Enhancing Our Well-Being

By now, this is not news to you: burnout among physicians is common. A 2017 Medscape survey indicated that 55% of internists experienced burnout, defined in this context as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.  ACP recognizes burnout as a significant threat and in response has developed an initiative to enhance physician well-being and professional satisfaction. In their statement of commitment, the College talks about “identifying strategies and necessary infrastructure to improve the efficiency of practice, reduce administrative burden, promote an organizational culture of wellness and enhance individual resilience.”  In her recent column on the topic, Susan Thompson Hingle, MD, MACP, Chair of the ACP Board of Regents, writes: “ACP has long identified reducing administrative complexities or burdens as a priority, and the Patients Before Paperwork Initiative addresses systems challenges and seeks to reinvigorate the patient-physician relationship by challenging unnecessary practice tasks.”  This is one step towards addressing dissatisfaction with the weight of administrative burdens.  Regarding organizational culture, ACP offers “Top 10 Culture Change Interventions to Reduce Burnout and Improve Physician Well-being”, including identifying a wellness champion, focusing on leadership development, and establishing a culture that emphasizes teamwork and relationships; I highly recommend reviewing this.

Many of us have teaching and leadership roles.  At the residency level, the ACGME also recognizes a need for change; they updated the common program requirements in response.  In this context, they relate self-care to professionalism and describe it as a skill to be learned and developed along with other aspects of residency training. Promoting resilience is an important part of the approach to reducing burnout, particularly among trainees and junior colleagues. In a recent commentary in Academic Medicine, Abaza and Nelson speak to the issue of role modeling and resilience: “More than just being understanding and supportive of our learners’ self-care needs, this means providing the role modeling they need to see to understand the relevance of self-care. […] We need to openly talk about the dilemmas we face in making choices between our needs, our family’s needs, and our patients’ needs. […] Balance does not mean forgoing responsibility for obligations but finding ways, to the best of one’s ability that day, to accomplish them within a reasonable framework.” [Acad Med. 2018;93:157–158.]

The solutions aren’t easy, but there is no question we need to continue to focus attention on burnout and resilience for the good of our patients and our profession. I urge you to review ACP’s resources at https://www.acponline.org/practice-resources/physician-well-being-and-professional-satisfaction.

-Rob Nardino, MD, FACP

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What next?

Every day brings more unbelievable news. I started out writing this entry focusing on what we might expect in the upcoming weeks regarding the Affordable Care Act following the Senate and House votes to begin repeal. Connecticut could see a 92% increase in uninsured, and is estimated to be the 10th worst affected state overall considering costs and loss of coverage. But recently even more fundamental attacks on our democracy have made the healthcare coverage story seem to pale in comparison. I am going to reiterate the disclaimer that appears on the “About” section of this blog: “The opinions expressed by this blog do not reflect official policy of the American College of Physicians and reflect the opinion of the author.” I need to repeat that clearly, because ACP maintains a nonpartisan stance and seeks to work with each administration and iteration of the legislature, regardless of how far their policies veer away from the College’s position (on the ACA, Climate Change, Firearm Violence, etc).

Yesterday, a presidential executive order banning resettlement of properly vetted Syrian refugees from entering the country, as well as banning entry for people from seven other nations, went into effect. As you have no doubt already heard, although the order invokes the 9/11 terrorist attacks as one basis for the order, it does not extend the sanctions to the countries from which the perpetrators of those attacks come: countries in which, conspicuously, Trump Family businesses have interests. So it just comes off as xenophobic and hypocritical, affecting innocent people and not accomplishing its stated goal, and flying in the face of what this country is about (at least idealistically; our history is littered with the mistreatment of almost every group excluding straight WASP men, but this still feels like a step backward).

There are worrisome threats to the First Amendment as the administration attempts to quash any journalistic criticism or questioning. At the same time, blatant mistruths are spouted by the official White House communications department (and POTUS tweets). Not to mention the Orwellian sounding “alternative facts” and the sad and pointless insistence on fraud impacting the popular vote. Authoritarianism seems to be rearing its ugly head.

