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Our Health Care Workers Are Struggling — That’s Why I Introduced Legislation to Help

By Burnout, Health, Work-Life BalanceNo Comments

As the husband of a physician, I like to say that issues affecting health care workers aren’t just dinner tables issues — they’re breakfast, lunch and dinner table issues. This has never been truer than it is during the current coronavirus crisis.

When the greater Chicago area was overrun with COVID-19 patients this past spring, my wife, an anesthesiologist, was among those on the front lines placing intensive care unit (ICU) patients on ventilators. She did so while wearing a welder’s mask that she purchased from a hardware store because there was simply not enough personal protective equipment (PPE) to go around. Our children and I could not have been prouder of her bravery, but we worried about her constant exposure to the virus and the pressures of being a frontline health care worker during a pandemic.

Although case numbers have come down in our area, the virus is far from quashed, and any amount of progress feels fragile. For many who served in hot spots like New York City in the early days of the pandemic — and those in areas currently experiencing surges, like Miami and Houston — navigating the emotional toll of being on the front lines has proven to be among the pandemic’s greatest challenges.

As with so many other areas of policy, the COVID-19 crisis has forced us to confront the ways we have failed as a nation to look out for the well-being of our health care workforce. Too many have struggled in silence for decades; now, they have been called to respond to a once-in-a-century public health crisis without an emotional safety net. It is for these reasons that I introduced the bipartisan Coronavirus Health Care Worker Wellness Act (H.R. 7255), along with my colleagues Reps. John Katko (R-N.Y.) and Frederica Wilson (D-Fla.). This legislation seeks to accomplish two goals:

  • First, the bill will authorize U.S. Department of Health and Human Services (HHS) to distribute grant funding to health care providers who wish to establish or expand programs dedicated to promoting the mental wellness of their workers on the front lines of COVID-19; and
  • Second, the bill will authorize a comprehensive, multi-year study on the issue of health care worker mental health and burnout, including an assessment of underlying factors, barriers to seeking and accessing treatment, implications for the health care system and patient outcomes, and the impact of the COVID-19 crisis.

Studies and events of the past several months have confirmed that many health care workers are indeed struggling with their mental health as a direct result of COVID-19. Consider the following:

  • Health care workers have witnessed death on an unprecedented scale, and social distancing orders have put them in the agonizing position of denying families access to their loved ones and notifying them of deaths over the phone;
  • With morgues overflowing, some hospitals have parked refrigerated trucks outside to store additional bodies;
  • Critical shortages of PPE in the spring forced health care workers to re-use equipment or go without it, and there is a fear that shortages could return if cases spike again this fall;
  • Over 135,000 health care workers have been infected with COVID-19 to date, and more than 600 have died;
  • Data from China — a country that experienced an acute outbreak much like our own in March and April — put startling figures on reported rates of depression (50.4%), anxiety (44.6%) and insomnia (34.0%) among frontline workers;
  • Another study conducted between March and May found that the average U.S. health care worker — not just those on the front lines — reported enough depressive symptoms to be considered clinically depressed;
  • Rates of post-traumatic stress disorder (PTSD) among frontline workers are expected to rival those among first responders to the 9/11 terrorist attacks; and
  • Lorna M. Breen, MD — an emergency room physician in New York City who contracted COVID-19 herself — tragically believed she had no choice but to take her own life amid the devastation.

As dire as the current situation is, the unfortunate truth is that burnout and mental health challenges were common among health care professionals long before the world had ever heard of SARS-CoV-2 — something that likely comes as no surprise to members of the neurosurgery community.

COVID-19 will, unfortunately, be with us for an extended period. Frontline workers needed our support back in March — not just with our words, but with Congressional action — and we failed to provide it. We simply cannot overlook this situation any longer, nor can we continue to ignore the importance of the long-term job satisfaction of our nation’s health care workforce. We must pass the Coronavirus Health Care Worker Wellness Act as soon as possible.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtag #PhysicianBurnout.

