| a_virtuous_cycle | A Virtuous Cycle | WSMA_Reports | Shared_Content/News/Latest_News/2020/March/a_virtuous_cycle | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Cover-WSMA_MarApril-2020-v6-645x425px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>March 4, 2020</h5>
<h2>A Virtuous Cycle</h2>
<p>
By Nicholas Rajacich, MD
</p>
<p>
I was surprised to hear a colleague express hesitation when I suggested that her practice, struggling with caseloads and administrative work, hire a physician assistant. After all, at my orthopedic practice, we were preparing to hire even more PAs (which will mean more than one PA per doctor).
</p>
<p>
For our practice, it's simple: PAs help us increase access to our services (more care for more people) and help manage many of our day-to-day tasks (fewer hours spent by our physician specialists on administrative work and less-complex procedures). Put even more simply, the bottom line is that our PAs are good for our practice's bottom line - both for patient care and practice revenue.
</p>
<p>
With most PAs trained in primary care, few come to us with experience or training in our surgical specialty. Some choose to do an additional year of specialized training, which we have found to be quite valuable. While it requires a significant commitment of time to train them both in the clinic and in the OR, the returns on this investment accrue rapidly.
</p>
<p>
For example: In the OR, our PAs prep the patients for surgery, handle the post-op orders, apply tourniquets during the operation and, in the case of a PA who's been around a while, close and dress incisions. Complicated patient discharges? Our PAs have us covered, arranging follow-up visits, DME prescriptions, and so on.
</p>
<p>
As their training moves along, and as the individual PA gains more experience, we give them expanded independence in our practice. With experience, we allow our PAs to see an independent panel of patients, saving the complex patients for our physicians.
</p>
<p>
And of course, a PA can do many of the tasks that doctors are being tasked with (more and more...and more) these days. With the development of EMRs and increasing regulatory requirements, there's a large burden of administrative material that a PA can help me with.
</p>
<p>
At this point, our investment in teaching these PAs has more than paid off. Our physicians are now freed up to practice at the highest level of our training and to see more new patients, which is a win-win for everyone.
</p>
<p>
We do at times allow PAs to run clinics offsite. In most situations when a PA is seeing patients in clinic, there is a physician available, either by phone (with the ability to review X-rays via PACs) or in person, to answer questions or provide advice as needed.
</p>
<p>
There are some relatively simple legal hurdles that one must address before hiring a PA, most of which can be navigated with the help of staff at the WSMA and the Washington Academy of Physician Assistants. Promising work is being done by those organizations at the state level to modernize the requirements around the PA delegation agreement - the document describing what training and supervision will be provided and what duties delegated to the PA. Ultimately, what's important is to clearly define and document the clinical partnership and to regularly revisit and revise as needed. This is key to building a successful physician-PA team and to ensure the highest quality of care for our patients.
</p>
<p>
At our practice, the use of PAs has led to greater access to care, which, in turn, has led us to hire more PAs (I envision a day when we may well have two PAs per doctor). It's a virtuous cycle if there ever was one, and one I'll continue to recommend to other physician colleagues.
</p>
<p>
<em>Nicholas Rajacich, MD, is a pediatric orthopedic surgeon at Mary Bridge Children's Orthopedic Clinic.</em>
</p>
<p>
<em>This article was featured in the March/April 2020 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> | 3/4/2020 2:50:22 PM | 3/4/2020 12:41:00 PM | 3/4/2020 12:00:00 AM |
| partnering_to_solve_the_health_care_puzzle | Partnering to Solve the Health Care Puzzle | WSMA_Reports | Shared_Content/News/Latest_News/2020/March/partnering_to_solve_the_health_care_puzzle | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Cover-WSMA_MarApril-2020-v6-645x425px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>March 4, 2020</h5>
<h2>Partnering to Solve the Health Care Puzzle</h2>
<p>
By Rita Colorito
</p>
<p>
Residents of rural Grays Harbor County know what it means to wait for health care. The coastal southwestern Washington community has one primary care physician for every 2,980 residents, compared to the statewide ratio of one physician for every 1,220 residents, according to a 2019 analysis by the Robert Wood Johnson Foundation. Lack of access, among other factors, has taken its toll: The county ranks 36th of out 39 for overall health outcomes.
</p>
<p>
Working in an environment that's chronically underserved requires a collaborative approach to health care, says Ken Dietrich, MD, chief medical officer for Summit Pacific Medical Center in Elma. That's where physician assistants come in. These practitioners are nationally certified and licensed to prescribe medication and practice medicine in inpatient and outpatient settings in all 50 states and the District of Columbia.
</p>
<h3>Improving access to care</h3>
<p>
To improve patient access to care, Summit takes a team-based approach, using non-physician practitioners such as physician assistants as primary care providers, or PCPs. Over the last decade, Summit has focused on recruiting PAs to fill the PCP gap. The use of these skilled and flexible practitioners, says Dr. Dietrich, is something medical centers and physician practices should consider.
</p>
<p>
"We tell patients we have all these PCPs; does it matter who they see? Oftentimes, they say, 'I just want to get in as soon as I can,' so that's really created an opportunity for us," he says.
</p>
<p>
Two kinds of patients need access to care, says Dr. Dietrich: those who don't have a primary care physician and those who do, but can't get in to see them. To accommodate in-paneled patients, a PA runs Summit's same-day clinic, serving as a conduit between the patient and their physician.
</p>
<p>
"Patients can get in when they need to and the PA communicates collaboratively with that patient's physician, if necessary," says Dr. Dietrich.
</p>
<p>
For rural communities such as Elma, PAs have proven to be an essential piece of the health care puzzle. They're also invaluable in urgent care, where reducing wait times is paramount regardless of geographic location, says Eileen Ravella, a PA-C with 36 years' experience who works in urgent care for Kaiser Permanente in Olympia.