Cabinet appointees also appear poised to spearhead an attack on science, education, public well-being and ethics. I’m really trying not to be an alarmist. I try to be understanding of views that don’t align with my admittedly liberal leanings. I’m trying to believe this isn’t one big business deal for our chief executive, and he really does care what happens to the country.  Really, I am; but I’ll admit week one is making it look like such belief will be challenging to maintain.

In the meantime, I will take it as my sworn responsibility to defend patients, the education of medical students and residents, the practice of medicine, and the very integrity of science against any misdirected or ill-informed policies.

MedChallenge 2016: The CT Chapter’s knowledge competition for internal medicine residents

For 19 years, the Connecticut Chapter has been conducting a Jeopardy-style medical knowledge tournament for internal medicine residents in the state. This is a rousing event, one of the best the chapter has to offer. Since 2011, the final round has been held at the Chapter Annual Meeting, after a preliminary round at another site. It is truly one of the highlights of the annual meeting. Every year, talented resident physicians amaze us with their ability to recall exact details of routine and obscure medical conditions, and the treatments required, under tremendous pressure. It is one thing to come up with the answer while sitting in the audience, and yet another to do so with buzzer in hand – with everything on the line. This year, the initial round was held at Waterbury Hospital. Nine teams battled in three preliminary heats to become one of the four teams that will play in the final round on October 28. The three preliminary match winners were Bridgeport Hospital, Yale-Traditional and University of Connecticut; Norwalk Hospital also qualified as the highest scoring second place team.  The winner of the final will have the right to represent the CT Chapter at Internal Medicine 2017 in San Diego.

Please come to the Annual Meeting to support the four programs that will face off in MedChallenge 2016: Bridgeport Hospital, Norwalk Hospital, University of Connecticut, and the Yale Traditional Program.  The final starts at 3 p.m.  See the Annual Chapter Meeting agenda.

Below is a list of winners from past years:

• 1998-1999: University of Connecticut*
• 1999-2000: Hospital of Saint Raphael
• 2000-2001: University of Connecticut
• 2001-2002: Hospital of Saint Raphael
• 2002-2003: Hospital of Saint Raphael
• 2003-2004: University of Connecticut Primary Care
• 2004-2005: University of Connecticut
• 2005-2006: University of Connecticut
• 2006-2007: University of Connecticut
• 2007-2008: University of Connecticut
• 2008-2009: University of Connecticut
• 2009-2010: University of Connecticut
• 2010-2011: University of Connecticut
• 2011-2012: University of Connecticut
• 2012-2013: University of Connecticut
• 2013-2014: University of Connecticut
• 2014-2015: Yale University (Traditional)
• 2015-2016: Yale University (Traditional)

*In 1999, as our inaugural entry into the national ACP Doctor’s Dilemma competition, the University of Connecticut won the competition. See the link for more on the ACP Doctor’s Dilemma, including a list of past winners.

Join us at this year’s CT ACP Chapter Meeting for an introduction to the arts of physician wellness

This entry is submitted by Lisa Sanders, MD, FACP, chair of the chapter wellness committee.  RJN

Physician wellness is part of the solution to the problem of burnout. We’ve heard so much about burnout lately. But what, you might ask, is wellness? One of the first papers to promote it described wellness as a “dynamic and ongoing process involving self-awareness and healthy choices resulting in a successful, balanced lifestyle.” In other words, wellness is the result of activities of the mind and body you choose as a counterbalance to the mad dash from patient to patient and computer screen to computer screen that medicine has become in the 21st century.

This year the American College of Physicians is focusing on wellness as one technique to make the practice of medicine better for both physicians and our patients. In support of that initiative, this year we are offering a smorgasbord of activities to promote both physical and mental health. These include classes on Mindfulness and Meditation, on T’ai Chi – a Chinese martial art and system of calisthenics, consisting of sequences of very slow controlled movements – and on Yoga. These are not lectures about the benefits of these practices. These are short hands (and bodies) on introductions to the practice of these ancient and well-studied arts given by local masters. The classes will be structured so that they can be done in normal work clothes so no special equipment is needed.

