UTTAAHHPHYSICIAN MENTAL HEALTH: FINDING A PATH FORWARD - Utah Medical Association
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
UTAHPHYSICIAN JUNE | JULY 2021
MENTAL
HEALTH:
FINDING
A PATH page 6
FORWARD
PHYSICIANS: PREPARE PRIOR AUTH HASSLES CAUSE
BEFORE A MENTAL HOLDING SPACE
page 14 TOO MANY CARE DELAYS
HEALTH CRISIS page 18
page 12
utahmed.org
Trust the specialists. Helping physicians reach their financial goals since 1993. Entrust your financial goals to an organization dedicated to physicians. At UMAFS, we understand the unique circumstances of school loans, insurance needs, career changes, family and retirement goals. Take your financial needs to the specialists. Call us for a no-cost financial analysis today. C A L L 8 01 - 74 7- 0 8 0 0 O R V I S I T O N L I N E A T U M A F S . O R G
UTTAHPHY
HYSIC
SICIA
IANN
Utah Medical Association’s Bulletin is
published 6 times per year for members
Features of the UMA. All advertising, articles
and editorials represent the views of
the advertisers/ authors and do not
6
Mental Health from Medical School to Medical Practice:
necessarily reflect the official policy of the
UMA. Copyright 2021.
Finding a Path Forward
By Stuart Slavin, MD, Med
Editorial Board
12 Physicians: Prepare Before a Mental Health Crisis
Wallace Akerley, III, MD
Brian J. Moench, MD
Press Release from The Physicians Foundation Karen M. Radley, MD
Daniel R. Faber, MD
14 Holding Space Carissa S. Monroy, MD
By Lisa Weaver, MD Staff
Chief Executive Officer
18 Prior Auth Hassles Cause Too Many Care Delays Michelle S. McOmber, MBA, CAE
AMA Survey Results
Managing Editor &
V.P. of Communications
20 Rebalancing- Portfolio Fixed Income Decisions Mark Fotheringham
By Eric Halvorsen, MBA, CFP®, CIMA®
Editorial Office
23
COVID-19 Public Health Emergency Extended; Telemedicine, Utah Medical Association
310 East 4500 South, Suite 500
Other Waivers Extended Salt Lake City, Utah 84107-4250
Compiled by UMA staff from several sources Phone: (801) 747–3500
Fax: (801) 747–3501
24 Help Available on Complying with Info Blocking Rules E-mail: mark@utahmed.org
Adapted from several AMA sources Publisher
Mills Publishing, Inc.
25 UMA Members in the News President
Dan Miller
Office Administrator
Cynthia Bell Snow
Departments Art Director
Jackie Medina
Graphic Design
Ken Magleby, Patrick Witmer
4 President’s Message
Sales Staff
By Sharon RM Richens, MD Paula Bell, Dan Miller, Paul Nicholas
26
Utah Health Status Update
Utah Physician is published by
28 CME Calendar
Mills Publishing, Inc.
772 East 3300 South, Suite 200
Salt Lake City, Utah 84106
801–467–9419
info@millspub.com
millspub.com
Inquiries concerning
advertising should be directed to
Mills Publishing, Inc.
Cover Photo Credit: Photo licensed by Ingram Image. Design by Patrick Witmer
PRESIDENT’S MESSAGE
contagious. We are thrilled to see less flu,
RSV, and common cold. This preserves
days in school for our children and at
work for adults.
It has been interesting to see re-entry
angst among many of my older patients
and colleagues. A little statistics refresher
regarding the real current risks of
exposure and illness, with vaccine status
and local community prevalence in mind,
has been helpful in some cases. Believe
PRESIDENT’S it or not, even if it’s decades old and in
need of dusting off, your math and stats is
better than most. Some have internalized
MESSAGE
BY SHARON R.M. RICHENS, MD, UMA PRESIDENT
“the fear” or are having trouble shaking off
the blues, others just got used to the quiet
life alone indoors and learned to like it,
along with online shopping.
S
ummer greetings! Regarding the wary and skeptical among your The second defining feature of this
COVID19, we seem finally to be in patients, staff, family, and friends to be UMA year has been the scope of
the bottom of the ninth inning, vaccinated. Tell them what you know practice discussions. The PAs want to
hallelujah and yet not quite amen. With and be candid about what we really do practice independently, as NPs do, and
nearly half of our eligible Utah population not know. If you have war stories about pharmacists, optometrists, podiatrists,
vaccinated, the reprieve from masking patients you have cared for, or your own physical therapists, and…and…. and
and social distancing without an upshot COVID19 illness, please share. Sharing the question begs, with an alternative
in ICU census has been most welcome. is therapeutic even if they never pursue pathway to primary care, why bother
I would like to extend a special thanks to vaccination. I am hopeful that FDA going to medical school? Will for-profit
the “first responders” in our midst, those approval for the vaccines will come in and online DO, NP, PA and other programs
of you who work the ERs, Instacares, and September, without a fall surge. usurp the role of university medical
primary care clinics, who were willing schools? What does this mean for the
to risk your own health to protect public The CDC still recommends that masks be character, tone and timbre of medicine
health, and individual patients. I would worn by everyone in health care settings and patient care? For patient safety? For
especially like to thank the “tertiary through September 13, 2021, even if they MDs of DOs? Will MDs and DOs be able
responders” in our ICUs who helped are fully vaccinated, and especially if they to practice independently anymore, or
those most-afflicted through all stages are not vaccinated yet. This is also true in only as part of an institutional team? (For
of this pandemic. It goes without saying transportation hubs and transportation some this is a multigenerational set of
that as physicians we recognize and are venues. Please encourage and post questions as our children consider their
grateful for all the frontline nurses and “masks are always welcome” for anyone choices in medicine, or not.)
staff, in hospital and clinic settings, who concerned or at risk, especially those
make what we do possible. who are immunosuppressed by health Student debt is already a driving factor
conditions or prescription medications, in choice of specialty and practice mode
As schools shutter for summer and masks and those who have non-COVID for MDs training in traditional allopathic
come off, please continue to encourage respiratory conditions that may be programs. Why would we expect this
4 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.
