprising result of the survey was that no large medical groups, hospitals, or health systems in Washington beat the national benchmarks for both burnout and professional fulfillment.
</p>
<p>
"With the investments that the WSMA and many medical systems and groups have put into leadership development, I thought that more groups, particularly those in a strong physician-led culture, would have had a higher professional fulfillment score," she said.
</p>
<p>
She said she was also deeply concerned, as the results support that growing numbers of physicians may be on a tragic path. Some studies have shown that about 400 physicians nationally die by suicide each year.
</p>
<p>
The WSMA has targeted burnout and lack of fulfillment since 2014 when it launched Healthy Doctors, Healthier Patients, which is aimed at drawing attention to how increasing administrative burdens affect physicians and threaten optimal patient care.
</p>
<p>
Before that, the attitude in medicine was that physicians needed more skills to increase resilience. In other words, Hanscom said, it was physicians' responsibility to take care of themselves. Thinking evolved away from individual responsibility into how to fix a broken system that is overwhelming physicians and employees.
</p>
<p>
In tackling the issue, the WSMA found a fitting partner in the Washington State Hospital Association, as the two groups regularly bring together medical officers to address issues related to quality and patient safety. "There was a recognition in our Medical Officers Collaborative that together, we could address the issue of burnout—this is our collective responsibility," Cassie Sauer, chief executive officer of WSHA said. "We decided to launch a statewide assessment of physicians and advanced practitioners to inform our work. It is so important for both the clinician and his or her patients that we create more support for wellness."
</p>
<h3>Four factors drive fulfillment and burnout</h3>
<p>
The survey results pointed out that four factors—gratitude, alignment between personal values and organizational values, control over schedule, and peer supportiveness—were independently linked with professional fulfillment and burnout.
</p>
<p>
Addressing those key areas may be the "secret sauce" in Washington, said Christopher Bundy, MD, MPH, executive medical director of the Washington Physicians Health Program.
</p>
<p>
He pointed out the scope of the survey was important: "The goal really shouldn't be just the reduction of burnout, but to really promote professional fulfillment, and this report provides some strong pointers to where we should look," he said.
</p>
<p>
A top area of concern, Dr. Bundy said, is organizational leadership, which had the most impact on burnout and professional fulfillment among the factors highlighted in the report.
</p>
<p>
"Physicians are often accidental leaders," Dr. Bundy explained. "They are good doctors who are respected by colleagues for their clinical acumen and their emotional intelligence who want to serve the profession and essentially volunteer to be in leadership roles, for which they have little training or experience."
</p>
<p>
Management is a science, he said, and physicians need leadership training and development, professional coaching, and leader certification programs. Complicating leadership is the rising turnover that occurs with mergers and acquisitions.
</p>
<p>
Increasing peer support will also be crucial in bolstering physician wellness, Dr. Bundy said. He pointed to the example set by Confluence Health in Wenatchee which, he said, was able to turn peer review into peer support.
</p>
<p>
"So often, peer review is thought to be a blame game," Dr. Bundy said. Peer review there focuses on discussion about how the organization can improve after a poor outcome, leading physicians to feel supported instead of interrogated.
</p>
<h3>Some strategies are inexpensive</h3>
<p>
Some of the problem areas identified have very inexpensive fixes. For example, a culture of gratitude is a strong driver of professional fulfillment, the survey noted.
</p>
<p>
This is simply the frequency with which physicians and advanced practitioners are thanked by leadership and how often health care providers are thanking the people they work with, said Mickey Trockel, MD, PhD, a clinical associate professor in psychiatry and behavioral sciences at Stanford and the primary developer of the survey measures.
</p>
<p>
Shifting culture can be a challenge, but the cost is low and if the thanks are sincere, it can be effective, he said. A culture shift also is needed to remove the stigma from seeking mental health treatment in medicine. Dr. Trockel pointed to higher anxiety levels in the survey for Washington physicians compared with the national benchmark and said reasons for that are worth exploring further.
</p>
<p>
Alignment between an organization's professed values and the way physicians see the organization's values is also important, he said. An example of misalignment might be an organization that says it values physician wellness but allows surgical residents to work more than 80 hours a week.
</p>
<p>
Hanscom said the WSMA will use the survey results to explore with national experts how to facilitate improvements at the practice level and through the association's advocacy agenda.
</p>
<p>
That support—and the ongoing focus on burnout from medical leadership across the state—is vital as physicians such as Dr. Bloom work to maintain a healthy balance between taking care of their patients and themselves.
</p>
<p>
If burnout is a 1-10 scale where "1 is Pollyanna" and 10 is the peak of despair, she said her worst days hit about a 7. With the help of a life coach and through her work as a leader of the Physicians' Wellness Alliance, she says she hovers around a 3. But she is well aware that the number can bounce and it's "a process and a practice to stay as whole as we can."