U.S. Congressman Raja Krishnamoorthi (IL-8)

September 11, 2020
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Burnout to Wellness: Dr. Joseph Maroon’s Journey to a Balanced Life

By Burnout, Health, Work-Life BalanceNo Comments

Joseph Maroon, MD, FAANS, tells an interesting story that sets the scene for his journey from burnout to wellness in his book, Square One: A Simple Guide to a Balanced Life.

FLIPPING HAMBURGERS and working at gas stations are jobs some people might do during the summer months in high school, or maybe to make a living if they haven’t pursued a higher education. I, however, did both of these jobs at the age of 41, after I’d been a successful neurosurgeon for over a decade. Decidedly out of order on a résumé, right? But exactly one week after serving as the chief neurosurgeon in an operating room at a premier teaching hospital in Pittsburgh, I was filling up 18-wheelers and figuring out how to use the deep fryer at a truck stop in the small town of Wheeling, located in West Virginia’s northern panhandle.

The reader immediately wants to know how he got to the truck stop, what the circumstances were, and, most importantly, did he make it back to neurosurgery. Fortunately, he did; however, Dr. Maroon’s journey of highs and lows were made public long before his recent book. For the last several decades, he has regularly used his own example of an Icarus-like fall as a teaching lesson for both residents and staff. To this end, it was also the subject of his presidential address — From Icarus to Aequanimitas — to the Congress of Neurological Surgeons (CNS) in 1986.

The stresses Dr. Maroon experienced as a neurosurgeon, the toll on his personal life and the concurrent physical as well as mental decline are today recognized as burnout. At the time, however, burnout was only a taboo topic whispered in the halls of medical institutes. Dr. Maroon famously recounts his story of overcoming burnout after rediscovering a childhood book, I Dare You, by William H. Danforth. In the book, Danforth relates a balanced life to a square, with each of the four sides being labeled as family, physical, work and religious. In a balanced square, each side would have equal length indicating the same participation in each category. Dr. Maroon relates how his “square” was a flatline EKG with his life totally consumed by work.

Using Exercise to Overcome Burnout and Depression

During his recovery from burnout, Dr. Maroon reconnected with his inner athlete. As a former collegiate All-American running back, he used physical exercise to help rebuild both his body and brain to overcome the depression that ensued with his burnout. His passion for exercise ultimately led to him becoming an 8-time Ironman Champion.

With a background in playing football, and realizing his own benefits for mental health with routine exercise, he became an advocate for team sports and exercise.

Burnout to Wellness Programs

As a living example of professional burnout, Dr. Maroon has worked with numerous neurosurgical residency programs, including his program at the University of Pittsburgh Medical Center (UPMC), to advance the recognition and interventions needed to reduce burnout. Neurosurgery as a profession now speaks openly about burnout with the initiation of several wellness programs nationally,

At UPMC, Dr. Maroon, along with a group of senior faculty and residents, initiated a wellness program several years ago based, in part, on the concept of Danforth’s square. The following characterizes the UPMC Wellness Program goals:

  • Improve work/life balance;
  • Decrease psychological stress;
  • Increase social support through activities and mentorship; and
  • Improve general health and fitness by monitoring biomarkers of physical and psychological health.

A significant milestone for the program recently occurred with the dedication of the Maroon Fitness Center. The center is located within a dedicated room in the department with both aerobic and weight lifting equipment that can be accessed by both staff and residents 24-hours a day. Dr. Maroon continues to lecture on the subject of burnout prevention within UPMC and beyond. His leadership by example continues to be an inspiration for past, present and future generations of neurosurgeons.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtag #PhysicianBurnout.

Nitin Agarwal, MD
Chief Resident
University of Pittsburgh Department of Neurological Surgery
Pittsburgh, Pa.

 

 

Jeffrey Bost, PA-C
Clinical Instructor in the Department of Neurosurgery at University of Pittsburgh Medical Center
Clinical Assistant Professor at Chatham University
Pittsburgh, Pa.