</p>
<p>
"The flexibility of PAs helps with patient care and throughput," says Ravella, who also serves as the president of the Washington Academy of Physician Assistants. "I'm seeing all levels of acuity I'm comfortable with. I may see a complicated patient and work with physicians to get the patient admitted, do all the evaluations, and order tests. Or I may see the lesser acuity patients and the physicians may see the extremely complicated patients to help patient flow."
</p>
<h3>What collaboration looks like</h3>
<p>
Physicians who work with PAs say they help practices see more patients and provide continuity of care. Collaboration is at the core of the PAs role in health care.
</p>
<p>
"The collaboration looks different depending on the context, the geographic location, and the complexity of the patient," says Leah Yoke, PA-C, MCHS, who holds a joint appointment at the Seattle Cancer Care Alliance (SCCA) and Fred Hutchinson Cancer Research Center.
</p>
<p>
Yoke, who specializes in internal medicine and infectious disease, works in inpatient and outpatient settings in concert with oncologists and hematologists to diagnose, prevent, and treat infections in patients with cancer.
</p>
<p>
Cancer care centers also face a shortage of infectious disease physicians. Here, too, PAs can fill the gap, says Yoke, who promotes PA usage to cancer centers nationwide in her member ambassador role with the Infectious Diseases Society of America. For cancer patients, who often face a cascade of treatments and a dizzying number of specialists, PAs provide a familiar presence, says Yoke, as they are often the only provider who sees them across multiple treatments and teams.
</p>
<p>
"Typically, we're seeing really complex patients that have multiple comorbidities," says Yoke. "Because we don't have a ton of ID physicians, I'm able to see all the patients and help teams make decisions in a timely manner and provide some of that logistical legwork that we wouldn't otherwise be able to do."
</p>
<p>
"For the transplant service in particular, they're really a major piece of how cancer patients are cared for," says Steve Pergam, MD, MPH, an infectious disease faculty member and medical director of infection prevention at SCCA.
</p>
<p>
"We see patients together. We review cases together. But I think they've really allowed us to see more patients in our practice," says Dr. Pergam. "Because they're consistently on service whereas as doctors we're coming on and off service all the time, they have the ability to provide additional context and continuity for patient care."
</p>
<h3>At the top of everyone's profession</h3>
<p>
PAs also allow physicians and other PCPs to work at the top of their license to focus their energies on their most complex cases.
</p>
<p>
"In academic environments where we're often doing lots of things—research, teaching, and other responsibilities beyond just direct patient care—they are critical to our service. They communicate with teams directly and we often do a lot of shared decision-making, specifically for our complex patients," says Dr. Pergam, an associate professor in the division of allergy and infectious diseases at the University of Washington School of Medicine in Seattle.
</p>
<p>
PAs practice in nearly every area of medicine, with approximately 50% providing primary care services. The next largest proportion, some 23%, focus on surgery or surgical subspecialties.
</p>
<p>
"The physician assistants I've been most familiar with definitely assist the entire team in being able to be more efficient in what we do," says Jeanne Poole, MD, a professor of medicine in the division of cardiology at UWSOM.
</p>
<p>
PAs can do a fair amount of high- level work alongside surgeons and proceduralists, says Dr. Poole. "We train them to be able to specialize and do portions of procedures, like sutures and getting access to venous systems."
</p>
<p>
Lyle Larson, PA-C, PhD, entered the field of cardiac electrophysiology in 1986 when it was a new subspecialty at the UW Medical Center in Seattle. Along with Dr. Poole, who was a new attending physician at the time, Larson helped build the practice into what it is today. In 2018, the two also co-edited the textbook "Surgical Implantation of Cardiac Rhythm Devices."
</p>
<p>
"It has been a positive, collaborative experience," says Larson. Because of his deep experience, Larson helps to teach electrophysiology fellows how to do the surgical aspects of pacemaker and defibrillator implantation. "When there are particularly difficult cases, the electrophysiologists expect and ask for me to be on their cases to assist them," he says.
</p>
<p>
Dr. Poole says highly experienced PAs such as Larson are integral to the cardiac electrophysiology practice. In the operating room, a PA's experience with complicated procedures, such as carefully implanting or removing cardiac rhythm devices and leads, makes the entire procedure safer, she says. "It's also an educational opportunity for young physicians who may not have had that same degree of experience."
</p>
<h3>The question of oversight</h3>
<p>
Despite the many positives, Ravella says PAs aren't being used to their fullest potential as a result of ongoing misconceptions.
</p>
<p>
"We're coming up against physicians who have real concerns about the perceived competition between physicians and PAs, and there is none. We can't practice without them. They are our team," says Ravella. "We're not here to replace physicians. We can't replace you. We are dependent practitioners."
</p>
<p>
Larson echoes that sentiment: "I'm certainly qualified to do procedures on my own, but that does not make me a surgeon. That does not make me an electrophysiologist. That makes me a very, very skilled PA who can function as a right-hand man for the physicians to take care of their patients."
</p>
<p>
Another barrier to utilization: the idea that PAs require direct supervision. In reality, PAs need minimal supervision, says Ravella.
</p>
<p>
At Summit, physicians are available if a PA has a question or concern, but they don't have to be there physically to provide oversight, says Dr. Dietrich. "Because we have such an integrative model, on a day-to-day basis, our PCPs are touching base with one another, connecting with patients, so there's a lot of collaborative care."
</p>
<p>
"Certainly, you don't have to have a physician right next to a physician assistant if they are working within the scope of their training," says Dr. Poole. "For procedures, that's different because you are really working as a team— multiple hands trying to accomplish a certain procedure."