</p>
<p>
<em>This article was featured in the March/April 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
<p>
<em>Marcia Frellick is a freelance journalist who specializes in health care topics.</em>
</p>
</div> | 9/16/2019 3:48:28 PM | 3/8/2019 2:13:43 PM | 3/8/2019 12:00:00 AM |
| a_lonely_but_not_isolated_experience | A Lonely, but Not Isolated, Experience | WSMA_Reports | Shared_Content/News/Latest_News/2019/March/a_lonely_but_not_isolated_experience | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" /></div>
<h5>March 6, 2019</h5>
<h2>A Lonely, but Not Isolated, Experience</h2>
<p>
David Gavareski, MD
</p>
<p>
David Gavareski, MD, practiced family medicine for more than 30 years at Family Health Associates in Bellingham. Retired in 2018, Dr. Gavareski shared his experience with burnout with <em>WSMA Reports.</em> To read more about the work WSMA is doing to support physician wellness, visit the <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA_Reports_Archive/WSMA/News_Publications/Publications/WSMA_Reports_Archive/WSMA_Reports_Archive.aspx?hkey=d3cb4400-8f2b-4fd4-9e4f-f970296623b3">WSMA Reports archive</a> and look for the March/April 2019 edition.
</p>
<p>
<strong><em>WSMA Reports: What was your experience with burnout?</em></strong>
</p>
<p><strong>Dr. Gavareski</strong>: My personal experience has a significant component of addiction and chemical dependency. When I was a child, I had asthma, and there was little to treat it other than vaporizer and cough syrup. I always felt better, but thought it was the vaporizer. Later, when I took codeine cough syrup, I felt much better, more relaxed, and had more energy. I never dreamed that occasional use, either for a cough or to relax, would lead to addiction. And with a "candy store" full of samples readily available in the late ’70s and early ’80s, that process was helped along. As with most drugs of addiction, the initial good feelings were never replicated. Ultimately, that added to my stress, worries, and frustrations over not being able to control my use.
</p>
<p>
Following medical school, residency, and beginning practice, I experienced significant stress as I coped with the arrival of a daughter, an extremely busy practice and trying to live up to all of the expectations. I did not do a good job balancing time and priorities. It was difficult to deal with the pressure to succeed and to try to be the best.
</p>
<p>
The burnout I experienced in a highly demanding profession and family life, coupled with a disease that I was not able to control or cure on my own, became terribly oppressive. I clearly had a problem, but I was extremely fearful of the consequences of admitting it.
</p>
<p>
<strong><em>What was key to healing and what kept you in medicine?</em></strong>
</p>
<p><strong>Dr. Gavareski</strong>: Ultimately, through an intervention with my wife and a counselor, I went to treatment at a local recovery center, which was the best decision I had made in years. I was introduced to 12-step recovery (which I have actively participated in since) and referred to what would become the <a href="https://wphp.org/">Washington Physicians Health Program</a>. Learning that there was a positive way to deal with the addiction as well as learn to live a more balanced life, I began a journey which, though difficult, has provided me with tools, advice, and relationships that added to my personal, professional, and family life.
</p>
<p>
WPHP has been an amazing partner and mentor. The fears I had about having to be involved with a state-sponsored monitoring program were unfounded. While they are tasked with protecting the public, they are also extremely committed to helping physicians and other professionals regain useful and productive lives, both professionally and otherwise.
</p>
<p>
<strong><em>Your advice for physicians suffering from burnout?</em></strong>
</p>
<p><strong>Dr. Gavareski</strong>: There are many of us who have been through the same difficulties, have found answers and a much better way of life. WPHP is an incredible resource. <a href="https://www.kavumd.org/">KAVU</a> and the wellness programs that are being developed have a potential to be a significant help. You don't have to be afraid to say something and seek help.
</p>
<p>
<em>Dr. Gavareski is part of the Physicians Wellness Alliance, as are Drs. Laura Backer, Richard Krebs and Jessica Bloom. Read their stories in the <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA_Reports_Archive/WSMA/News_Publications/Publications/WSMA_Reports_Archive/WSMA_Reports_Archive.aspx?hkey=d3cb4400-8f2b-4fd4-9e4f-f970296623b3">WSMA Reports archive</a>, March/April 2019 edition. They are available for speaking engagements. Call 541.543.7283 or write <a href="mailto:info@physicianswellnesalliance.org">info@physicianswellnesalliance.org</a>.</em>
</p>
</div> | 9/16/2019 3:47:00 PM | 3/6/2019 11:29:14 AM | 3/6/2019 12:00:00 AM |
| physicians_are_not_alone_in_the_journey | Physicians Are Not Alone in the Journey | WSMA_Reports | Shared_Content/News/Latest_News/2019/March/physicians_are_not_alone_in_the_journey | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" /></div>
<h5>March 6, 2019</h5>
<h2>Physicians Are Not Alone in the Journey</h2>
<p>
Richard Krebs, MD
</p>
<p>
Excerpts from this commentary by Richard Krebs, MD, appeared in the March/April 2019 print edition of WSMA Reports. Dr. Krebs practiced family medicine for 20 years, served as a surgical assistant for 18 years, and retired in 2015. Here, he shares his journey through burnout in the hopes that doing so will help others.