September 9, 2020
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Physician Burnout in Neurosurgery: An Under-Recognized Phenomenon

By Burnout, Health, Work-Life BalanceNo Comments

As conversations about work-life balance are becoming more prevalent, and given the stresses associated with the COVID-19 pandemic, there has been a renewed interest in the issue of physician burnout. Burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization and a lack of sense of personal accomplishment. In recent years, the rising prevalence of burnout among clinicians — more than 50 percent according to a Medscape report — has led to probing questions on how it affects access to care, patient safety and care quality. Burned-out physicians are more likely to leave their practices or the practice of medicine altogether, which reduces patients’ access to and continuity of care. Burnout can also threaten patient safety and care quality when depersonalization leads to poor interactions with patients, and when burned-out physicians suffer from impaired attention, memory and executive function.

In addition to the impact of burnout on physicians and patients, according to a recent study published in the Annals of Internal Medicine, the health care system loses more than $4.8 billion a year due to this phenomenon. Although neurosurgeons work long hours, balance outpatient and inpatient practices, and deal with life and death issues, we have paid limited attention to burnout in this field.

For the next few weeks, Neurosurgery Blog will highlight the issue of burnout — including in the field of neurosurgery. Here are some staggering facts about burnout in neurosurgery:

  • A recent survey of 783 neurosurgeons found the rate of burnout to be 62.9 percent among nonacademic neurosurgeons and 47.7 percent for academic neurosurgeons;
  • Poor work-life balance, health care reform and financial uncertainty were the major factors contributing to career dissatisfaction; and
  • Burnout and depression — sometimes associated with emotional exhaustion — were a significant predictor of preventable major medical errors in a study using data from 7,905 members of the American College of Surgeons.

Among neurosurgeons, many factors were found to lower the chances of burnout. High volume surgeons, with stable families, who are intellectually challenged, with leadership roles and a good work-life balance, are more effectively shielded against burnout.

Understanding burnout will push more health care organizations to adopt strategies to protect their members from this phenomenon. Physician engagement will undoubtedly be crucial to the prevention of burnout. We must take the lead by being active and vocal for ourselves, our colleagues and our patients and fight against the forces that erode our mental health and the quality of our work.

Join us in an insightful journey, understanding burnout as it pertains to the field of neurosurgery. We aim to identify the reasons behind this phenomenon and the best strategies to prevent it or minimize its impact on the careers of neurosurgeons.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtag #PhysicianBurnout.

Kimon Bekelis, MD
Vice-chair, AANS/CNS Communications and Public Relations Committee
Catholic Health Services of Long Island
West Islip, N.Y. 

 

 

Kristopher T. Kimmell, MD, FAANS
Vice-chair, AANS/CNS Communications and Public Relations Committee
Rochester Regional Health
Rochester, N.Y. 

 

 

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, Pa.

September 3, 2020
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Lasting Change: Assessing the Potential Long Term Impact of COVID-19

By COVID-19, HealthNo Comments

“Real change, enduring change, happens one step at a time.”

Ruth Bader Ginsburg

Associate Justice, U.S. Supreme Court

The economic, medical, political and psychological tsunami unleashed by the COVID-19 virus is unlike anything we have seen in our lifetime. The traumatic disruption of 9-11 was limited in comparison to our current crisis. While impossible to include up to the minute statistics, already more than 15 million cases have been confirmed with at least 620,000 deaths, and U.S. unemployment is approximately 11%. Is it possible that any good will come of these months of tragedy and lock-down? What do we know about the immediate and longer-term consequences on us as humans, on the health care community and neurosurgery? I have been given the monumental task of trying to peer into that future as the Neurosurgery Blog’s focus on COVID-19 draws to a close.