</p>
<p>
PAs can and do serve as resources for others in the medical community. Larson and Yoke both work as teaching associates at the UW Medical Center. Dr. Dietrich says experienced PAs at Summit often serve as mentors for new doctors.
</p>
<p>
"Our PAs are highly expert, spending all of their time dealing with high- risk, immunocompromised patients," says Dr. Pergam. "Because they are so knowledgeable, they can be a great first resource for the teams to ask questions directly. And then the PA will come to us with the more complex questions."
</p>
<h3>Investing in the future</h3>
<p>
The approach to using PAs to their fullest credentialed potential needs to be well thought out, says Dr. Dietrich. Summit has a flat hierarchical structure. All team members go through initial onboarding and an external yearly peer review. This makes for a more effective, integrative, and collaborative approach to care, he says.
</p>
<p>
Summit typically hires experienced PAs, but about three years ago, it began adding PAs directly out of training. For these PAs, Summit provides a year- long residency-style program. While there's a lot of initial oversight, as these PAs gain experience and confidence, they are given more responsibility and eventually obtain their own panel of patients to manage.
</p>
<p>
"By investing in their training, you're investing in a resource who is hopefully going to stay with you," says Dr. Dietrich. "Can they see all complexity of patients? No. But they can see 75% of patients."
</p>
<p>
The investment has paid off. About 25% of Summit's PCPs are PAs. If a patient develops a complex diagnosis while under a PA's care, the PA consults with physicians or other PCPs, but they would continue to manage that patient's care, says Dr. Dietrich. "It's the right care by the right person at the right time."
</p>
<p>
It comes down to the breadth of skills PAs bring to a team, says Dr. Poole. "PAs are very well-educated individuals. Many have had some sort of prior experience, such as medic experience in the military, so their training is solid," she says. In her work, PAs have proven highly valuable members of the team. "They should be sought after and included as part of the allied professional team for anyone considering expanding their practice in that manner."
</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 March/April 2020 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> | 3/4/2020 2:50:23 PM | 3/4/2020 12:42:30 PM | 3/4/2020 12:00:00 AM |
| training_to_address_the_regions_unmet_health_care_needs | Training to Address the Region's Unmet Health Care Needs | WSMA_Reports | Shared_Content/News/Latest_News/2020/March/training_to_address_the_regions_unmet_health_care_needs | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/Cover-WSMA_MarApril-2020-v6-645x425px.jpg" class="pull-right" alt="WSMA Reports cover" /></div>
<h5>March 4, 2020</h5>
<h2>Training to Address the Region's Unmet Health Care Needs</h2>
<p>
By Pat Curry
</p>
<p>
In 1968, 14 former medics or corpsmen enrolled in a new program jointly sponsored by the WSMA and the University of Washington School of Medicine and funded by the National Center for Health Services Research. The 18-month program, called the MEDEX Demonstration Project, would allow them to continue the training they had gained in the military and use it to begin careers in civilian health care as physician assistants.
</p>
<p>
The program, only the second of its kind in the nation, was created by Richard A. Smith, MD, to address a shortage of qualified medical professionals. By the time MEDEX Northwest celebrated the 50th anniversary of that first graduating class in 2019, the program had graduated more than 2,600 physician assistants.
</p>
<p>
Over the years, the program expanded beyond accepting former military medics—it now accepts applicants with health care experience, including nurses, EMTs, Alaska community health aides, medical assistants, and athletic trainers. The original class of 14 is now 140 students training in four locations in Seattle, Spokane, Tacoma, and Anchorage, with a fifth location in Hawaii in the works.
</p>
<p>
Central to the mission at MEDEX Northwest is a commitment to educating "experienced health personnel from diverse backgrounds to practice medicine with physician supervision."
</p>
<p>
"As one of the original programs in the country, our program was established on people with prior health care experience," says Terry Scott, PA-C, MPA, DFAAPA, program director of MEDEX Northwest. "We still think that matters. When you walk into medicine after just two years of study, you need some experience with the health care field."
</p>
<p>
A graduate of MEDEX, Scott trained and worked in both rural and urban communities in Washington, worked in HIV vaccine research, and provided primary care to HIV-positive patients. He joined the MEDEX faculty in 1996 and maintains a practice at the University of Washington Family Practice Residency in Seattle.
</p>
<p>
The PA program also has gotten longer; it is now a master's degree with 27 months of training and a capstone project. The first year consists of didactic training, followed by a four- month family practice preceptorship and then six one-month clerkships in behavioral medicine, emergency medicine, surgery, inpatient, and underserved populations; and one elective. During that time, the students also work on an in-depth, clinically relevant capstone project.
</p>
<p>
"There's been a maturing of the profession," Scott says. "The complexity of the profession requires the education be extensive and exhaustive."
</p>
<h3>Keeping the vision alive and moving forward</h3>
<p>
Senior Medical Director Tim Evans, MD, PhD, FACP, is one of the MEDEX faculty the students see in the classroom in their first year of training. Dr. Evans gives 250-300 hours of lectures a year; he says he has immense admiration for their commitment to medicine.
</p>
<p>
"Our students, year after year after year, are really terrific," Dr. Evans says. "They're smart, they're hardworking, they're here for a reason. ... They're making some very serious sacrifices. You have to honor that, and I do."
</p>
<p>
With the MEDEX program residing in UW's department of family medicine, the training PAs receive complements that of physicians in the same way PAs complement physicians in clinical practice.
</p>
<p>
"Medicine is a team sport," Scott says. "You need to teach everyone how to get the highest level from their training. We want all of us out there making a difference in the lives of our patients, delivering care to the public."