PRESIDENT’S MESSAGE
to be any different in these alternative are enough? By type of training, or your engaged participation, medicine is
(and often for-profit) programs with by specialty? and can continue to be richly satisfying.
equally high tuition? These programs The Utah Medical Association is here
have no obligation to ensure residency Is there an infinite supply of student to serve physicians and advocate to
or employment for the graduate, and loan money for aspiring medical and legislative and regulatory decision makers
the for-profit business model of the health science students? whatever comes, and we are stronger for
program drives them to produce as many every well-informed and vocal physician
“tuition-paid” “graduates” as possible. How do you define and discern quality, who engages.
The argument for expansion of scope or safety?
is usually “access” in “rural” areas, but Happy Spring! May it be full of sunshine,
provider service distribution doesn’t How super-specialized can a warm embraces and renewed will to fight
actually change after an expansion of smart multiple-fellowship-trained the good fight on behalf of our patients
scope of practice, unless the arrangement practitioner be without getting bored and one another.
is an enforceable contract. to death after ten, or twenty years
within that super-specialized “scope” Yours,
How do patients discern the or “turf”?
differences in our alphabet soup? Sharon R.M. Richens, MD
Thank you to all who participated in the UMA President
Who decides how many providers legislative session in any capacity. With
Infectious Disease
in Primary & Specialty Care 2021
Keynote Lunch Speakers 76th Annual CME Conference
Petronella Adomako, MD, Presiding
save the date! 21.50
CME?!?!
Sarah L. Berga, MD Kristen Ries, MD, MACP
October 6, 7, & 8, 2021
YES!
In person, streamed, and recorded
✓ Most inexpensive CME multi-day conference
✓ Longest ongoing medical meeting in the Western U.S.
✓ Designated for AMA
CME 21.50 AMA PRA PRA Category
Category 1 Credit(s).
1 Credit(s)™
Questions? Contact Teresa Puskedra at 801-564-5585 or
RJ Bunnell, MD David M. Oshinsky, PhD email teresapuskedra@ogdensurgical.com
View list of topics and register at www.ogdensurgical.com
FEATURE
MENTAL
HEALTH FROM
MEDICAL
SCHOOL TO
MEDICAL
PRACTICE:
FINDING A
Image licensed by Ingram Image PATH FORWARD
BY STUART SLAVIN, MD, MEd
As individuals cultivate skills to promote their own satisfaction and well-being, efforts must also be made to improve the clinical
and learning environment.
ABSTRACT problems.1-4 Mental health challenges sufficient in the midst, and aftermath, of
Medical students, residents, and from the COVID-19 pandemic have this pandemic.
practicing physicians experience added new stressors—professional,
high burnout, depression, and suicide personal, and financial—for many.5,6 A PATH FORWARD
rates, and the COVID-19 pandemic Uncertainty—often a primary source of A number of foundational principles
has exacerbated stress for many.1-6 anxiety—has never been greater for so can inform approaches to a looming
While laudable, current well-being many of us. While significant numbers mental health crisis for physicians and
efforts appear insufficient to meet the of medical schools and medical centers trainees. First, we tend to conceive
challenges that so many are facing. have ramped up their mental health of well-being and mental health as
This essay explores approaches that services in recent months, these are not binary—you are depressed or you
individuals and organizations can take likely to meet the mental health needs are not; you are burned out or you
to promote mental health and well-being of trainees and physicians in the face are not. This is not accurate, and not
from medical school to practice. of widespread, unprecedented levels particularly functional, because these
of stress and traumatic exposure in the conditions all exist along a continuum.
INTRODUCTION healthcare setting. Using a treatment Second, well-being may not be the best
Medical student, resident, and physician model, rather than a preventative model, primary goal for our efforts. Instead,
mental health has been the focus of to meet the mental health needs of a more reasonable goal may be to
growing concern in recent years as it physicians was not sufficient pre-COVID increase satisfaction with your work,
becomes increasingly clear that burnout, as burnout and depression rates remain your life, and, for some, yourself. The
depression, and suicide are serious stubbornly elevated— and it will not be goal should then be to help people move
6 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.
FEATURE up the continuum no matter where they found in physicians can contribute Impostor phenomenon: the feeling are, so that if you are fairly satisfied, substantially to personal distress that you are incompetent, that you are perhaps you can become very satisfied; and mental illness. We need to help a fraud, and it is only a matter of time and, if you are extremely dissatisfied physicians and trainees develop skills to before other people discover this. perhaps you can become moderately recognize and address these damaging dissatisfied. This, for many, will feel mindsets and patterns of thinking. Personalization and self-blame: the more attainable than reaching some tendency to place complete blame on magical state of well-being. Our focus MINDSETS AND yourself when things don’t go well. cannot only be on those who meet a THOUGHT PATTERNS clinical diagnosis of depression or Common physician mindsets that Feelings of guilt and shame: anxiety, or those who meet criteria for contribute to distress can be categorized Thoughts of imperfection and self- burnout; our approach must target into three main clusters. These mindsets blame can contribute to self-critical those from across the continuum. often have been acquired on the long and thoughts and feelings of guilt and Third, it’s important to note that arduous path to becoming a physician, shame, often adding substantially to encouraging physicians to work on and people should feel no shame or guilt personal distress. their resilience comes with risks. Many if they have them. Like well-being, they physicians feel they are very resilient, exist along a continuum that is fluid and Hiding vulnerability and distress: and rightly so.7 They tolerate enormous subject to change with circumstances many physicians and trainees tend demands and pressures, working and environment. These mindsets are to hide their distress which can then heavy hours, and they show up to not always dysfunctional in moderation, create the impression that others work, take care of their patients, and and they even may have contributed to are doing fine. This can lead to complete their charting. While this is many physicians’ success along their individuals’ belief that they are the true, this is only one kind of resilience, academic paths. Cognitive psychologists only ones struggling. what I term survival resilience. But have documented many of these mindsets