The following is an edited transcript of an MDAdvantage podcast with Steve Adubato and Dr. Ripley Hollister, Board Member and Chair of the Research Committee of The Physicians Foundation. In his role as a family medicine specialist, Dr. Hollister serves as President and CEO of Dynamic Healthcare Team, a five-provider primary care group in Colorado. In this interview, Dr. Hollister explains why those on the front lines need their emotional vital signs read to prevent the devastating effects of physician burnout, and he discusses what can be done going forward to ease their burden.
ADUBATO: Tell us about The Physicians Foundation. What is its mission and its goals?
HOLLISTER: The Physicians Foundation is a non-profit organization that is unique in its focus on empowering practicing physicians. As the U.S. healthcare system is in evolution, the Physicians Foundation remains steadfast in its determination to strengthen the patient–physician relationship in all arenas of medical practice. We support physicians as they navigate this changing healthcare system, focusing on three main pillars. The first is physician leadership, the second is physician well-being and the third is patient care and access with a focus primarily, at this time, on the social determinants and drivers of health, such as inequities due to poverty, employment, food access, education and housing.
ADUBATO: I know that the Foundation conducts surveys on a regular basis, but lately, you’ve made some changes due to the pandemic. Tell us about that.
HOLLISTER: Last April, we were ready to send out our regular biennial survey. The pandemic hit at that time, so we needed to make a significant pivot. Our surveys are unique in that we reach out to every practicing physician in the AMA database. We understood that a large survey at that time would be flatfooted, so in April we decided to modify the survey strategy in order to remain relevant, current and sensitive to practicing physicians. The original survey was just too long, and doctors were already overwhelmed. But our surveys are critical to understanding the physician’s perspective, so we decided to go forward with our survey, but to break it into three smaller surveys* that would be effective in communicating the message that overwhelmed, practicing physicians wanted to deliver.
ADUBATO: What did your surveys find to be the greatest impact of COVID-19 on physician practices?
HOLLISTER: Part One, “The Impact of COVID-19 on Physicians’ Practices and their Patients,” showed that 8 percent of physicians had already closed their practices as a result of COVID-19. That calculates to about 16,000 practices nationwide. In addition, 43 percent of physicians had reduced their staff due to the pandemic. Nearly half, about 41 percent, saw their volumes decrease by 26 percent or more, which simply isn’t sustainable for many months. Patient access challenges were a looming concern, and the impact of reducing elective procedures was significant in all specialties—dermatology, ophthalmology, orthopedic surgery, gastroenterology, just go through the list—as well as on primary care, as patients elected to delay essential services that provide early prevention and detection.
ADUBATO: It’s one thing to talk about the impact of COVID-19 on physician practices, but it’s another thing to talk about the impact of COVID-19 on physicians themselves. What are you seeing in terms of physician stress, anxiety, mental health and such?
“Physician well-being had been a public health crisis even before COVID-19. COVID-19 only exacerbated and compounded this issue.”
HOLLISTER: Physician well-being had been a public health crisis even before COVID-19. COVID-19 only exacerbated and compounded this issue. Even before the pandemic, physicians were being unnecessarily burdened by the administrative demands of regulatory and reimbursement mandates that increase physician workloads, as well as interference with patient needs that contribute to physician burnout and early retirements. The stress of the pandemic has compounded physician burnout. In our survey, 58 percent of respondents indicated that they felt burned out. Before the pandemic, physicians had the highest suicide rate of any profession, and more than twice that of the general population. We don’t yet have complete data about the impact of COVID-19 on burnout, but no doubt, it has been significant.
ADUBATO: What are the implications of 58 percent of physicians saying that they feel burned out?
HOLLISTER: In previous surveys, we’ve seen that at times 80 percent of physicians have symptoms of burnout about 50 percent of the time. Our survey this time around showed almost 60 percent of physicians feel burned out. That, we feel, is a huge increase, and we have a fairly clear understanding of why that would be, with the stress and anxiety that are going on. The implications of that are devastating. Nearly one in four doctors knows a physician who has actually committed suicide. As I mentioned, 58 percent felt burned out; 18 percent reported increasing their use of medications, alcohol and illicit drugs (this number really is surprising to me); 13 percent of physicians have actually sought medical attention for a mental health problem as a result of the COVID-19; and 30 percent cited feelings of hopelessness or having no purpose at all.