</p>
<p>
While much has changed over the last half century, Scott notes that one thing has stayed the same: the program remains committed to diversity and inclusion, equity and justice.
</p>
<p>
"We want to provide training and education to meet the nation's health care needs," he says. "That's from Dr. Richard Smith. He had an idea of what he wanted this program to be; those values have remained. It's in our DNA. We are the current caretakers of that vision."
</p>
<p>
The message Scott would share with WSMA members is that MEDEX is a well-established program and that PAs are not technicians.
</p>
<p>
"We are health care providers trained to deliver high-quality health care in collaboration with physicians," he says. "What doesn't change is a team- based approach to medicine. We are still here determined to deliver high-quality health to the region and the country."
</p>
<h3>A mission of rural service</h3>
<p>
Heritage University, Washington state's second PA training program, currently is training its fifth class of PAs. Program Director Linda Dale, PA-C, DHEd, has been a PA since 1996 and taught for 10 years at MEDEX.
</p>
<p>
The mission of Heritage University's program is to put its students in primary care in rural, underserved areas.
</p>
<p>
"We are in Toppenish," she says. "We're in the middle of the hop fields; we are a Hispanic-serving institution. I was born and raised in this area; it's always been medically underserved. Most Washington counties are. Even in King County and Spokane County, there are pockets that are underserved. Our mission is to increase access to health care for those populations."
</p>
<p>
"That's an intense need," says Medical Director Joseph DiMeo, DO. "I'm also a clinician in town. The deficits in patient access to care are acute."
</p>
<p>
The school has "done pretty well so far" in addressing that mission, Dale says. The national average for PAs working in rural areas is 12.5%; Heritage has 24% of its grads working in rural areas, she says. Nationally, 26.7% of PAs work in primary care; for Heritage grads, it's 46%.
</p>
<p>
The focus of Heritage University's training is primary care. It complements the training of physician students by following the medical model for training. On a weekly basis, students attend class with DO students at Pacific Northwest University.
</p>
<p>
"We are side-by-side with DO students doing case discussions and workshops where they'll do sutures, splinting, casting," she says. "It's an interprofessional education, not only with DO students but nursing, pharmD, and paramedic students, for some of our clinical case discussions."
</p>
<p>
Heritage teaches in systems modules, such as the cardiovascular system. A module covers anatomy and physiology, how to do an exam, what it looks like in a child, an adult, an elderly patient, chronic conditions and how that presents in the ER, Dale says.
</p>
<p>
"In that same model, we'll teach how to treat it, including pharmacology and lifestyle," she says. "When complete, we test on it. Once that's tested, we moved to the next system."
</p>
<p>
The biggest difference from MEDEX's curriculum comes in the clinical year, Dale says. Heritage places students in a clinical site for a full year, working there two days a week. For the rest of the week, they do their specialties—surgery, pediatrics, obstetrics and gynecology, inpatient, emergency medicine, and mental health—switching about every six weeks. Sites are primarily in Washington, Idaho, Montana, and Alaska.
</p>
<p>
"The beauty of that is that when they learn something in their specialty, they'll bring it back to primary care," she says. "It gives them a great handle on it and takes the fear away from having to know everything as a primary care provider. I think that is why we have 46% of our students in primary care; they've been in it for a full year.
</p>
<p>
"This training is what a family practice physician used to do in the old days," she says. "Now with changes in their training, we're seeing more and more physicians go to specialties. We're trying to go back to the family medicine model. Sometimes, the old ways might be better."
</p>
<p>
That focus is being coupled with more and more simulation, Dr. DiMeo says. The result is that students get a greater experience of hands-on integration with medical decision-making "so they can handle more difficult things in a safe environment before they go into clinical practice."
</p>
<h3>Evidence of impact</h3>
<p>
Even with just four graduating classes under its belt, Heritage University already is seeing its efforts rewarded with increased access to health care in underserved areas.
</p>
<p>
"The impact on those patients' lives is difficult to measure, but relieving the pressure on the other clinicians in the area cuts down on their stress and ultimately keeps them practicing in those areas longer," she says.
</p>
<p>
To help address the workforce challenges physicians are facing, Heritage University works to get students ready to see patients as soon as they finish their clinical rotation, Dr. DiMeo says. "They're not a draw against the number of patients the [physician] has to see in a day."
</p>
<p>
"Over the course of their training and then when they go into clinical practice, their education needs to continue," he says. "They need to fit into the practice; there needs to be a comfort level between what the PA thinks they can handle and what the physician thinks they can handle, communicating on a daily basis about any complicated things. That's less and less over time. ... Even at times a physician will be challenged and call for a consult. That is the way medicine is practiced."