there is also another form of resilience in terms of automatic thoughts and The second cluster of mindsets is which is a thriving resilience, and cognitive distortions.9 characterized by negative mood or this also exists along a continuum. affect—cynicism, negativity, and What is exciting is that there are easily The first cluster of mindsets is the pessimism—that are understandable teachable, learnable skills that anyone largest, and it consists of mindsets that given the professional and emotional can use to cultivate this latter form are characterized by a self-critical voice. challenges in medicine. While of resilience. Fourth, because many understandable, these mindsets physicians have limited time to learn Performance as identity: the can fuel personal dissatisfaction and practice time-consuming well- tendency to view your performance— and diminish well-being both in the being practices, the tools we offer whether academic in school, or workplace and at home. to support physician mental health professional as a physician—as your and well-being may have greater identity and worthiness. If you make The final cluster consists of two impact as they require little time to an error, the thought process is often, miscellaneous, but critically important, use and learn. Still, this is largely an “I’m a bad doctor and a bad person,” mindsets and thinking patterns. The environmental health problem, rather rather than “I made an error.” first is having a fixed mindset rather than an individual one.5 Finally, while than a growth mindset. Fixed mindsets this piece focuses largely on individual Maladaptive perfectionism: a have been associated most typically with strategies, it does not remove the condition where you set the bar so cognitive ability10—namely, holding obligation to work to improve clinical unattainably high for yourself that narratives such as “I’m not good at and learning environments. And while you are repeatedly disappointed math”—but the same mindset presents environmental factors are the main in yourself. The key here is around skills like resilience, and this drivers of distress,8 individual mindsets disappointment in yourself, not just can inhibit personal growth. If a person and patterns of thinking commonly in your performance. has a fixed mindset around their own utahmed.org JUNE | JULY 2021 7
FEATURE
personal resilience, they will be less COGNITIVE REFRAMING Albert Ellis, one of the fathers of
likely to become more resilient. The We tend to go through life thinking cognitive-behavioral therapies,
other problematic pattern of thinking that an adverse event equals an adverse introduced many helpful concepts for
involves automatic thoughts and outcome—meaning that if something challenging these types of thinking.14
cognitive distortions that can activate bad happens, that is the personal Cognitive reframing, also known as
other mindsets. outcome as well. This is not true; it is cognitive restructuring, consists of
an adverse event plus your cognitive/ three steps. First is to simply notice
These mindsets are common in medical emotional reaction that equals the your thoughts. This requires having
students, residents, and physicians outcome.13 We all suffer from distorted some skill in mindful awareness, which
and can contribute to both personal reactions or automatic thoughts that I will outline next. Second is to label
distress and mental illness. A study can contribute to distress, but there the thought—whether a mindset or a
that I led of first-year medical students are concrete steps we can take to gently cognitive distortion—to recognize that
found that those who screened positive reframe them. Following are some of you are, for example, magnifying, or
for maladaptive perfectionism or the most common automatic thoughts: are thinking in perfectionistic terms.
impostor phenomenon were more The third step is to try to dispute the
likely to have feelings of inadequacy, Magnification: taking a relatively thought distortions. There are many
embarrassment, or shame about their small event and blowing it up into a options for disputing strategies, but
academic performance.12 Those who much bigger problem. the following two are particularly easy
experienced these latter feelings were to understand and to use. The first
significantly more likely to screen positive All or none thinking: either getting is to simply examine the evidence
for depression and anxiety. The good news the result you wanted or feeling like there is to support the thought, and
though is that every one of these mindsets a failure. the evidence there is against it. For
is changeable through the cultivation of example, some medical students who
simple techniques of metacognition and Tunnel vision: focusing on one perform poorly on an exam can feel
mindful awareness. negative event and ignoring or “stupid.” The evidence that they are low
discounting the many positive ones. in intelligence is non-existent; they
METACOGNITION are in medical school, and there are a
Metacognition is simply the ability Overgeneralization: seeing a whole host of reasons why someone
to examine your thoughts and to negative event as part of a pattern of would not perform well on an exam.
change to be more accurate and bad things that always happen to you. The second approach, called the double
beneficial to your mental health. The standard, is one that I find particularly
most important metacognitive skill Fortune-telling: predicting a future illuminating and helpful. Here is an
is cognitive reframing, the basis for outcome with certainty. example. Let’s say a colleague comes up
Cognitive Behavioral Therapy (CBT). to you and says, “I feel terrible, I didn’t
CBT is the preferred treatment for Mind-reading: feeling like you know know the answer when I was asked a
anxiety disorder and panic attacks, with certainty what another person simple clinical question by my boss
helpful for depression, and useful for is thinking. For example, when today.” Would you say to them? “Well,
addressing maladaptive perfectionism a colleague passes in the hallway you’re stupid. You’re not cut out to be
and/or impostor phenomenon. and looks up and frowns, we create a doctor.” Of course not (or at least I
Unfortunately, we usually don’t teach narratives that we must have done hope not!). The goal in countering the
these skills until someone has already something to offend the person and double standard is to extend the same
developed clinical depression or anxiety they are angry at us. compassion you have toward other
and seeks support from a therapist. people to yourself.
The key to preventative mental health “Should” statements: second-
care is learning these skills before many guessing yourself when the outcome Metacognition can also help in
mindsets, cognitive distortions, or isn’t ideal by thinking “I should have managing future oriented worries,
emotions culminate in mental illness. done this; I should have done that.” fears, and anxieties. A common and
8 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.