In addition, we will have massage therapists here that morning to provide another kind of hands-on stress reduction treatment to help you relax and enjoy the rest of your day.

And throughout the conference day we will be exhibiting art works of ACP members who practice the visual arts as part of their own wellness plan. (For more information on that, or to participate, please email me: lisa.sanders@yale.edu.)

So join us on Friday, October 28 at the Aqua Turf Club to catch up on the latest in Medicine and MOC and to practice a little physician wellness.

The Comprehensive Addiction and Recovery Act

Deaths due to opioids are reaching epidemic proportions.  According to the Centers for Disease Control and Prevention, the number of deaths attributable to overdose on prescription drugs increased from approximately 9,000 in 2001 to nearly 26,000 in 2014.  This includes a 3.4-fold increase in opioid-related deaths, to a number of 18,893 in 2014.  This has also been accompanied by a 6-fold rise in heroin overdose deaths, as people who cannot afford or otherwise continue to obtain prescription opioids turn to cheaper, more available heroin.

On July 22, President Obama signed the Comprehensive Addiction and Recovery Act (CARA) into law. This represents an achievement for ACP, which advocated for important provisions in the law which were incorporated by the conference committee that ironed out the differences between House and Senate versions.

Some key provisions of the legislation will be to:

• Expand prevention and educational efforts—particularly aimed at teens, parents and other caretakers, and aging populations—to prevent the abuse of methamphetamines, opioids and heroin, and to promote treatment and recovery.
• Expand the availability of naloxone to law enforcement agencies and other first responders to help in the reversal of overdoses to save lives.
• Expand resources to identify and treat incarcerated individuals suffering from addiction disorders promptly by collaborating with criminal justice stakeholders and by providing evidence-based treatment.
• Expand disposal sites for unwanted prescription medications to keep them out of the hands of our children and adolescents.
• Launch an evidence-based opioid and heroin treatment and intervention program to expand best practices throughout the country.
• Launch a medication assisted treatment and intervention demonstration program.
• Strengthen prescription drug monitoring programs to help states monitor and track prescription drug diversion and to help at-risk individuals access services.

The passage of CARA shows that there is still common ground between the two political parties as it passed the House 407 to 5 and the Senate 92 to 2.  However, there are limits to the collaboration as funding that would have really bolstered treatment efforts was not included.  The final law appropriated $160 million for treatment, although Democrats had asked for up $920 million.  Still, as President Obama stated: “Given the scope of this crisis, some action is better than none.”

Stemming the Escalating Cost of Prescription Drugs

Back in October, I wrote about escalating drug prices.  Last week, ACP President Nitin Damle was testifying before Congress about the CREATES Act (“Creating and Restoring Equal Access to Equivalent Samples Act of 2016”).  This bill, if it were to become law, would make it easier for generic drug manufacturers to get access to samples of the reference product in order to support bioequivalence testing required for an FDA application.

This was also one of the topics we discussed on Capitol Hill during Leadership Day last month.  We advocated for the development and introduction of legislation in both chambers that will include these elements:

1) Increased transparency in drug pricing by requiring pharmaceutical manufacturers to publically disclose production costs, including research and development investments for specific high‐cost drugs that the Secretary identifies through regulation. Unlike many other countries, the United States lacks regulatory authority to control the price of drugs or devices. As a result, pharmaceutical companies may price drugs at will and there is very little transparency or understanding of how companies arrive at the price of a drug.