</p>
<p>
<em>Pat Curry is senior editor of WSMA Reports. </em>
</p>
<p>
<em>This article was featured in the March/April 2020 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> | 3/4/2020 2:50:23 PM | 3/4/2020 12:42:33 PM | 3/4/2020 12:00:00 AM |
| Behind_the_Cover | Behind the Cover | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/Behind_the_Cover | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" alt="WSMA Reports Extras logo" /></div>
<h5>January 17, 2020</h5>
<h2>Behind the Cover</h2>
<p>Kicking off the new year with our January/February edition of <em>WSMA Reports</em>, art director Erin Foster selected internationally renowned Spanish-Argentinian illustrator <a href="http://www.martinelfman.com/" target="_blank">Martín Elfman</a> as the issue's cover illustrator. </p>
<p>"What drew me to Martín's work is his keen sensibility for pinpointing a story's concept with striking minimalist elements," she says. "He also has a deft line quality and sense of color that I felt would make for a strong cover art. He definitely did not disappoint!"<br />
<br />
<a href="javascript://[Uploaded files/News and Publications/Publications/WSMA Reports Archive/WSMA_JanFeb 2020-PRINTERS FINAL.pdf]">View the cover illustration for <em>WSMA Reports</em>' January/February 2020 issue</a>.</p>
<p>
The cover story focuses on the federal and state actions that may impact the medical profession during the legislative sessions in 2020. From that broad-based topic, the article touched on many of the concerns currently plaguing physicians—administrative burdens caused by prior authorization, the threat to independent physician practices from the state’s business and occupation (B&amp;O) tax, and the need for reimbursement to catch up with the emerging technology of telemedicine. </p>
<p>
Here’s how Martín saw the challenge: “The story behind the cover is about the challenges lawmakers will face in the next legislative session. How to give a graphic shape to concepts as abstract as legality and health? After much thought, I suddenly realized that the dome of the Washington State Capitol building can easily be transformed into the bell of a stethoscope. This is my favorite moment of the creative process, the spark in which everything fits and an unexpected solution appears. From there, with that little finding in my pocket, it was just about adding a doctor at the other end of the stethoscope, listening carefully to measure the state of health of the legislative chamber."</p>
<p>
His concept was spot on from our perspective. All that was needed was to make the Capitol building look like our own state Capitol in Olympia, and to write a headline that tied it all together. And done! Check it out and let us know what you think.
</p>
<p><em>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> | 1/26/2020 9:17:25 AM | 1/17/2020 10:36:14 AM | 1/17/2020 12:00:00 AM |
| a_doctor_in_the_house | A Doctor in the House | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/a_doctor_in_the_house | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA_JanFeb-2020-PRINTERS-FINAL-Cover-645x425px.jpg" class="pull-right" alt="WSMA Reports January-February 2020 cover" /></div>
<h5>January 2, 2020</h5>
<h2>A Doctor in the House</h2>
<p>
By John Gallagher
</p>
<p>
It was just a year ago that Issaquah pediatrician Rep. Kim Schrier, MD, entered the U.S. House of Representatives representing Washington state's 8th Congressional District. She became not only one of 89 first-time members of the House, but also the only woman physician in Congress. "I had no idea really what to expect," Dr. Schrier says now, looking back. "I had no idea of what a day-to-day life of a member of Congress would be."
</p>
<p>
What she discovered was that the environment on Capitol Hill wasn't the snake pit that most people think exists in the current Congress.
</p>
<p>
"I was so pleasantly surprised to find good people who just want to do the best for their communities, who sacrifice their lives at home, their time, and their privacy," Dr. Schrier says. "They're very welcoming. It's an honor to be part of the freshmen class with so many people from different backgrounds, but all motivated to run for the same reasons."
</p>
<h3>A doctor's heart for health care</h3>
<p>
Dr. Schrier's reason for running was to advance health care policy. "I spent a lot of time on the campaign trail talking about having a woman doctor in Congress," she says. "A lot is happening in the health care arena, and we shouldn't leave these decisions up to people who haven't worked in, lived in, and been patients in this crazy system of ours."
</p>
<p>
Living up to her promise, Dr. Schrier began her first term by diving right in to health care policy and legislation and serves as co-chair of the New Democratic Coalition Health Care Task Force. As is befitting for a pediatrician, one of her key issues has been the Vaccines Awareness Campaign to Champion Immunization Nationally and Enhance Safety (VACCINES) Act, which she introduced. The bill would track places with high vaccine hesitancy, or decreasing vaccine rates, study why this is happening, and then target information to those places specifically tailored to the reason.
</p>
<p>
"If my VACCINES bill can help increase immune rates and push back against the narrative of the anti-vaxxers, I would feel great, even if that's the only thing I accomplished," she says.
</p>
<p>
Dr. Schrier has been heavily involved in other health care legislation, such as efforts to shore up the Affordable Care Act. She has also been active in efforts to expand Medicare to include vision coverage and to protect patients against surprise billing.
</p>
<p>
She heard stories of patients who checked their plans' provider directories to make sure that their physician would be in network, only to discover when they were hit with a huge bill that the directory was out of date. As a result, Dr. Schrier reached across the aisle to co-sponsor legislation with Republican and fellow physician Rep. Phil Roe that would mandate insurance companies update their provider directories in a timely manner.
</p>
<p>
Dr. Schrier is also a supporter of HR 3, The Lower Drug Costs Now Act, which would authorize the Secretary of Health and Human Services to negotiate prices for the 250 most expensive drugs covered by Medicare, with the cost savings passed on to the private market.
</p>
<p>
"I'm really excited about HR 3," she says. "I've heard over and over again, 'I don't understand why they pay less in Canada than we do.' That's essentially would this bill would do."
</p>
<p>
Dr. Schrier has also introduced a bill that would speed up development of a biosimilar version of insulin. But her perspective on the issue is as much as a patient than as a physician, since she has Type 1 diabetes.
</p>
<p>
"I just yesterday called to order another bottle of my own insulin, Humalog, and it was no longer on the dispensary," she says. "It would cost $300 for a bottle! It's kind of crazy to me that it costs so much and that formularies change like that for no apparent reason."
</p>
<h3>A trusted resource</h3>
<p>
While all these legislative initiatives are the logical outgrowth of her own experience, Dr. Schrier has also become a resource for other members of Congress.
</p>
<p>
"What I find is my colleagues come to me to run questions by me about surprise billing or women's health," she says. "I get questions about milk and the Dairy Council pressuring my colleagues to support sweet milk in schools."
</p>
<p>
That extends to medical advice.
</p>
<p>
"I still get to be the consultant for all my colleagues with children about their rashes, fevers, and sleeping through the night," she notes. Then there was the time when a member of Congress fainted and she offered medical assistance.