</p>
<p>
My relationship with burnout has been a long journey, a road I've travelled many times. In the past, there weren't many travelers who were willing to share in the journey, and it was a lonely path. Now, nearly 25 years later, more colleagues are sharing their experiences, and I don't feel so alone, so ashamed.
</p>
<p>
My journey began in the late 1980s and early '90s, when I finally realized and acknowledged I had nothing left to replenish my emptied emotional and physical well.
</p>
<p>
I had a loving family, a wife and two children, and a successful family practice. My joy was spending whatever time was necessary to be with my patients, and to "hear" the issues they brought to me. I was a doctor, but more importantly, I was a healer. I brought my heart to my practice every day and to every patient.
</p>
<p>
But as the business side of practicing medicine changed, it became more difficult to spend the time I thought was necessary to be with my patients. I was becoming emotionally and physically depleted. I was also less emotionally available to my family. My turning point was when, after a particularly difficult day, I had a fleeting thought of suicide while driving. I thought, "I just want to stop feeling like this. If I drive my car into the base of this bridge, it will all be over."
</p>
<p>
I sought help through counseling, personal growth groups and exercise. I was prescribed antidepressants for depression and stimulants for ADD in order to stay on task and see the number of patients necessary to maintain a viable private practice. I was physically and emotionally exhausted.
</p>
<p>
My wife and I attended a workshop titled "Physician Heal Thyself" in San Diego in February 1993. At that workshop, I realized I wasn't alone in my struggles and was able give a name to what I was going through: physician burnout.
</p>
<p>
After that conference, I was energized to work on healing myself and to offer support to others going through similar struggles. My wife and I started a group in Bellingham that we called ADAPT (And Doctors Are People Too). Our group was open to physicians and their spouses. We met twice a month, shared our stories and offered each other support. I continued individual counseling and personal growth groups. I started giving talks about burnout to physician groups and healers in correctional medicine. For me, sharing was healing. I was a survivor.
</p>
<p>
After much thought and counseling, I made the decision to leave my private family practice after 20 years. My partners told me: "Rich, when you leave, the heart will leave our practice." But with the support of my family, friends and colleagues, I stopped practicing medicine in 1997 for six months, using that as a time to renew and reflect. I realized that the type of medicine and healing that nourished my soul was no longer viable in the current medical and reimbursement climate.
</p>
<p>
I needed to support my family and wanted to stay involved with medicine. So, I went to work in a university student health clinic and started assisting in surgery. The surgical assisting became a full-time practice. Although I no longer had a practice and patients of my own, I enjoyed the interaction and "healing" I was able to bring to the working relationships with the support staff in surgery. I created an emotional and time boundary in my new work that I was unable to sustain in my private practice. I continued to give talks on burnout and stayed involved with other physicians interested in talking about and supporting colleagues affected by burnout.
</p>
<p>
Several of us started <a href="https://www.physicianswellnessalliance.org/">Physician Wellness Alliance</a> to address issues of burnout. As a result of that, we do presentations, and implemented the <a href="https://www.kavumd.org/">KavuMD</a> concept and website where physicians can anonymously assess their personal risk of burnout as well as have access to teletherapy. Several of us are available to meet with any physician who might be struggling. We meet informally as individuals, listening with the heart of someone familiar with the journey of burnout, who cares and has survived.
</p>
<p>
Burnout affects each of us differently, it is so personal. It affects more than 50 percent of our medical community. There is no one solution that can be prescribed for all. I believe the best way to help other healers is to tell our story, to be vulnerable and available, to listen to their unique story. We should encourage our colleagues to get whatever support is necessary, either peer support or professional counseling to help them make whatever changes are necessary to make them whole.
</p>
<p>
I'm grateful to have passed through that dark time with my marriage, family and professional life intact. I feel I can give back by being there for other healers who might be struggling. So many people in the healing profession and other walks of life have lost their balance and forgotten why they chose to serve. Our hearts and ears must be ever vigilant to be a support, to listen and care. Physicians are not alone.