FEATURE
understandable worry and fear that mortality rate below 1%, with child A key principle here is that the goal is
clinicians may have in the midst of mortality rates even lower. Therefore, not to eliminate thoughts and worries.
the pandemic is that they may get even if you or they become infected, Rather, it’s to hold them gently—to
ill, or that they may bring COVID-19 the great, great likelihood is that you work with them so they will cause you
home to their spouse, children, and/ will recover and your family members less suffering and harm.13
or other family members and that will too. In addition to managing
they could get sick and die. These are these understandable fears, you also MINDFUL AWARENESS
completely understandable fears to can move to the strategic. What can The second essential skill to develop is
have, and they may feel terrifying or you control? Do everything you can to mindful awareness. One needs to be
even debilitating.13 The question is reduce the risk that you and your family sufficiently present and aware to notice
not how to completely eliminate or members will get infected. Be vigilant thoughts and feelings in order to be
suppress these feelings, but rather how about protecting yourself. Change of able to work with them. The classical
to manage these thoughts to decrease clothes, a serious hand wash before approach to becoming more mindful
distress. One way of framing: yes, that you leave the hospital, hand wash when has been meditation, and numerous
reality that is possible, but how likely you get home, and continued social courses and apps are available for this.
are certain outcomes? Even though distancing outside the home are things Meditation works, but in my experience
you may face a relatively high risk of within your control. Optimizing sleep, relatively few physicians are willing
getting the infection, it is very likely nutrition, and exercise can boost your or able to incorporate regular formal
that you will recover.13 Those less than immune system and decrease the meditation practices in their lives. I
60 years of age without underlying likelihood of an adverse outcome from have given talks to audiences across
medical conditions appear to have a COVID-19 should you become infected. the country and have asked physicians
Our healthcare professionals can
help you navigate the increasingly
competitive healthcare market
with solutions such as payor &
value-based contracting, quality
& value-based care strategies,
practice analytics, revenue cycle
enhancement, partnerships/
mergers, outsourced business
services, tax reduction strategies
and more. Get real insight from a
INSPIRED
firm that cares as much as you do.
TO INCREASE
YOUR INCOME
What inspires you, inspires us.
801.456.5207 | eidebailly.com
FEATURE
to raise their hands if they have a stress, you can do it—even for a few CHANGING THE CLINICAL AND
meditation practice of 15 minutes or breath cycles—to calm your amygdala. LEARNING ENVIRONMENT
more a day. I have never seen more than To reduce activation of your limbic As individuals cultivate skills to promote
3% raise their hands even in places like system, be mindful of excessive caffeine their own satisfaction and well-being,
California where meditation may be consumption, as well as excessive efforts must also be made to improve the
more in mainstream consciousness. consumption of news and social media. clinical and learning environment. In
Meditation works but if many are not A study after the Boston Marathon 2009, Saint Louis University School of
likely to practice it due to time and bombing found that those who had Medicine embarked on a series of simple
effort, it may not be an optimal public heavy consumption of media in the changes designed to reduce pressure
health intervention for physicians week following the bombing led to on students—reducing class time and
unless we change the structural higher acute stress levels than those who curricular content, freeing time for
demands on their time. The good news witnessed the bombing in person.13,16 elective opportunities, and changing to
is that you can become significantly pass-fail grading—that led to decreases in
more mindful (moving up a mindfulness OTHER TOOLS IN A depression and anxiety of more than 80%
continuum) through informal practices RESILIENCE TOOLBOX in pre-clerkship students.17, 18 The clinical
that take little or no time to employ. Metacognition and mindfulness are environment is more challenging to
There are a number of informal mindful essential skills in finding greater change, but conceptual frameworks
practices, but a simple one is to just satisfaction with work, with life, and from organizational psychology can
focus on one of your senses (auditory, with the self, but there are other skills guide action. A helpful model for this
smell, touch, or sight) for just 30 to 45 that can also be helpful in this quest. merges the concepts from work by
seconds. As thoughts appear, just notice I view these as forming a toolbox, Christina Maslach and Daniel Pink,
them and return your attention to the and you can choose tools that you feel and includes eight main drivers of
sense you were focusing on. This can be that you need most. The tools include burnout in health care.19,20 They include
used as you are walking from one place the following strategies: combating the following:
to another, when washing your hands negativity bias and pessimism,
before seeing a patient, or in a myriad of cultivating positive emotions, emotional Workload: not just how much, but
other activities. self-regulation, dealing with difficult the qualities and characteristics of it.
people, investing in well-being, avoiding
REDUCING LIMBIC learned helplessness, cultivating a sense Rewards: not just financial,
SYSTEM ACTIVATION of generosity and gratitude, and finding but whether and to what extent
During the COVID pandemic, the skill meaning and purpose in life. a person feels appreciated
of reducing a sense of alarm and overall and valued.
limbic system activation is essential. A The key with the toolbox approach is its
self-calming technique that has been adaptability; some tools may be helpful Control: transparency in decision-
proven effective in the military is called for you, while others may not be—and making and feeling like your voice
tactical breathing.15 Here’s how it works: you can tailor your toolbox to fit your matters.
own specific needs. I do not use all of
Relax yourself by taking four breaths the tools listed here, but some have Community: sense of connection to
as follows. If you want, try to visualize changed my life in recent years in ways I others at work.
each number as you count. Breathe in did not think was possible. You can find
counting 1, 2, 3, 4. Stop and hold your more about the toolbox in a series of Fairness: whether people are treated
breath counting 1, 2, 3, 4. Exhale counting four podcasts produced by the ACGME with fairness and equity.
1, 2, 3, 4. Repeat the breathing cycle.13 at https://www.acgme.org/What-We-
Do/Initiatives/Physician-Well-Being/ Values: whether the organization
You can practice this as many times a AWARE-Well-Being-Resources, and on acts consistently with the values it
day as you would like, for just a minute Spotify and other podcast platforms by states.
or so. Then, when you are feeling acute searching ACGME AWARE.
10 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.FEATURE
Mastery: if effective and regular L, Sloan J, Shanafelt TD. Burnout among US 14. Rational Emotive Behavior Therapy in the
feedback on performance is given. medical students, residents, and early career Context of Modern Psychological Research
physicians relative to the general US population. https://albertellis.org/rebt-therapy-in-the-
Meaning: if people in the Academic Medicine. 2014 Mar 1;89(3):443-51. context-of-modern-psychological-research/
organization feel a sense of meaning 5. Shanafelt, T., Ripp, J., & Trockel, M. (2020). Accessed September 18, 2020
and purpose. Understanding and addressing sources of 15. Navy Bureau of Medicine and Surgery. (n.d.)
anxiety among health care professionals during Combat Tactical Breathing. https://www.med.