Silver Linings: Our World

Today, the canals of Venice are clear, and dolphins have returned — an amazing and rapid transformation. During the pandemic lock-down, our environment improved dramatically with blue skies seen across India, air pollution around major cities visibly and measurably improved, leading to improved health, and images from space revealing stunning clarity. Beyond recognizing how reversible the damage to our physical world is, we have witnessed the very best of humanity in our communities. Touching stories have filled our news feeds:

These represent the many things individuals are doing every day to make the lives of those around them safer and more fulfilling.

To fill the void left by social distancing, many have become facile with video technology to provide essential human contact during long weeks of isolation. Religious services, theaters, concerts and more have rapidly adapted to provide their communities invaluable connection and engagement.

Silver Linings: Health Care and Neurosurgery

As grim headlines unfolded, the health care community united. Traditionally competitive institutions have reached beyond those boundaries to share expertise, resources and staff to provide the best care for patients. Necessary innovation has blossomed creating change that will survive beyond COVID-19 such as:

The Centers for Medicare & Medicaid Services (CMS) authorized payment for telemedicine services, with many private insurance companies following on their heels. This marks a crucial advance and should herald a new era of health care delivery. A world free of many of the inconveniences associated with a visit to the doctor — days off work, parking, travel, navigating complex hospital corridors — is no longer a figment of the imagination. Reimbursement for these services will drive technological innovation that will enhance the value and experience of these visits. While there will always be an essential role for the face-to-face appointment —especially in the surgical disciplines such as neurosurgery — and the importance of human touch, the provision of telemedicine care should be more comfortable and more convenient.

Neurosurgery stepped up and came together in many meaningful ways. Many of our national and international organizations, as well as neurosurgical publications, provided state of the moment information to connect us around the world. Neurosurgeons continued to keep their practices afloat to provide care to those with emergent conditions despite considerable risks to themselves and, by extension, their loved ones. Many stepped into roles of supporting other physicians overwhelmed by the sheer volume and acuity of COVID-19 patients. In contrast, others assumed leadership roles helping their hospitals and communities in many ways — designing systems for surge redeployment of staff and creating new operating room policies to enhance airflow. Each institution has found ways to protect their resident team while ensuring they continue to receive valuable education and feel fully supported during a time of great strain.

Not All Roses

Still, many vulnerabilities were revealed, and scars will be left from the crisis. Neurosurgery lost one of our most beloved colleagues when COVID-19 took the life of James T. Goodrich, MD, PhD. Questions arose, such as how could things as simple as masks, gloves and gowns become such a challenge to procure? Known health care disparities were shown to exist, likely reflective of such differences at every level of medical care, but poignantly and tragically demonstrated in COVID-19 related deaths, morbidity and availability of resources. This was further brought into the spotlight by the death of George P. Floyd, Jr. and the dramatic national response that followed. Finally, people learned it isn’t so glamorous or pleasant to wear a mask, as neurosurgeons have known our whole careers.

Lasting Change

Most meaningful change does evolve incrementally; however, cataclysmic events like the COVID-19 crisis instigate sudden and dramatic change. Given the potential for positive unintended consequences, here is my wish list (please add your own!) for enduring gifts we deserve from COVID-19:

  • A deep appreciation not only for the fragility of the world around us but also its capacity for resiliency — let us remain mindful of how all of our actions impact the earth, our health, and our fellow humans;
  • A new dawn of real innovation in medicine that builds new frontiers of access and engagement by leveraging the best of augmented intelligence and melding it with the personal touch that only humans can provide;
  • Restoration of travel because of all the good it brings but with a profound sensitivity on how to preserve the beauty of the natural and man-made world; and
  • A renewed and sustaining appreciation for the difficult work done by neurosurgeons and all physicians, along with their dedicated teams, to care for patients and their loved ones every day.

We thank our readers for following Neurosurgery Blog as it recorded the real-time impacts of the COVID-19 global pandemic. As the world emerges from these trying times, we invite you to continue the conversation on Twitter by following and using the hashtag #COVID19. With new therapeutics and promising vaccines, the glimmer of hope becomes stronger with each passing day.