</p>
<p>
<em>Dr. Krebs is part of the <a href="https://www.physicianswellnessalliance.org/">Physicians Wellness Alliance</a> and is available for speaking engagements. Call 541.543.7283 or write <a href="mailto:info@physicianswellnesalliance.org">info@physicianswellnesalliance.org</a>.</em>
</p>
</div> | 9/16/2019 3:46:59 PM | 3/6/2019 10:59:30 AM | 3/6/2019 12:00:00 AM |
| sharing_struggles_yields_hope | Sharing Struggles Yields Hope | WSMA_Reports | Shared_Content/News/Latest_News/2019/March/sharing_struggles_yields_hope | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" /></div>
<h5>March 6, 2019</h5>
<h2>Sharing Struggles Yields Hope</h2>
<p>
Jessica Bloom, MD
</p>
<p>
WSMA Reports reported aspects of Dr. Jessica Bloom's story in the March/April 2019 cover story. In this online "extra," Dr. Bloom shares additional insights into her journey through burnout in the hopes that doing so will help others who share the same struggle.
</p>
<p>
I experienced "overwhelm" for decades as many of us in medicine do. There came a time when I felt like all of the important things in my life were like plates being spun on sticks: patient care, my kids, my marriage, my aging parent, and me too. I watched the plates wobble, but I couldn't figure out which to spin faster first. I knew something was going to drop.
</p>
<p>
When my father's wife died unexpectedly and I was suddenly his primary support again, I thought all the plates would fall. I cut back where I felt I could, but I couldn't make things better. I was depleted. I poured myself into my patients and my kids, but then I had nothing left for my physician spouse or for me.
</p>
<p>
I daydreamed about running away. But where to? What from? I wasn't sure. When I would share my fatigue, I was advised to go on a "retreat." When I shared my overwhelm from multiple call schedules, the advice was to cut back a part of my practice that I enjoyed.
</p>
<p>
What actually helped? When my dad got sick, I worked with a therapist. Then, I agreed to help an acquaintance who was training to be a life coach. I found that to be a way to externalize my thoughts and structure them for better perspective. In those appointments we discussed which plates I could put down and when. More importantly, we identified what I wanted to do that I couldn't because of the overwhelm.
</p>
<p>
I never wanted a solution that took me away from medicine. Some of the physician coaches out there have stopped practice, but I needed to find something that kept me whole to do the work I love.
</p>
<p>
Around this time, I was asked to spearhead a local physician wellness project. I needed to see if I could toss life lines to others. Incorporating compassion, connection, and creativity into the work became a gift that returned in kind.
</p>
<p>
Now I work on building a better safety net for physicians, such as <a href="https://www.kavumd.org/">KavuMD.org</a>, the <a href="https://www.physicianswellnessalliance.org/">Physicians' Wellness Alliance</a>, and the PeaceHealth Wellbeing Committee. Through all of that, we work on mindfulness opportunities for physicians, social gatherings to build community, working with our local hospital for improving spaces for physicians, trying to build a peer support system. All of this is extra work, but it is work that feeds me.
</p>
<p>
I like medicine so much more when I know my colleagues. I'm putting my heart into the work of wellness because I really love my docs. I get excited when I talk to others supporting physicians. In fact, each therapist I've interviewed to be a part of KavuMD has added to my thinking about how to support each other.
</p>
<p>
When our Physicians Wellness Committee presented a panel discussion on surviving physician burnout, it was one of our best attended county medical society meetings. I moderated the panel, but also shared my story because as the only physician mother on the panel, it rounded out the perspectives. Telling our stories is important in order to humanize the toll medicine can take.
</p>
<p>
Often with burnout we race to solutions: Get mindful! Cut back! Get a counselor! Get a scribe! Each of those may be very helpful, but if we don't start with connecting with the human story, the loneliness persists. And blame is heaped on the physician who just isn't getting it done.
</p>
<p>
In the time I've been working on physician wellness, my father has died, my kids are growing, life keeps marching forward. And I still dip into overwhelm. But mostly, I'm grateful, and I like my primary job as a physician.
</p>
<p>
On the day I wrote this article, I spent 40 percent of my clinic hours treating depression. That's the other thing about doing this work, it has given me tools to pass onto my patients. A physician who is supported into a healthier existence can have a huge ripple effect.
</p>
<p>
I'm working to be part of that ripple effect. I have been told by so many physicians in our community that the emails I send help them feel connected. Stories can do that. I'm sharing mine in hopes that it will be helpful.