CONCLUSION the COVID-19 pandemic. JAMA. 2020;323(21): navy.mil/sites/nmcphc/Documents/health-
I have ended virtually all of my talks 2133-2134. doi:10.1001/jama.2020.5893 promotion-wellness/psychological-emotional-
in the last two years with a quote 6. Galbraith N, Boyda D, McFeeters D, Hassan T. well-being/Combat-Tactical-Breathing.pdf
from Viktor Frankl, and I will end this The mental health of doctors during the Covid-19 16. Holman, E.A., Garfin D.R., & Silver, R.C. (2014).
commentary in the same way. Frankl, pandemic. BJPsych bulletin. 2020 Apr 28:1-4. Boston Marathon. Boston Marathon Bombings,
the noted psychiatrist, author, and 7. Burnout isn’t due to resiliency deficit. It’s still Media, and Acute Stress. Proceedings of the
Holocaust survivor wrote, “There is a system issue. https://www.ama-assn.org/ National Academy of Sciences. 111(1). 10.1073/
nothing in the world, I venture to say, practice-management/physician-health/ pnas.1316265110
that would so effectively help one to burnout-isn-t-due-resiliency-deficit-it-s-still- 17. Slavin SJ, Schindler DL, Chibnall JT. Medical
survive even the worst conditions as system-issue Published July 29, 2020 Accessed student mental health 3.0: improving student
the knowledge that there is a meaning September 17, 2020 wellness through curricular changes. Academic
in one’s life. There is much wisdom in 8. National Academies of Sciences, Engineering, Medicine. 2014 Apr;89(4):573.
the words of Nietzsche: ‘He who has and Medicine. Taking action against clinician 18. Slavin S. Reflections on a decade leading a
a why to live for can bear almost any burnout: a systems approach to professional medical student well-being initiative. Academic
how.’”21 Physicians, in the midst of the well-being. National Academies Press; 2020 Jan 2 Medicine. 2019 Jun 1;94(6):771-4.
challenges in medicine, need to find that 9. Beck, J. S. (1995). Cognitive therapy: Basics and 19. Maslach, C., & Leiter, M. P. (1997). The truth
why, feel that why, and be sustained by beyond. New York, NY, USA: Guilford about burnout: How organizations cause
that why. But we also have to remember 10. Dweck CS. Mindset: The new psychology of personal stress and what to do about it. San
that we can and must work to change success. Random House Digital, Inc.; 2008. Francisco, Calif: Jossey-Bass.
the how. 11. West CP, Dyrbye LN, Shanafelt TD. Physician 20. Pink, Daniel H. Drive: The Surprising Truth
burnout: contributors, consequences and About What Motivates Us. New York, NY :
References solutions. Journal of internal medicine. 2018 Riverhead Books, 2009. Print.
1. Rotenstein LS, Ramos MA, Torre M, Segal JB, Jun;283(6):516-29. 21. Frankl, Viktor. (2006). Man’s Search for Meaning.
Peluso MJ, Guille C, Sen S, Mata DA. Prevalence 12. Hu KS, Chibnall JT, Slavin SJ. Maladaptive Boston, Mass: Beacon Press.
of depression, depressive symptoms, and perfectionism, impostorism, and cognitive
suicidal ideation among medical students: a distortions: Threats to the mental health of pre- DISCLOSURE
systematic review and meta-analysis. Jama. 2016 clinical medical students. Academic Psychiatry. None reported.
Dec 6;316(21):2214-36. 2019 Aug 15;43(4):381-5.
2. Mata DA, Ramos MA, Bansal N, Khan R, Guille 13. Slavin, S. Mental health: “What residents can Article originally Published in Missouri Medicine
C, Di Angelantonio E, Sen S. Prevalence of do before a clinical surge at their institution.”
depression and depressive symptoms among ACGME. Accessed on October 28, 2020.
resident physicians: a systematic review and
meta-analysis. Jama. 2015 Dec 8;314(22):2373-83.
3. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile
W, Satele D, West CP, Sloan J, Oreskovich MR.
Burnout and satisfaction with work-life balance
Stuart Slavin, MD, MEd, is Senior Scholar for Well-Being, Accreditation Council
among US physicians relative to the general US
for Graduate Medical Education, Chicago, Illinois.
population. Archives of internal medicine. 2012
Oct 8;172(18):1377-85.
4. Dyrbye LN, West CP, Satele D, Boone S, Tan
utahmed.org JUNE | JULY 2021 11FEATURE
Image licensed by Ingram Image
PHYSICIANS:
PREPARE
BEFORE A
MENTAL
HEALTH
CRISIS
PRESS RELEASE FROM THE PHYSICIANS FOUNDATION
The Physicians Foundation Releases a Personal Crisis Management Plan to Help Prevent Physician Suicide
T
he Physicians Foundation has “Whether it’s stress, feelings of burnout “We continuously hear from the loved
recently launched A Personal or another challenge, physicians, just ones of physicians who died by suicide
Crisis Management Plan1 to help like anyone else, should feel comfortable that it could have been avoided,” said
physicians navigate their mental health seeking help,” said Gary Price, MD, Robert Seligson, CEO of The Physicians
needs. As part of the Foundation’s Vital president of The Physicians Foundation. Foundation. “We hope this tool gets us one
Signs initiative2, the plan was created “Our own research found that 58% step closer in breaking the culture of silence
to help physicians, their colleagues of physicians reported experiencing around physician mental health issues—
and their loved ones access and have feelings of burnout during the pandemic; helping physicians not be in fear of being
available the coping strategies and however, when asked about mental health judged or losing their right to practice.”
resources needed when navigating a support, only 13% of physicians reported
moment of crisis. seeking medical attention.” To explore Vital Signs, visit www.
physiciansfoundation.org/vitalsigns.