</p>
<p>
Dr. Schrier also brings her perspective as a pediatrician to issues that for many outside of medicine may seem unconnected to health care, such as immigration. The Trump administration's policy of separating children from their parents at the border is also a health crisis because it is creating adverse childhood experiences (ACEs), which studies have shown carry lifelong consequences.
</p>
<p>
"They've already been through all kinds of trauma in journey, then we take them away from parents, and it's adding ACEs upon ACEs and creating a generation with problems with their mental and physical health," she says. "This is no way to treat kids."
</p>
<p>
Whether any of Dr. Schrier's proposed legislation can make it to the president's desk in a polarized Congress is impossible to predict.
</p>
<p>
"I can always hope for cooperation," she says optimistically. "I think that's up to the president to rise above it. Then I think we can get a lot done."
</p>
<p>
Sometimes that polarization spills over into Dr. Schrier's congressional workday. A Republican colleague tried to introduce an amendment into a higher education bill that would prohibit universities with an associated medical center from getting federal funds unless they promised to provide medical care for any baby born alive.
</p>
<p>
"That's just a dog whistle for the crazy notion on the other side that doctors are killing babies," she says. "A woman doctor carries weight in that position. I would speak so authoritatively to it."
</p>
<p>
All these experiences and more have confirmed to Dr. Schrier that her decision to run for Congress was the right call.
</p>
<p>
"I worried that I might give up practice and not win, but I have to tell you that I have grown a ton as a person through this experience and I have not had a moment of regret," she says. "I can do a lot more good for kids from Washington than from the confines of my own doctor's office."
</p>
<p>
Besides, Dr. Schrier says, being in Congress isn't all that different from being a resident, with one big difference. "There's just a lot of running around, up and down stairs, hustling to get to somewhere where you're only going to be for 10 minutes, then hustling back to somewhere else," she says. "Except that I have to do it much less comfortable shoes."
</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 January/February 2020 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> | 1/2/2020 10:21:54 AM | 12/30/2019 2:48:09 PM | 1/2/2020 12:00:00 AM |
| policy_prognosis_uncertain | Policy Prognosis: Uncertain | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/policy_prognosis_uncertain | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA_JanFeb-2020-PRINTERS-FINAL-Cover-645x425px.jpg" class="pull-right" alt="WSMA Reports January-February 2020 cover" /></div>
<h5>January 2, 2020</h5>
<h2>Policy Prognosis: Uncertain</h2>
<p>
By John Gallagher
</p>
<p>
At a national level, the number of challenges affecting physicians and their practices seems almost endless. Administrative burdens, financial pressures, and emerging technologies are all changing the profession. Whether it's congressional legislation on tax policy or state-level insurance regulations, physicians around the country are buffeted by constant changes. In response, legislators are being forced to play catch-up with a rapidly shifting landscape.
</p>
<p>
Washington state is no exception.
</p>
<p>
Last year's legislative session was exceptionally busy, with bills addressing a broad range of issues, including vaccination exemptions, opioid prescribing, a public option plan, and a prohibition on balance billing.
</p>
<p>
"Last year saw a slew of big-ticket items," says Sean Graham, WSMA's director of government affairs. "Lawmakers told us they wanted to let those policies sink in. Of course, they always say that—then the next session everyone has bills they're pushing."
</p>
<p>
Still, the upcoming legislative session offers an opportunity to tackle plenty of other pressing issues. Among them are the administrative burdens caused by prior authorization, the threat to independent physician practices from the state's business and occupation (B&amp;O) tax, and the need for reimbursement to catch up with the emerging technology of telemedicine.
</p>
<h3>The prior authorization nightmare</h3>
<p>
The exact shape of any legislation about the first two issues will be determined as the session gets underway. In terms of the breadth of its impact, prior authorization is the biggest concern.
</p>
<p>
Imagine a patient presenting at a practice at 4 in the afternoon with severe abdominal pains. "We can't order a CT scan to rule out appendicitis because it requires prior authorization," says Amber Pedersen, the administrator for Valley Obstetrics and Gynecology in Spokane Valley. Because prior authorization takes at least one to three days, Pedersen says the patient will be referred to the ED, where the costs to her and to the health care system are far higher.
</p>
<p>
"Prior authorization is an everyday nightmare for every single doctor in every single specialty," says Teresa Girolami, MD, president of the King County Medical Society. "Prior authorization gets in the way of good medical care."
</p>
<p>
Prior authorization is also a major source of physician burnout. The American Medical Association estimates that physician practices complete an average of 31 prior authorizations a week per physician, consuming roughly 14.9 hours—almost two full business days—of physician and staff time. A bill is pending in Congress to standardize prior authorization across Medicare Advantage plans.
</p>
<p>
The AMA released its 2018 Prior Authorization Physician Survey results last year, surveying 1,000 practicing physicians about the impact of prior authorization on their work. More than 90% of the physicians reported care delays associated with prior authorization, and almost as many said that the burdens of prior authorization have increased over the past five years. Most disturbing was the fact that 28% of the physicians reported that prior authorization had led to a serious adverse event for a patient in their care.
</p>
<p>
Physicians and practice administrators in Washington echo the national survey results. Dr. Girolami recalls a patient who came to her office on a Friday. Dr. Girolami ordered a CT scan, which led to a biopsy and a diagnosis of metastatic colon cancer. By Wednesday, the patient was meeting with an oncologist.
</p>
<p>
"Then someone had the nerve to call me about prior authorization," Dr. Girolami says. After telling the insurer that she had quickly identified a lifethreatening condition, Girolami was able to get the plan to back down.
</p>
<p>
Then, there's the cumbersome administrative burden imposed by prior authorization. Pedersen, who works at a practice with nine providers, says that one staffer in the office deals with an average of five to seven prior authorizations each day.