</p>
<p>
<em>Dr. Bloom is part of the <a href="https://www.physicianswellnessalliance.org/">Physicians Wellness Alliance</a> and is available for speaking engagements. Call 541.543.7283 or write <a href="mailto:info@physicianswellnesalliance.org">info@physicianswellnesalliance.org</a>.</em>
</p>
</div> | 9/16/2019 3:47:15 PM | 3/6/2019 11:21:54 AM | 3/6/2019 12:00:00 AM |
| three_wellness_tips_for_residents | Three Wellness Tips for Residents | WSMA_Reports | Shared_Content/News/Latest_News/2019/March/three_wellness_tips_for_residents | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" /></div>
<h5>March 6, 2019</h5>
<h2>Three Wellness Tips for Residents</h2>
<p>
Elizabeth Parker, MD
</p>
<p>
Understanding and supporting physician wellness is a complex endeavor encompassing personal resilience, community, and system-level organization. From my own experience, and at the risk of sounding glib, it's not enough to have a yoga mat and expect to be well.
</p>
<p>
Instead, let's cultivate a wellness toolkit that supports optimal health within these major areas. Here's how it could play out for a trainee:
</p>
<p>
<strong>Personal resilience</strong>
We learn about Maslow's hierarchy of needs in medical school. But often, in training, our own base needs (sleep, water, food) may not be met. While resilience ideally goes beyond these basic needs, for many of us this would be a good first step. Recommendation: Sleep when you can, grab water for rounds, carry snacks in your pockets.
</p>
<p>
<strong>Community</strong><br />
Feeling connected and supported by your team, department, and mentors is key. Find your people. Recommendation: Check in with your peers, ask for help when you need it, and intentionally stay connected (see related article below).
</p>
<p>
<strong>System-level organization</strong><br />
There are aspects of modern health care that support physician wellness—thank you support staff! There are also aspects that drag us down, including EHR click fatigue, prior authorizations, lack of open hospital beds, etc. As trainees, while we may not have the power to change the organizational systems within which we work, we do have the opportunity to learn about organized medicine and the power of our collective voices. Recommendation: Join a departmental/institutional committee or a professional medical organization, such as the Washington State Medical Association. It's easy and free to join the WSMA!
</p>
<p>
<em>Elizabeth Parker, MD, is a pathology resident at the University of Washington Medical Center. </em>
</p>
</div> | 9/16/2019 3:48:40 PM | 3/5/2019 3:46:52 PM | 3/6/2019 12:00:00 AM |
| uw_residents_run_for_wellness | UW Residents Run for Wellness | WSMA_Reports | Shared_Content/News/Latest_News/2019/March/uw_residents_run_for_wellness | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" /></div>
<h5>March 6, 2019</h5>
<h2>UW Residents Run for Wellness</h2>
<p>
Elizabeth Parker, MD
</p>
<p>
As Saturdays dawn over Seattle, several University of Washington Medical Center pathology residents meet up to run for health, wellness, and support. The idea to organize group runs was born out of a desire to stay active, explore Seattle parks, and to connect with one another outside of work and away from the hierarchy of medicine.
</p>
<p>
The runs are open to all, and there are often residents from various levels of training running along with significant others, kids, and friends in tow. Occasionally attendings, trainees from other specialties, and physician assistants will join. The group sticks to Seattle-area parks and has even completed several races together.
</p>
<p>
While Saturday morning runs may not work for every physician group, the participants on these runs find wellness and leadership support. Here's what a few of them have to say about running together:
</p>
<ul>
<li><strong>Marie Perrone</strong>, PGY3 resident: "I never regret getting up on Saturday morning to go running with the resident running group: What could be better?" </li>
<li><strong>Alex Mays</strong>, PGY3 resident: "Running together is a great equalizer—it's a much more informal environment and we can connect about life outside the hospital." </li>
<li><strong>Chris Chandler</strong>, PGY2 resident: "The group has become a cornerstone of my weekends and I look forward to getting out and seeing the city." </li>
<li><strong>Angelica Lerma</strong>, PGY3 resident: "Making time to run has allowed me to get to know my fellow trainees and to become close friends."</li>
</ul>
<p>
Happy trails!
</p>
<p>
<em>Elizabeth Parker, MD, is a pathology resident at the University of Washington Medical Center. </em>
</p>
</div> | 9/16/2019 3:46:47 PM | 3/5/2019 3:56:07 PM | 3/6/2019 12:00:00 AM |
| in_appreciation_wsma_member_dr_richard_dick_whitten | In appreciation: WSMA member Dr. Richard Whitten | WSMA_Reports | Shared_Content/News/Latest_News/2019/January/in_appreciation_wsma_member_dr_richard_dick_whitten | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/AM_2017.10.062_Whitten_645x425.jpg" class="pull-right" /></div>
<h5>January 11, 2019</h5>
<h2>In appreciation: WSMA member Dr. Richard "Dick" Whitten</h2>
<p>By Graham Short</p>
<p><em>The following article was featured in the January/February 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em></p>
<p>
It's the end of an era: WSMA member Richard "Dick" Whitten, MD, of Sammamish has stepped down from his role as speaker of the WSMA House of Delegates, a position he held with dignity and aplomb for five years, and symbolically drawing to a close a time of tremendous leadership and service—more than 30 years worth—at the WSMA.