This resource was inspired by Angela The Physicians Foundation’s 2020 Survey The website is intended for educational
Chen, MD, Loice Swisher, MD, FAAEM, of America’s Physicians: COVID-19’s Impact purposes only. If you need further
and Mary Jane Brown, MD, who on Physician Wellbeing4 also found nearly guidance or are in a crisis, call the
introduced a personal crisis management 1 in 4 physicians knew a physician who National Suicide Hotline at 1-800-273
tool for residents, like safety plans used committed or considered suicide. While TALK (8255) for free 24/7 support.
by psychiatrists in suicidal patients. physician suicide has been a crisis long
Endnotes
They found3 nearly 60% of participating before COVID-19, the pandemic has
residents agreed that the tool would created a sense of urgency to better 1. https://physiciansfoundation.org/wp-content/
help them manage a crisis. Nearly a support physicians’ mental health uploads/2021/04/Physicians-Foundation-
Crisis-Management-Tool-for-Physicians.pdf
third of the participating residents and wellbeing. This personal crisis 2. https://physiciansfoundation.org/
(31.8%) indicated that they had used management tool offers physicians and physician-wellbeing/vitalsigns/
their personal plan within the first three their loved ones a personalized, step-by- 3. https://escholarship.org/uc/item/1v91z16g
4. https://physiciansfoundation.org/physician-
months of their internship. step plan to set themselves up for success and-patient-surveys/the-physicians-
in the event of a mental health crisis. foundation-2020-physician-survey-part-2/
12 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.Knowledge.
Relationships.
Trust.
Confidence.
Wilkins &
Associates
Insurance
Specializes in insurance
needs for Utah professionals
and businesses.
With more than 40 years
of experience, Utah physicians
depend upon our expertise,
knowledge and support
Insurance Coverages Available:
• Medical Professional Liability
• Commercial General Liability
• Business Property
• Workers’ Compensation
• Employee Benefits
• Personal Home & Auto
175 East 6100 South 801.268.6834
Murray, Utah 84107 wilkinsassoc.comFEATURE
HOLDING
SPACE
BY LISA WEAVER, MD
ORIGINALLY POSTED ON FAMMEDVITALSIGNS.COM Image licensed by Ingram Image
A
s a family medicine physician, are in the unique position to gain these residency, I would often leave these initial
I have the privilege of patient’s trust long enough to start visits feeling frustrated that I did not
getting to know my patients chipping away at their concerns and accomplish anything “medical” during the
across different moments in their have a positive impact on their health. visit as I attempted to (not always very)
lives. Sometimes these patients are patiently listen to their concerns. Each
establishing care with a primary care As I am over halfway through my time I saw these patients, I would ask
physician for the first time in their residency training, I have begun to myself why they kept coming back to me
adult lives and have multiple concerns. I establish a panel of such patients, and I when it felt like we did not make headway
have found that in many of these cases, have had the opportunity to deepen my on any of their “real” medical issues.
the patient has been estranged from relationships with them in this process.
the medical system because they have Often this includes listening to their I have found that if I continue to stick
significant trauma histories or even story and validating their concerns with these patients and see them
negative experiences directly related to for the first few visits. Sometimes I regularly, this will start to pay off as
the healthcare system. There is often will try to bring up my concern about we slowly develop a relationship. For
distrust surrounding doctors and the their high blood pressure or suggest example, I have a patient that was
entire medical system that has been a diabetes or cholesterol screen, and very hesitant to start a hypertension
present long before they walked through this will be met with varying degrees of medication because they were concerned
our clinic doors. Primary care doctors receptivity. I remember in my first year of about the side effects of starting any
Continued on page 16…
14 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.Make the Smart Choice with MICA
Why Do Physicians Choose MICA for Their Medical Professional Liability Coverage?
Since 1976, MICA has specialized in medical professional liability insurance. Dedicated to protecting
and defending the practice of medicine, MICA offers our members:
• Financial Strength and Longevity • High-Touch Customer Service
• Assertive Claims Defense • Proactive Risk Mitigation
Contact MICA today to learn more or request a quote. Visit mica-insurance.com/quote or call
602.956.5276.
This policy has exclusions, limitations, and terms under which the policy may be continued in force
or discontinued. For costs and complete detail of coverage, contact MICA or your insurance agent.
®
Mutual Insurance Company of Arizona®
Medical Professional Liability Insurance
© Copyright 2021 by MICA. All rights reserved. 602.956.5276 | mica-insurance.comFEATURE
Image licensed by Ingram Image
medication and didn’t believe it was times that he has shown up, he has shared reminding myself that the best I can do
necessary. After several visits with this that he hasn’t made it to his appointments a lot of the time is listen to my patient’s
patient where I learned more about their because he was recently evicted from his story, validate their experiences and
history of deep trauma from sexual abuse home and has been unable to get access past traumas, and continue to show up
and family abandonment, they trusted to a cell phone. In “The Hot Spotter” from and be present. Historically, the medical
that I was invested in their wellbeing and the New York Journal which discusses field has done a poor job of doing this—
were ready to start a medication. After focusing on patients that are high particularly in BIPOC, LGBTQIA+, and
this, we slowly started chipping away at utilizers of healthcare, Dr. Brenner states economically disadvantaged individuals.
other medical concerns such as getting that “The ones you build a relationship We as healthcare providers are working
a colonoscopy, catching up on vaccines, with, you can change behavior. Half we against centuries of oppression, trauma,
and initiating a statin. It took several can build a relationship. Half we can’t.” and discrimination, but we are also
months of seeing this patient, but I truly While it can be frustrating to feel like we working in a system that continues
believe that most of the healing that took can’t make progress in some situations, it to be flawed. Unfortunately, we still
place in that clinic room started with is important to continue to be present for often fail at building trust with at-
simply holding space for that patient these patients when they do show up. risk populations, but it is our job as
to share their story and express their physicians to be persistent and hold
doubts and concerns. As I build my practice in residency space for the individuals that do grace
and beyond, it is important to keep our clinic rooms.