</p>
<p>
"I can grasp the concept, but it's gone too far," she says. "We spend anywhere from 30 minutes to an hour for one prior authorization for certain carriers. What the staff complain about most is that when you call the carrier for assistance, on average you get transferred three times. Sometimes, it takes 10 minutes just to get to the right person to answer a question or to get the correct form that needs to be filled out. Some carriers have different forms depending on the test or medication."
</p>
<p>
For an obstetrics practice, genetic screening is now the standard of care, but Pedersen says that most screenings still require prior authorization. New medications almost invariably require prior authorizations, but plans also request prior authorizations for even common treatments.
</p>
<p>
"When I first started in health care, I don't remember getting prior authorizations except for chemo meds," Pedersen says. "Now I'm getting them for everyday therapy."
</p>
<h3>B&amp;O tax burden unfairly targets independent practices </h3>
<p>
While all practices struggle with the costs that prior authorization imposes on them, independent practices are now struggling with an additional burden due to legislation passed last year. The state legislature increased the B&amp;O tax on independent practices by 20%, threatening the viability of many of those practices, particularly in already underserved rural areas where they are common. Getting the legislature to roll back the increase, which funds college financial aid for students from families earning below the state median income, will be a challenge.
</p>
<p>
While other professions were included in the tax increase, they can make their customers pay for it. "Medicine should have been excluded from this increase because we are not like other forms of business getting taxed," says Chelsea Unruh, MD, a physician at Yelm Family Medicine and president of the Thurston-Mason County Medical Society. "We don't get to control our prices and we don't get to say what we charge."
</p>
<p>
Dr. Unruh says managing a private practice is difficult enough, given the tight margins. "I have to make sure I pay staff and keep the lights on, and pay my salary, too, so I can pay my loans back," they say.
</p>
<p>
The B&amp;O tax has had a direct impact on the care the practice is able to provide, leading to care being restricted or even ended for poorer patients. "I have to limit how many Medicaid people I can see because of the overhead of being in a private practice," they say. "The B&amp;O tax added even more pressure onto that already-tight overhead and is making it more difficult to be able to serve the vulnerable population. It's one of the most frustrating parts of being in medicine."
</p>
<p>
As an internist in a solo practice, Dr. Girolami experiences similar pressures. "If you take charity care, Medicaid, or Apple Health, you're already running in the hole," she says. "You have to limit the number of people you see, which gives them way less choice. It's painful."
</p>
<p>
Dr. Girolami also says that the additional expense leads to diverting investments that could improve office efficiency. "That money may have been earmarked for a texting service or software," she says. "Now you have to take a hard look at it." As a result, she says, the tax "is punitive to smaller groups."
</p>
<p>
The fallout may not be limited to current investments. Dr. Unruh says that the tax will make it harder to recruit physicians to rural practices, worsening an already bad problem.
</p>
<p>
"Folks coming out of medical school are coming out with more loans than we've ever seen in the past and not as much incentive to go into private practice," they say. "We're limiting our ability to be competitive for a new workforce."
</p>
<h3>The technology reimbursement gap</h3>
<p>
Technology—specifically telemedicinewill also be on the agenda for the next legislative session. By allowing for long-distance clinician-patient contact, telemedicine has the potential to provide medical care to those who would otherwise have to travel for it or not receive it at all.
</p>
<p>
However, while Washington insurers must provide coverage, telemedicine may be reimbursed at a lower rate than an in-person visit, which disincentivizes use of the technology. About 10 states, including California and Florida, have passed legislation to correct this disparity, but a bill to do so in Washington, SB 5385, failed to pass last year. The bill will automatically be reintroduced in the new session. Sen. Randi Becker, sponsor of the legislation, worked in the medical field for 24 years, starting as a practice receptionist and ending as an administrator.
</p>
<p>
"The intent of the legislation is to acknowledge the value of treating patients in a location that works for them," she says. "We want people to get the care they need at the time they need without having to travel." She points out that the need is especially keen in rural areas of the state where specialists are in short supply.
</p>
<p>
Becker notes that advances in health care technology often lag behind policy. (As an administrator, she led her clinic in developing the first internet billing system to transmit a claim to Medicare.) "I have always believed in technology in the health care arena," she says. "As a nation, we have embraced technology. But why do we not embrace it as easily in health care? We can't get in the way of technology."
</p>
<p>
By eliminating the payment disparity, Becker believes that telemedicine will be able to develop its potential more readily. She's hopeful about the bill's chances this time around. "Time was a factor last time," she says. "There's optimism about this going through this year."
</p>
<p>
<em>John Gallagher is a freelance journalist specializing in covering health care.</em>
</p>
<p>
<em>This article was featured in the January/February 2020 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> | 1/2/2020 10:21:54 AM | 12/30/2019 2:42:59 PM | 1/2/2020 12:00:00 AM |
| practice_health_in_jeopardy | Practice Health in Jeopardy | WSMA_Reports | Shared_Content/News/Latest_News/2020/January/practice_health_in_jeopardy | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMA_JanFeb-2020-PRINTERS-FINAL-Cover-645x425px.jpg" class="pull-right" alt="WSMA Reports January-February 2020 cover" /></div>
<h5>January 2, 2020</h5>
<h2>Practice Health in Jeopardy</h2>
<p>
By Teresa M. Girolami, MD
</p>
<p>
<em>Dear Valued Customer: Due to an increase in operating costs, we're raising prices on our coffee beverages - please pardon the inconvenience.</em>
</p>
<p>
When I read that note at my favorite coffee shop, I didn't hesitate to accept the price increase. As the owner of small private practice in Redmond, I empathize with decisions that must be made with increasing expenses.