</p>
<p>
Dr. Whitten presided over the House of Delegates, with his trusted gavel and dog-eared copy of parliamentary procedures, starting in 2013, replacing departing speaker and Tacoma family physician Richard Hawkins, MD. Assuming his place, starting with the 2019 WSMA House of Delegates, will be Spokane pediatrician Deborah Harper, MD, who has served as vice speaker since 2016, and who will be flanked by a new vice speaker, Matthew Grierson, MD, sports medicine physician from Seattle.
</p>
<p>
Dr. Whitten's service as House speaker was just the latest in a long line of leadership roles at the WSMA held by the indefatigable physician and longtime member. His service included six years as a delegate representing King County (2007-13), four years as chair of the WSMA bylaws committee, and 25 years as a member of the AMA delegation, representing the interests of Washington physicians and patients on the national level at the AMA House of Delegates. Dr. Whitten has been a dedicated member of the AMA for more than 37 years.
</p>
<p>
WSMA's current AMA delegation chair, Spokane anesthesiologist Rod Trytko, MD, believes Dr. Whitten has been a fierce physician champion. "We all have benefitted from his relentless efforts to make Washington a great place to practice medicine and receive care. He also has been one of my most trusted friends."
</p>
<p>
Another champion of physicians and patients, Seattle internist and Qualis Health CMO John Vassall, MD, agrees: "For those of us involved in the practice of medicine and in advocacy for our patients and our colleagues, we know that words matter and details matter. Dick took this very seriously and made sure we did not forget the important words and the important details."
</p>
<p>
Dr. Whitten currently serves as medical director and vice president of health policy at Noridian Healthcare Solutions.
</p>
<p>
From all of WSMA, a hearty "thank you" to Dr. Whitten for his leadership, service, and continued membership (38 years and counting). We are proud to have you as a member!</p>
<p><em>Graham Short is WSMA’s associate director of communications.</em></p>
</div> | 9/16/2019 3:47:36 PM | 1/11/2019 3:15:00 PM | 1/11/2019 12:00:00 AM |
| wsma_reports_physician_advocates_are_vital_to_wsmas_legislative_success | WSMA Reports: Physician advocates are vital to WSMA's legislative success | WSMA_Reports | Shared_Content/News/Latest_News/2019/January/wsma_reports_physician_advocates_are_vital_to_wsmas_legislative_success | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMA-Reports%20article%20graphic2018-Jan-Feb.jpg" class="pull-right" /></div>
<h5>January 8, 2019</h5>
<h2>Physician advocates are vital to WSMA's legislative success</h2>
<p>
By Marcia Frellick
</p>
<p>
<em>The following article was our featured cover story in the January/February 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
<p>
With the 2019 state legislative session looming, thoughts of advocacy are fresh and physicians are among leaders looking for ways to change policies or to protect hard-won gains.
</p>
<p>
Washington physicians who embrace advocacy told WSMA Reports how they got started and why advocacy is important.
</p>
<h3>
Kim Schrier, MD, newly elected to Congress from Washington's 8th District</h3>
<p>
Dr. Schrier, a community pediatrician in Issaquah, said she never had thoughts of running for office until the 2016 election.
</p>
<p>
"When my member of Congress sided with party over the people in our district by voting to repeal the Affordable Care Act, hurting thousands in our district, I stepped up to run against him," she said.
</p>
<p>
Dr. Schrier, who has spoken at both the WSMA Legislative Summit and WSMA Annual Meeting, says it's critical that physicians step up and share expert perspectives on health care policy.
</p>
<p>
"Otherwise, we end up working in a system designed by non-physicians that may not work well for patients or doctors," she said.
</p>
<p>
Key health care-related issues facing the state and country need physicians' insight, she said, among them how to cover our uninsured or underinsured, how to address the opioid crisis, and how to expand access to health care in rural communities.
</p>
<p>
She advises physicians to "jump in and encourage your colleagues to join you. Physicians are natural advocates. We go to bat for our patients every day. We are inclined to study the issues and be thoughtful about solutions, to listen respectfully, and to speak up on behalf of our patients."
</p>
<h3>
Nariman Heshmati, MD, outgoing chair, Washington Medical Political Action Committee (WAMPAC)</h3>
<p>
In addition to his role with WAMPAC, WSMA's nonpartisan campaign arm, Dr. Heshmati is chair of the surgery section and a member of the clinical leadership board at The Everett Clinic and chief of women's and children's services at Providence Regional Medical Center in Everett.