Of course, there are times that my
patients will not be able to establish a
relationship with me, either because
they are looking for something else or Dr. Weaver is a University of Utah Family Medicine Resident from Ephrata,
because of other barriers beyond their PA. Her medical interests include women’s health, obstetrics, pediatrics, mental
control. I have a patient who has been in health, and LGBTQ medicine. During her free time, she enjoys running,
the hospital multiple times this year for camping, weight training, playing violin, reading, and baking bread.
alcohol withdrawal and frequently has
not shown up to appointments. On the
16 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.FEATURE
PRIOR AUTH
HASSLES CAUSE
TOO MANY CARE
DELAYS
AMA SURVEY RESULTS
Image licensed by Ingram Image
M
ost physicians know that health reduce administrative burdens and • 40% employ staff who exclusively
insurers’ prior authorization support rapid patient access to needed work on tasks associated with prior
policies delay access to drugs, tests and treatments,” AMA authorizations, and
care, often causing serious harm to President Susan R. Bailey, MD, said
patients. A survey of physicians taken in in a statement. “By the end of 2020, • 30% said prior authorizations led to a
December 2020 by the American Medical as the U.S. health system was strained serious adverse event for a patient in
Association1 shows just how often prior with record numbers of new COVID-19 their care.
auth delays occur. cases per week, the AMA found that
most physicians were facing strict The Utah Medical Association has
According to the AMA survey, 94% of authorization hurdles that delayed continuously worked to ease the burden
physicians reported delays while waiting patients’ access to needed care.” prior authorizations put on physicians
for health plans to authorize necessary and the harm it can cause to patients. If
care, and 79% have had patients abandon According to the AMA survey, you have first-hand examples of cases
treatment because of prior auth. In only 15% of physicians reported where prior authorization delays caused
addition, 70% of the 1,000 physicians health plans’ prior authorization patient harm, please let UMA know.
surveyed said health insurers had criteria were often or always based
reverted to pre-COVID-19 authorization on evidence-based medicine.
policies or never relaxed these policies. Other survey findings include:
“As the COVID-19 pandemic began
in early 2020, some commercial • 85% said burdens associated with Reference
health insurers temporarily relaxed prior authorization were high or 1. https://www.ama-assn.org/system/files/
prior authorization requirements to extremely high, v2021-04/prior-authorization-survey.pdf
18 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.2020 AMA prior authorization (PA)
physician survey
Patient impact
Care delays associated with PA Abandoned treatment associated with PA
Q: For those patients whose treatment requires Q: How often do issues related to the PA process
PA, how often does this process delay access to lead to patients abandoning their recommended
necessary care? course of treatment?
100% 100%
15%
21%
80% 80% Always (3%)
Always 79% report that Often
39% Often PA can at least Sometimes
60% 60% sometimes lead
94% report Sometimes Rarely
to treatment
care delays Rarely (4%) 55% abandonment Never (1%)
40% Never (1%) 40% Don’t know (2%)
Don’t know (1%)
40%
20% 20%
18%
0% 0%
21%
of physicians report that PA has led to a
PA and
patient’s hospitalization.
18%
of physicians report that PA has led to a
patient 30% of life-threatening event or required
intervention to prevent permanent
impairment or damage.
harm physicians
9%
of physicians report that PA has led to
report that PA has led to a a patient’s disability/permanent bodily
serious adverse event for a damage, congenital anomaly/birth
(See below, Survey question “A.”) patient in their care. defect or death.
Clinical validity of PA programs Impact of PA on clinical outcomes
Q: How often are health plans’ PA criteria based on Q: For those patients whose treatment requires PA,
evidence-based medicine and/or guidelines from what is your perception of the overall impact of
national medical specialty societies? this process on patient clinical outcomes?
Always (2%)
100%
Often
13% Sometimes 9%
80% Rarely
Never (3%)
Somewhat or significant
60%
42% Don’t know
negative impact
No impact
While 98% of health plans
report they use peer- Somewhat or significant
40%
reviewed evidence-based positive impact (2%)
29% studies when designing 90%
their PA programs,1 32% of
20%
physicians report that PA
criteria are rarely or never
0%
11% evidence-based Percentages do not sum to 100%
due to rounding.
© 2021 American Medical Association. All rights reserved.FEATURE
Image licensed by Ingram Image
REBALANCING-
process. Normally rebalancing occurs
between stocks and fixed income assets;
PORTFOLIO
this rebalancing is especially important
when growth assets like stocks are at, or
near, peaks. When unmonitored stocks
FIXED INCOME
can drift away from the desired target
and expose an investor to additional and
DECISIONS
sometimes unknown risks. Behaviorally,
in the moment, it is challenging to trim
the “winners” and buy the perceived
“losers”. Given this known flaw in human
BY ERIC HALVORSEN, MBA, CFP®, CIMA® nature it is important to have a pre-
UMA FINANCIAL SERVICES determined plan in place so that when
T
the moment arrives, we can confidently
here has been much discussion 500. Markets, by nature, do fluctuate act combatting our innate biases. A well-
in the news recently about new on a consistent basis and as such it is built portfolio should have a disciplined
highs in stock indices like the Dow always important to be aware of one’s rebalancing process in place; most
Jones Industrial Average and the S&P strategic allocation and rebalancing commonly this consists of allowable
20 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.FEATURE
tolerance ranges around an asset’s target pushing their equity allocation higher. inflation, Fed monetary policy, and the
percentage within a portfolio. Each of these changes can materially like. So, according to this principle, the
alter the overall risk of an investor’s possibility of rising interest rates is
The fixed income portion of one’s portfolio—some of these changes may be already factored into fixed income prices.
portfolio may appear basic although it is challenging to see or understand.1
vitally important when controlling the This is one reason investors should
risk of a strategic allocation. Its role can So, what’s an investor to do? How can you view future interest rate movements as
vary according to an investor’s financial make prudent fixed income decisions unpredictable. Even the market experts
needs, concerns, and goals. For example, while also addressing today’s low interest who have access to vast amounts of
many investors look to fixed income rates? Consider these principles: research have a hard time predicting the
for safety, income, and more stability direction of interest rates.
in their portfolios. They must weigh REMEMBER HOW
these priorities against their concerns MARKETS WORK Rather than trying to predict
over future interest rates, inflation, macroeconomic forces that are difficult to
government debt, and other factors that The same core investment principles foresee, investors can look to the market
might affect fixed income returns. apply in any market environment. One to set prices and focus on the variables
key principle is that in a well-functioning within their control.