Deborah L. Benzil, MD, FACS, FAANS
Cleveland Clinic, Vice-Chair, Neurosurgery
Cleveland, Ohio

July 24, 2020
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Aerosolization, Endonasal Surgery and the Neurosurgeon

By COVID-19, HealthNo Comments

Neurosurgeons never stop learning. As a result of the COVID-19 pandemic, previously obscure terms such as airflow and aerosolization — the dispersal of a substance such as medicine or viral particles in the form of an aerosol — have entered our regular lexicon. We can now readily identify which of our operating rooms has the highest airflow — usually the smallest room — and the standard for the minimum number of air exchanges per hour, which is at least 15.

COVID-19 has brought to light a new spectrum of difficulties for neurosurgeons. Of particular concern are increasing reports of significant morbidity and mortality among otolaryngologists in several countries that have been putatively linked to endonasal surgery. Patel and coworkers from Stanford University highlighted this issue in a letter to the editor in Neurosurgery. They urge precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic due to the concern that aerosol droplets coming from surgery may increase the possibility of infection of medical staff in the operating room.

In a reply, Huang and colleagues from Huazhong University of Science and Technology in Wuhan, China, were able to provide additional information regarding COVID-19 spread. They believe that compared to droplet transmission, contact transmission may be an equally important factor in transmission in medical workers and was ignored during the early stages of the pandemic due to lack of knowledge. They urge washing hands and cleaning all surfaces in patient units and living areas.

The authors also share that they have learned that intraoperative aspirators, protective clothing, N95 masks and face shields can provide sufficient protection to our medical staff in the surgery room. Huang and colleagues warn that the claim that endonasal surgery will increase the possibility of infection of medical personnel in the operating room might provoke unnecessary anxiety toward endonasal endoscopic procedures based on an anecdotal statement.

Patel and collaborators in their rebuttal accept some of these arguments but point out that emerging evidence also points towards a high viral load within the nasal cavity. When performing endoscopic surgery, while working in and through this corridor, surgical maneuvers can aerosolize mucus particles along with the virus.

In a convergence of the scholarly debate, both groups arrive at similar recommendations with an emphasis on preoperative COVID-19 testing, which should be performed whenever possible. Reduced contact with infected patients and the use of personal protective equipment — including N95 masks, face shields and protective clothing — should be employed for all endoscopic cases and all involved personnel. Powered air-purifying respirator use should be encouraged in cases of symptomatic COVID-19-positive patients needing emergent endonasal surgery. A negative pressure operating room is also recommended. Elective endoscopic transsphenoidal surgery should be delayed, and consideration should be given to transcranial approaches for certain locations where possible.

We share the optimism for the future of endonasal surgery as more data comes to light to guide best practices that will maximize its benefit for our patients while minimizing potential risks to surgeons and other operating room personnel.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, PA

July 13, 2020
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AANS Neurosurgeon Spotlight: The State of Neurosurgical Education

By AANS Spotlight, Burnout, COVID-19, GMENo Comments

Recent global circumstances have had considerable effects on neurosurgery. In the latest articles from AANS Neurosurgeon, the official socioeconomic publication of the American Association of Neurological Surgeons (AANS), authors discuss the state of neurosurgical education. Practices have taken steps to not only adapt to a multitude of changes due to the COVID-19 pandemic, but to thrive among them, while helping their patients do the same. Browse the Education issue for a scientific, artistic and realistic view from those tasked with providing and navigating valuable educational experiences during a time when there is no such thing as “normal.”

Article Spotlight

This Crisis is an Opportunity
Lola B. Chambless, MD, FAANS

Dr. Chambless explains how the pandemic has provided an unprecedented opportunity to study, learn and reform.

A Combined Spine Surgery Fellowship
Jason Savage, MD ꟾ Michael P. Steinmetz, MD, FAANS

Discover the makings of a successful spine fellowship – strong leadership, constant re-evaluation and a collaborative surgeon group.