</p>
<p>
Dr. Heshmati first got involved in advocacy nearly 20 years ago when he joined a political action committee as a medical student and started going to lobbying days. He saw the need to go beyond just what the patient needs at the moment and look ahead to making the system better for that patient and all others later on.
</p>
<p>
Physicians are uniquely qualified to speak on patient care, he said.
</p>
<p>
"We're not speaking on behalf of insurance companies," he emphasized. "We sometimes don't realize how much our opinions, voiced in unison, matter. It's a trusted opinion and we have to utilize that to make positive changes."
</p>
<p>
Time is always going to be a struggle for physicians, he acknowledged, but advocacy can also save time by changing the cause of inefficiencies, such as problems with electronic medical records, extensive regulations, and prior authorizations.
</p>
<p>
"You can make that system better and more efficient and then you'll have more time," Dr. Heshmati said.
</p>
<h3>
Avanti Bergquist, MD, child psychiatrist</h3>
<p>
Dr. Bergquist of Renton, a psychiatrist with Eating Recovery Center and Seattle Children's Hospital, got interested in advocacy when she saw the impact her husband, a public school teacher, could have when he was elected representative in Washington's 11th Legislative District in 2012. That was also the year she finished her child psychiatry fellowship.
</p>
<p>
Through the training they got in running a campaign (the Bergquists attended the American Medical Association's AMPAC Candidate Workshop, which teaches doctors how to run a political campaign) and her husband's election, she saw how one constituent and one legislator being interested in something important can make a huge difference.
</p>
<p>
Legislators need to hear from the experts to make informed decisions, she said. In her case, she worked on a state committee that advocated expanding the scope of a phone line offered by the University of Washington and Seattle Children's Hospital. The service helps physicians treating children with mental health issues since there is a severe shortage of child psychiatrists in the state.
</p>
<p>
Her advocacy work led her to run for election to her local school board, where she is now serving in her second year.
</p>
<p>
Advocacy has had a personal benefit as well. "This has really resolved my burnout," she said. "I'm helping patients and families in my direct clinical work but I was also able to make a positive impact on a much bigger scale. In clinical work, we get frustrated by red tape, but once I understood the policies and how to make a change, it's really helped me."
</p>
<h3>
Judy Kimelman, MD, an OB-GYN in private practice</h3>
<p>
Dr. Kimelman, an obstetrician-gynecologist in Seattle, works with the American College of Obstetricians and Gynecologists on the state and national level.
</p>
<p>
At the state level, she has helped organize the state chapter's lobbying day in Olympia, which helps mobilize advocacy for legislation that supports women's reproductive health issues. She teaches physicians the right and wrong way to lobby and how to navigate the legislative process. She even created a video, "Lobbying: the Good, the Bad, and the Ugly," on the process (available on YouTube).
</p>
<p>
On the national level, she meets with members of Congress on specific issues and has joined national lobbying efforts.
</p>
<p>
Her advocacy work started with efforts to try to stop nuclear proliferation when she was an undergraduate at Berkeley. Then at Stanford Medical School, she helped organize students across the country to advocate for change.
</p>
<p>
Later in practice, she saw colleagues struggling in the medical malpractice crisis.
</p>
<p>
"People were practicing so much defensive medicine, it didn't feel like good medicine," she said.
</p>
<p>
She contacted the WSMA to see what could be done with tort reform.
</p>
<p>
"That reinvigorated my desire to be involved in advocacy," she said. "We know the medicine and we know the science and it's important to use the authority that the MD or DO behind our name gives us to tell legislators why a bill is important or why it's important that it not pass."
</p>
<h3>
MOC law is evidence advocacy works</h3>
<p>
Kathryn Kolan, JD, director of legislative and regulatory affairs for the WSMA, said physicians need to be ahead of legislators in formulating policy or they will be governed by rules set by those with no experience in health care.
</p>
<p>
She added that she has seen physician input repeatedly result in policy change. One of the most recent examples was the law passed in the last state legislative session on maintenance of certification.
</p>
<p>
Physicians in the WSMA House of Delegates fought against MOC being a condition of licensure. The policy was adopted by WSMA in October 2017 and in January 2018, the state legislature passed the bill.
</p>
<p>
"Translating the patient and physician experience to policymaking is vital," she said.
</p>
<p>
<em>Marcia Frellick is a freelance journalist who specializes in health care topics.<br />
</em>
</p>
<div class="AsiInformation">
<h3><strong>What you can do</strong></h3>
<p>
Physician advocates offer these tips for taking action on advocacy.