Striking this balance can be a challenge in capital market, securities prices reflect
any market environment, but especially all available information. Today’s START WITH A CLEARLY
now, as low interest rates have sent bond values reflect everything the DEFINED GOAL
many investors on a quest for higher- market knows about current economic
yield bonds, alternative investments, or conditions, growth expectations, Fixed income choices should follow a broader
Uncovering
smarter solutions
Your liability exposure isn’t limited to clinical care – and
your insurance coverage shouldn’t be, either. Uncover all your
potential risks and get comprehensive liability protection. Using
our predictive data and revolutionary new visual simulation tool,
you see your whole picture. You’ll know you’re buying exactly
what you need, making you stronger.
MagMutual.com | 800-282-4882FEATURE
investment strategy that defines the role of primary ways to increase expected yield helping to control risk. Although selling
fixed income in a portfolio. The portfolio can and returns on bonds. They can: the “winners” to buy the perceived “losers”
then be customized to meet those specific does not feel great it is an important
goals while managing tradeoffs. • Extend the overall maturity of their part of controlling risk. If you don’t have
bond portfolio (take more term risk). one, I’d encourage you to determine a
An investor who seeks to avoid losing rebalancing strategy. If you’re interested
market value might have a different fixed • Hold bonds of lower credit quality in engaging with an investment advisor
income allocation than someone who (take more credit risk). familiar with the goals and concerns of
needs immediate income or is seeking Physicians one of our trained UMAFS
higher returns. Investors with different These may be reasonable actions. But financial advisors would welcome the
objectives typically have different pursuing higher income means accepting opportunity to review your portfolio and
tradeoffs regarding risk, expected return, more risk, as measured by interest rate discuss these topics in further detail.
and costs. movements, price volatility, or greater
odds of losing value if the issuer defaults. This information is for educational purposes
KNOW WHAT YOU OWN Higher yield can also bring potentially only and should not be considered investment
higher volatility. advice or an offer of any security for sale.
Strive for transparency in a portfolio. UMAFS is an investment advisor registered
This means understanding an investment PAY ATTENTION TO COSTS with the Securities and Exchange Commission.
manager’s basic strategy and knowing
how the instruments held in the portfolio Investors typically do not realize that Investing risks include loss of principal and
might respond in different economic, investment-related costs determine a fluctuating value. Fixed income securities are
market, and interest rate scenarios. large part of a portfolio’s yield and return. subject to increased loss of principal during
In a low interest rate environment costs periods of rising interest rates. Fixed-income
Unfortunately, investors who chase are important to fixed income securities. investments are subject to various other risks
performance often make their investment In fact, research has shown that a bond including changes in credit quality, liquidity,
decisions based on the past performance mutual fund’s expense helps explain much prepayments, and other factors.
and perceived popularity of the strategy. of its net performance—and funds with the
For example, some of the mutual fund highest expenses tended to have the lowest Endnotes
categories experiencing the heaviest performance within their peer group.2
inflows of cash in the industry are in asset 1. When interest rates rise, the value of an existing
bond declines; when rates fall, existing bond
groups that have recently experienced SUMMARY values rise. The market adjusts a bond’s price to
higher than average yields. Higher yields match the yield available on a new instrument.
are typically accompanied by higher risks. Investors who hold fixed income securities with
No one can perfectly predict the speed
longer maturities are exposed to the amplified
But do investors know what risks their and magnitude of interest rate changes. effects of term risk. A long-term bond is more
managers are taking to deliver those Most investors are best served by building exposed to rate changes than a short-term
instrument, and usually (but not always) offers
attractive yields? a fixed income strategy to complement a higher yield to compensate investors for the
their broader portfolio objectives, extra risk. Also, lower-coupon bonds are more
UNDERSTAND THE TRADEOFFS understanding the sources of risk, and affected by interest rate changes than higher-
coupon bonds. For example, if rates move 1%, a
paying attention to fees. Pursuing a bond that pays 3% will experience a greater gain
When reaching for higher yield, investors defined strategy in a disciplined fashion or loss than one paying 5%.
should carefully consider the potential has proven to be a successful way to
2. The study examined monthly alpha and
effects of their decisions on expected approach investing. Rebalancing is a expense ratios for bond funds in the CRSP
portfolio performance and risk. In the vital risk management tool which will survivorship-bias-free mutual fund database
fixed income arena, investors have two assist you and reaching your goals while from January 1992 to December 2011. Source:
Dimensional Fund Advisors.
22 JUNE | JULY 2021 UTAH PHYSICIAN
Still the Greatest Profession.FEATURE
COVID-19 PUBLIC HEALTH
EMERGENCY EXTENDED;
TELEMEDICINE, OTHER WAIVERS
EXTENDED COMPILED BY UMA STAFF FROM SEVERAL SOURCES
The national public health emergency related including paying the same rate for physicians who use certain telemedicine
to COVID-19 has been extended to July 20 telemedicine visits as for in-person platforms in good faith will not be
and likely will be extended throughout 2021, visits, and allowing use of audio-only penalized for noncompliance.
according to the federal Health and Human telemedicine services.
Services (HHS) Department. Throughout the pandemic, UMA has called
T
The extension also means private health on state and federal leaders continuously
he public health emergency, insurers’ copayments related to COVID-19 to allow flexibilities and expand
originally issued in January of last testing (though not necessarily treatment) programs to protect practices
year, has been renewed every 90 and related to any forthcoming vaccinations financially. Watch for updates in the UMA
days throughout the pandemic. It was will be waived. The Utah Insurance MediByte newsletter.
last set to expire April 21 before being Department website at https://insurance.
References
again extended. utah.gov/featured-news/coronavirus
includes the various Utah insurance carriers’ 1. https://www.cms.gov/about-cms/emergency-
The current extension allows the Centers COVID-19 cost-sharing policies. preparedness-response-operations/
current-emergencies/coronavirus-waivers
for Medicare & Medicaid Services (CMS)
to maintain several COVID-19-related Certain HIPAA enforcement2 actions also 2. https://www.hhs.gov/hipaa/for-professionals/
Medicare waivers and flexibilities1, will continue to be relaxed. Specifically, special-topics/hipaa-covid19/index.html
We want to be your
Hospice Agency
Fax Referrals to: (801) 261-5856
Serving You and your Patients since 2004
HOSPICE HOME HEALTH PRIVATE DUTY
www.Heartwood.net Office: (801) 639-5000You can also read