ADUBATO: What have the physicians you’ve surveyed shared in terms of what, if anything, would be helpful to their own well-being?
HOLLISTER: Nearly half of the doctors tell us that COVID-19 will not be under control until the middle of 2021. I think that is pretty accurate. In the meantime, it’s critical that we do more to support the physicians who are fighting on the frontlines and putting their lives at risk to care for patients. Our surveys show that physicians say we need to reduce administrative hassles, and we need to streamline treatment approvals. We need to get those unnecessary blockages out of our way. We need to ensure adequate reimbursement to support our practices during this time, get the vaccine out to frontline clinicians, ensure support from local legislatures and support telehealth.
ADUBATO: Is there anything that can be done to reduce physician burnout and intervene to help those who are suffering?
HOLLISTER: The Physicians Foundation’s Vital Signs initiative empowers physicians and their colleagues and loved ones to do a check-up on each other’s well-being. That Vital Signs checkup is available at www.PhysiciansFoundation.org. The HEART acronym helps us remember the warning signs:
H is for health: Watch out for increasing use of medications, alcohol or illicit drugs and for physicians who are talking about hurting themselves or wanting to die.
E is for emotions: Watch out for extreme mood swings and feeling hopeless or of having no purpose.
A is for attitude: Watch out for negative feelings about your professional and personal lives or having inappropriate outbursts of anger or sadness.
R is for relationships: Watch for withdrawing and isolating from family, friends and coworkers or talking about being a burden to others.
T is for temperament: Watch out for acting anxious or agitated, or behaving recklessly or being uncomfortable, tired or in unbearable pain.
If you notice yourself, friends or colleagues showing any of these warning signs, reach out and get help.
ADUBATO: This is very helpful in outlining what we can do for friends and family who are physicians and what physicians can do for themselves. Now, in the big picture of the American healthcare system, are there any policy or administrative changes that would really make a difference for our physicians?
HOLLISTER: In our last survey, physicians were asked to rank options regarding the direction of healthcare in the future, thinking about things like patient access, value, quality, health system efficiency, physician autonomy, compensation, as well as the current response that we’ve had as a public to COVID-19. The ranking system allowed for options from #1 (“best”) to #4 (“worst”). Thus, the survey reveals not only support for an option but also opposition. The clear winner was support for an implementation of a two-tiered system in which a single-payer plan is available for all who choose that option, while private pay or insurance options through employers or direct purchase would also be available: 36 percent of physicians gave this the most favorable ranking, while only 11 percent gave it the “worst” ranking. This shows significant enthusiasm for that option with fairly weak opposition. Coming in next with neither strong enthusiasm nor strong opposition was the option of improving the current ACA influence system: 19 percent ranked it #1 (“best”) and only 12 percent ranked it #4 (“worst”). Coming in third was the option to move to a market-driven system with health savings accounts and associated tax savings, as well as catastrophic policies such as high-deductible insurance plans. This option had strong support of 30 percent of survey participants, with strong opposition from 42 percent, showing significant polarization. Coming in as a clear loser was the option for the government-funded and -administered, single-payer Medicare system: 19 percent ranked it #1 (“best”); 38 percent ranked it as the “worst.” Clearly, I think the voice of physicians is in favor of having significant options for our patients while assuring good insurance coverage for everyone at a very basic level.
When you review the survey, I hope you’ll see that we really tried to cover the gamut and give physicians a voice on this important issue. Additionally, you’ll see that more than 700 physicians took time to add poignant comments ensuring that we hear the true voice of America’s physicians. You can see the survey and those comments on our website at www.PhysiciansFoundation.org.
* The Physicians Foundation’s three-part survey series: Part 1: The Impact of COVID-19 on Physicians’ Practices and their Patients. Part 2: The Impact of COVID-19 on Physician Wellbeing. Part 3: The Impact of COVID-19 and the Future of Our Health Care System. The full results of each survey can be found at https://physiciansfoundation.org/physician-leadership/physician-and-patient-surveys.