</p>
<ul>
<li>Attend the annual WSMA Legislative Summit. The next one is Feb. 7 in Olympia. <a href="[@]WSMA/Events/Legislative_Summit/Legislative_Summit.aspx">Register online today</a>.</li>
<li>Enroll in the American Medical Association's <a href="http://www.ampaconline.org/political-education/ampac-candidate-workshop/">AMPAC Candidate Workshop</a>, which teaches doctors how to run a political campaign.</li>
<li>Connect with one legislator or policymaker who shares your interest on a particular topic.</li>
<li>Be patient, as change is often slow. Developing relationships is a good first step.</li>
<li>Write letters to the editor of your newspaper.</li>
<li>Post opinions on social media.</li>
<li>Call or email legislators.</li>
<li>Write a check to political action committees doing the work you support.</li>
</ul>
</div>
</div> | 9/16/2019 3:48:07 PM | 1/8/2019 3:40:49 PM | 1/8/2019 12:00:00 AM |
| wsma_reports_the_regulatory_process | WSMA Reports: The Regulatory Process | WSMA_Reports | Shared_Content/News/Latest_News/2019/January/wsma_reports_the_regulatory_process | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/News/WSMA-Reports%20article%20graphic2018-Jan-Feb.jpg" class="pull-right" /></div>
<h5>January 8, 2019</h5>
<h2>The Regulatory Process</h2>
<p>
By Jeb Shepard
</p>
<p>
<em>The following article was featured in the January/February 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may <a href="https://wsma.org/WSMA/News_Publications/Publications/WSMA/News_Publications/Publications/Publications.aspx?hkey=8f14076c-10b8-48ab-9595-8c256836e393">purchase a subscription</a>.</em>
</p>
<p>
While the legislative branch's political intrigue and drama are at the center of our media circus, the fanfare fades once an executive signs a bill into law—and dwindles to a hum by the time regulatory departments and agencies initiate rulemaking. In fact, rulemaking is a process that barely registers on most people's radars.
</p>
<p>
Conducted in meeting rooms around the state (with a concentration in Tumwater), the process unfolds far from the illustrious marble of the Capitol dome. There are rarely television cameras. But for all the attention given to the legislative process, rules quietly written by bureaucrats carry the same force of law as those written by elected officials.
</p>
<p>
In Washington state, language from bills that pass the Legislature and are signed into law by the governor is added to the Revised Code of Washington (RCW), the compendium of all state laws in force. Legislative language will contain specific concepts and goals, while often directing regulatory agencies and departments to fill in the details through rulemaking.
</p>
<p>
Lawmakers do this for several reasons, including a hesitancy to place complicated policy (think about the ever-evolving practice of medicine) in the RCW because it is so difficult to update; you have to pass another law. Deferring to regulatory bodies provides flexibility.
</p>
<p>
It also offers a more deliberate and comprehensive policymaking arena that facilitates expert input through a process not subject to the pressures and time constraints of the legislative session. Plus, regulatory bodies have the authority to conduct emergency rulemaking any time of year (not just when the Legislature is in session) to address issues that arise or when required to advance the agency's objectives.
</p>
<p>
The Administrative Procedures Act (APA) outlines how the rulemaking process must be conducted in our state. In short, an agency or department must release a "preproposal statement of inquiry," officially referred to as a CR-101, which is a "heads up" to the public that they intend to write a rule. The second step, the CR-102, includes draft language and an opportunity to comment. The CR-103 is the final, adopted rule. Once finalized, rules are added to the Washington Administrative Code (similar to the RCW, the WAC catalogues all state regulations).
</p>
<p>
In a typical year, the WSMA tracks a dozen or more rules and submits comments on a wide array of issues impacting medicine to various regulatory bodies, including the Washington Medical Commission, the Department of Health, the Health Care Authority, the Office of the Insurance Commissioner, Labor &amp; Industries, and the Department of Licensing. While our Olympia team has an intimate understanding of how the process works and a strong grasp on how a proposal will impact your practice, we are not clinicians; your feedback is critical to help guide our approach.
</p>
<p>
For example, in 2017, the legislature passed House Bill 1427, which directs relevant boards and commissions to write opioid rules for the professions they regulate. We worked on the bill while it was under consideration by the Legislature and participated in every stage of the rulemaking.
</p>
<p>
We were successful in many of our goals, but only because we solicited feedback from WSMA members and urged you to submit your thoughts to the state or endorse our comprehensive comment letter. Hearing directly from physicians and physician assistants had an impact on the rulemaking, as the APA requires that each comment be considered during the rulemaking process.
</p>
<p>
We thank you for your participation in prior efforts and hope you will get involved with us in the future.
</p>
<p>
The regulatory process, in all its mundanity, is a serious state policy tool that carries significant weight and will impact your patients and your practice.
</p>
<p>
<em>Jeb Shepard is WSMA's associate director of policy and regulatory affairs. </em>
</p>
</div> | 9/16/2019 3:48:02 PM | 4/24/2019 3:38:06 PM | 1/8/2019 12:00:00 AM |