2) Authorization to appropriate $2.74 billion in discretionary spending for the FDA to expedite, through fast-track approval, new drugs that address unmet medical need in the treatment of a serious or life threatening condition, as well as to address the back-log of pending generic drug applications. The median approval times for standard and priority review drugs in fiscal year 2013 dropped to 12 months and 7.9 months. Drugs can move through the regulatory approval process more rapidly if they qualify for fast track designation, accelerated approval, priority review, or breakthrough therapy designation. Although an FDA report showing the agency is approaching targets and commitments made by the agency to improve review times is encouraging, we continue to advocate for additional resources for the FDA so that progress can continue on clearing the backlog. ACP also supports robust oversight and enforcement of restrictions on product-hopping, evergreening, and pay-for-delay practices as a way to increase marketability and availability of competitor products. In these practices, companies prevent generic competition from entering the market by making small adjustments to a drug with no real therapeutic value that grant the company longer patent protection, or they remove the drug from market, forcing patients to switch to a reformulated version of the same drug.

3) Granting authority to the Secretary of HHS to negotiate prescription drug prices with manufacturers for high‐cost drugs and biologics covered under Part D of the Medicare program. Medicare Part D pays on average more than other federal health care programs: 73% more than Medicaid and 80% more than the Veteran’s Health Administration (VA). The VA operates as a closed system and provides care directly to veterans. They purchase drugs and other pharmaceuticals directly from manufacturers, and have a national formulary which does not exist in Medicare or Medicaid. The ACP has longstanding policy advocating for the ability of Medicare Part D to negotiate drug prices and rebates directly with pharmaceutical manufacturers as a way to keep costs to the system down. Although the Congressional Budget Office, in a 2007 letter to Senator Wyden, contended that the savings would be negligible, other recent estimates show Medicare Part D could save $15-16 billion a year if it were allowed to negotiate drug prices.

The CREATES Act could be one step in the right direction.

To read the ACP Position Paper, Stemming the Escalating Cost of Prescription Drugs, click here.

Annals This Week: Physicians, Patients and Firearms

Last December, I wrote about ACP activity to counteract firearm violence.  This week, the Annals of Internal Medicine published a review on physician practice regarding asking about firearms. It is striking that 40% of Americans are worried they could be victims of firearm violence.  That doesn’t sound like the domestic tranquility envisioned by our founding fathers.

We are hopefully beyond the discussion of whether or not gun violence is a public health issue.  You’ll recall that the nomination of the current Surgeon General, Vivek Murthy, was contested because he dared to publicly state that it is an important issue of public health.  But physicians could do better at preventing firearm violence.  The article summarizes barriers and makes suggestions for implementing a preventive approach.

Legislative action such as Florida’s so-called “Docs versus Glocks” law have led some clinicians to be, um, gun-shy about asking questions related to firearms.  The authors point out that existing laws, even the Florida gag rule, do not prohibit the clinician from asking about firearms when that information is relevant to the care of the patient or the patient’s safety, or the safety of others.  It is the routine collection and documentation of information about gun ownership that is prohibited.  The three other states with firearm/health statutes also do not outlaw collection or recording of information about firearm ownership when it is medically necessary. More proscriptive bills have come up in North Carolina and Ohio but have not been passed as laws.

The authors then outline three conditions for which, even if a physician was having difficulty incorporating firearm discussions as a matter of routine, there should be selective implementation.  First, when a patient is at acute risk for harm to self or others: suicidal or homicidal ideation or intent.  Second is the presence of individual risk factors for engaging in future violence, including a history of violence; certain phases of mental illness such as recent discharge from an ED or inpatient facility, or experiencing a first psychotic episode; and cognitive disorders.  Third, there are high risk groups: for suicide, middle-aged or older white men; for homicide, young African-American men.

The authors identified lack of familiarity with the benefits and risks of firearm ownership, with how to counsel about firearm and with firearms themselves as the most significant barriers.  Little has been done to assess specific interventions.  But there is advice about how to counsel.  They advocate for respectful conversations recognizing the cultural aspect of gun ownership, best occurring in the setting of an existing patient-physician relationship.  They give other suggestions for the content of such conversations.  Finally, they remind us that disclosure of protected health information to authorities is permissible when harm to self or others is imminent.