Pen versus Penfield: A Proposed New Training Modality for Neurosurgery Residents
Erin N. D’Agostino, MD

Dr. D’Agostino describes how art “can serve a role in surgical skill building, learning and teaching of anatomy, patient education and combating burnout.”

Read More

Follow @aansneurosurg on Twitter, Instagram and like AANS Neurosurgeon on Facebook!

July 10, 2020
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Neurosurgeons Launch Campaign to Protect Patient Access to Care

By Access to Care, COVID-19, Guest Post, Health Reform, MedicareNo Comments

Our health care system is under extraordinary pressure. The COVID-19 pandemic has created an uncertain financial future for health care professionals. And now, coming on the heels of this devastating pandemic, Medicare is poised to implement drastic cuts. These cuts threaten patients’ access to timely surgical care and may impact the quality of life for the people neurosurgeons care for every day. To help policymakers and the public understand how these payment cuts will hurt patients and their neurosurgical care teams, on June 18, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), along with 10 other national surgical associations, officially launched the Surgical Care Coalition (SCC).

The coalition, which represents more than 150,000 surgeons, was formed to stop these Medicare cuts to protect patients, improve their quality of life and ensure that our nation’s seniors have access to the neurosurgeon of their choice when they need life-saving neurosurgical care. Specifically, the SCC is worried about new Medicare payment policies for office and outpatient visits that the Centers for Medicare & Medicaid Services (CMS) will implement in January 2021. Changes to these visit codes — also known as evaluation and management (E/M) codes — will reduce payments for surgical care, which may lead to reduced access to care for older Americans. Working together, the coalition is putting this issue on the nation’s agenda and is urging Congress to pass legislation that will prevent these payment cuts.

To learn just how fragile our health care system is, the SCC recently commissioned a survey of more than 5,000 surgeons. According to this study, surgical practices are facing severe financial distress due to the COVID-19 pandemic. While the cuts were announced before the pandemic, with the combined impact of the planned CMS cuts and the economic challenges due to COVID-19, surgeons and hospitals will face difficult decisions to keep surgical practices afloat. For neurosurgeons, the survey found that even before the CMS cuts take effect:

  • More than one-half (54%) of respondents are concerned that they could be forced to shut down their practice, limiting choice and access to neurosurgical care;
  • Three-quarters (74%) of neurosurgeons are concerned about the finances of their practice, and to keep the doors open, 38% have cut their own salary, and one-quarter (24%) have taken on debt as a result of COVID-19; and
  • In the face of declining revenues, 86% of respondents are worried that they will have to cut employee’s salaries and 76% fear that they may have to permanently layoff employees.

In announcing the SCC initiative, John A. Wilson, MD, FAANS, president of the AANS, noted that “Neurosurgeons take care of critically ill patients who suffer from painful and life-threatening neurologic conditions such as traumatic brain injury, brain tumors, debilitating degenerative spine disorders and stroke, and without timely neurosurgical care, our patients can face permanent neurologic damage or death. He added, “The planned cuts to Medicare payments will further stress a healthcare system critically affected by the pandemic crisis and may negatively impact Medicare beneficiaries’ access to care.”

Echoing his remarks, Steven N. Kalkanis, MD, FAANS, president of the CNS, stated, “It is essential that policymakers understand how these payment cuts may impact access to surgical care. COVID-19 has placed an unprecedented strain on our health care system, and additional Medicare payment cuts will not only threaten timely access to quality care but will also stress an already fragile health care system.”

Our seniors need to take comfort in the fact that a neurosurgeon will be there if and when they ever require neurosurgical care. Medicare cuts hurt patients, and the Surgical Care Coalition is fighting to prevent payment cuts that threaten patients’ timely access to neurosurgical care.

Editor’s Note: Neurosurgery Blog encourages you to follow the coalition on Twitter and LinkedIn, and we invite you to join the conversation at #CutsHurtPatients.

Katie O. Orrico, Esq., director
AANS/CNS Washington Office

June 24, 2020
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