</p>
<p>
It also got me thinking again, as I often do, of the ways in which running a private practice or independent clinic differs from other small businesses—and how our business model is increasingly under threat in Washington state.
</p>
<p>
Last year, state lawmakers passed a 20% increase in the business and occupation (B&amp;O) tax on small service businesses, including independent physician practices like mine. I doubt the Legislature realized the impact this tax increase has on independent practices and clinics—where roughly a third or more of our state's physicians practice—and the patients they serve.
</p>
<p>
How are physician businesses unlike other small businesses? We get paid mainly by insurance companies, not by our primary customers. We have limited negotiation power and we get paid less each year. Unlike a coffee shop, when our expenses go up, we have no way to recover the resulting loss. We cannot—and don't want to—pass this expense on to our patients.
</p>
<p>
And yet it's patients—largely our most vulnerable ones—who bear the brunt of this legislative decision. Unfairly targeting independent physician businesses with tax increases forces them to make hard decisions to keep their doors open in a highly competitive environment. Patients covered by public programs that are low payers, like Medicare and Medicaid (which covers many of our state's children), are being turned away.
</p>
<p>
In a worst-case scenario, a practice will close, with many more patients losing access to their primary physicians. Just last year, three rural practices closed, citing increasing business expenses.
</p>
<p>
The health of our state's independent practices should concern all physicians. Patients who can't access preventive care often end up in urgent care clinics and emergency rooms. This adds strain to already over-burdened emergency centers and drives up everyone's cost of care. In other instances, patients are absorbed by employed physicians with panels already stretched thin, leading to more burnout.
</p>
<p>
Increasing the B&amp;O tax impacts businesses like mine in too many crucial ways to cover here, but each is essential to maintaining the health of independent practices and the balance of our health ecosystem.
</p>
<p>
On behalf of King County Medical Society, I sponsored a resolution passed unanimously by the WSMA House of Delegates that directs the WSMA to advocate to amend state law to exempt all physicians from the B&amp;O tax increase to protect the vital health interests of our communities. I urge all WSMA members, and all Washington state physicians, to oppose this unfair tax increase that will disproportionately harm independent practices and clinics.
</p>
<p>
I trust my local coffee shop will weather its increased expenses. But I am deeply concerned about thousands of small businesses like mine. Our health, and the health of Washington's medical community, is in jeopardy. Those consequences are far more serious than the loss of a morning cup of coffee.
</p>
<p>
<em>Teresa M. Girolami, MD, is the president of King County Medical Society and owner of BelRed Internal Medicine, PLLC.</em>
</p>
<p>
<em>This article was featured in the January/February 2020 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> | 1/2/2020 10:21:54 AM | 12/30/2019 2:48:05 PM | 1/2/2020 12:00:00 AM |
| behind_the_cover | Behind the Cover | WSMA_Reports | Shared_Content/News/Latest_News/2019/December/behind_the_cover | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/News/WSMAReports-Extras-Website-645x425.jpg" class="pull-right" alt="WSMA Reports Extras logo" /></div>
<h5>December 17, 2019</h5>
<h2>Behind the Cover</h2>
<p>With this year's redesign of <em>WSMA Reports</em> by <a href="https://www.journeygroup.com/">Journey Group</a>, we began featuring illustrations on the magazine cover to convey the complex topics of medicine we wanted to cover. The issue theme for the November/December 2019 edition centered around preparing for value-based care.</p>
<p><em>WSMA Reports</em> Art Director <a href="https://www.erinfostercreative.com/">Erin Foster</a> chose internationally renowned artist <a href="https://hannabarczyk.com/about">Hanna Barczyk</a> to create the original illustration. "I love Hanna's unique illustration style and how she whittles down complex concepts to a simple human emotion so well," she said. "This edition's <a href="https://wsma.org/Shared_Content/News/Latest_News/2019/November/preparing_for_value_based_care">cover story about value-based care</a> needed exactly that touch, and Hanna's illustration perfectly pinpointed the heart of the story."</p>
<p><a href="javascript://[Uploaded files/News and Publications/Publications/WSMA Reports Archive/WSMA_NovDec19-PRINTERS FINAL-singles.pdf]">View the cover illustration for <em>WSMA Reports'</em> November/December 2019 issue</a>.</p>
<p>Hanna began by closely reviewing the cover article written by health care journalist <a href="https://ritacolorito.com/">Rita Colorito</a>. With that inspiration, she worked on several concepts for review by Erin and the publication's editors. Of the six sketches, we selected the one that best visually conveyed the issue.</p>
<p>"I wanted to focus on the physicians' care for the patient, using scale; the two large doctors, both focusing, holding up, and providing support and attention to the patient's needs," Hanna says about that particular concept. To create the art, she used ink, and hand-rolled acrylic texture to create a grunge effect.</p>
<p>Hanna's award-winning work has appeared in <em>The New York Times</em>, <em>The New Yorker</em>, Penguin/Random House, <em>National Geographic Traveller</em>, <em>The Atlantic</em>, and <em>The Economist</em>, as well as many other national and international publications. Born in Germany, she's inspired by her family's Hungarian folk art traditions, vintage Polish film posters, German Expressionism, memories, love, music, movement, and a passion for dance often illustrating emotionally driven solutions that are bold, conceptual, and delicate all at once.</p>
<p>We think Hanna's graphic concept worked well for this issue. What about you? Let us know your thoughts by writing <a href="mailto:editors@wsma.org">editors@wsma.org</a>.</p>
<p><em>This WSMA Reports Extra is exclusive to the WSMA website.</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> | 12/17/2019 3:16:53 PM | 12/17/2019 2:55:25 PM | 12/17/2019 12:00:00 AM |
| 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 |