Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice

Abbasi J.

JAMA. Published online March 30, 2022.

doi:10.1001/jama.2022.5074

Here is an excerpt:

Worsening staffing issues are now the biggest stressor for clinicians. Health care worker shortages, especially in rural and otherwise underserved areas of the country, have reached critical and unsustainable levels, according to the National Institute for Occupational Safety and Health (NIOSH).

“The evidence shows that health workers have been leaving the workforce at an alarming rate over the past 2 years,” Thomas R. Cunningham, PhD, a senior behavioral scientist at NIOSH, wrote in a statement emailed to JAMA.

In the absence of national data, Etz says the Green Center data point to a meaningful reduction in the primary care workforce during the pandemic. In the February 2022 survey, 62% of 847 clinicians had personal knowledge of other primary care clinicians who retired early or quit during the pandemic and 29% knew of practices that had closed up shop. That’s on top of a preexisting shortage of general and family medicine physicians. “I think we have a platform that is collapsed, and we haven’t recognized it yet,” Etz said.

In fact, surveys indicate that a “great clinician resignation” lies ahead. A quarter of clinicians said they planned to leave primary care within 3 years in Etz’s February survey. The Coping With COVID study predicts a more widespread clinician exodus: in the pandemic’s first year, 23.8% of the more than 9000 physicians from various disciplines in the study and 40% of 2301 nurses planned to exit their practice in the next 2 years. (The Coping With COVID study was funded by the American Medical Association, the publisher of JAMA.)

A lesson that’s been underscored during the pandemic is that physician wellness has a lot to do with other health workers’ satisfaction. “The ‘great resignation’ is affecting a lot of our staff, who don’t feel necessarily cared for by their organizations,” Linzer said. “The staff are leaving, which leaves the physicians to do more nonphysician work. So really, in order to solve this, we need to pay attention to all of our health care workers.”

Nurses who said they intended to leave their positions within 6 months cited 3 main drivers in an American Nurses Foundation survey: work negatively affecting their health and well-being, insufficient staffing, and a lack of employer support during the pandemic.

“Health care is a team sport,” L. Casey Chosewood, MD, MPH, director of the NIOSH Office for Total Worker Health, wrote in the agency’s emailed statement. “When nurses and other support personnel are under tremendous strain or not able to perform at optimal levels, or when staffing is inadequate, the impact flows both upstream to physicians who then face a heavier workload and loss of efficiency, and downstream impacting patient care and treatment outcomes.”

The info is here.

Italian nurse with coronavirus dies by suicide over fear of infecting others

Yaron Steinbuch
nypost.com
Originally published 25 March 20

A 34-year-old Italian nurse working on the front lines of the coronavirus pandemic took her own life after testing positive for the illness and was terrified that she had infected others, according to a report.

Daniela Trezzi had been suffering “heavy stress” amid fears she was spreading the deadly bug while treating patients at the San Gerardo Hospital in Monza in the hard-hit region of Lombardy, the Daily Mail reported.

She was working in the intensive care unit while under quarantine after being diagnosed with COVID-19, according to the UK news site.

The National Federation of Nurses of Italy expressed its “pain and dismay” over Trezzi’s death, which came as the country’s mounting death toll surged with 743 additional fatalities Tuesday.

“Each of us has chosen this profession for good and, unfortunately, also for bad: we are nurses,” the federation said.

The info is here.

Nurses Wrestling With the Moral Uncertainties of MAiD

Barbara Pesut and Sally Thorne
Impact Ethics
Originally posted October 23, 2019

Have you tried to imagine what it is like to be the healthcare provider who provides medical assistance in dying (MAiD)? What would it feel like to go into a strange home, to greet a patient and family, to start an intravenous line, to deliver the medications that rapidly cause death, and then to bring some sort of closure before leaving? Although there has been a great deal of attention paid to the regulation of MAiD, and its accessibility to the Canadian population, we have heard relatively little about the moral experiences of the healthcare providers at the forefront of providing this service. That is surprising in light of the fact that all but 6 of the 6,749 MAiD deaths in Canada that occurred between December 10, 2015 and October 31, 2018 were administered by physicians or nurse practitioners.

In a recent study we interviewed 59 nurses from across Canada, who had diverse experiences with participating in, or choosing not to participate in, the MAiD process. Canada is the first country to allow nurse practitioners to act as both MAiD assessors and providers. Canadian registered nurses also play a key role in providing care to patients and families considering, planning for, or receiving MAiD. We learned a lot about the experiences of being involved in MAiD and about the type of wrestling with moral uncertainty that the involvement can entail. Nurses worked hard to make sense of this radical new end-of-life option. Making sense required some soul searching, some important conversations, and in some cases, encounters with the procedure itself.

Encounters with MAiD were inevitably deeply impactful. Some participants described an emotional overload that was unanticipated and didn’t necessarily fade over time. Others described a deep sense of compassion and purpose—a sense of beauty. Still others described an accumulating sense of distress, a rising tide that they didn’t necessarily know how to deal with. This was particularly true for those nurses who worked alone on multiple cases because they were the sole person willing to provide MAiD. Even those who had experienced MAiD only as observers described an emotional climate within the care environment that was far-reaching.

The info is here.

More than 300 overworked NHS nurses have died by suicide in just seven years

Alan Selby
The Mirror
Originally posted April 27, 2019

More than 300 nurses have taken their own lives in just seven years, shocking new figures reveal.

During the worst year, one was dying by suicide EVERY WEEK as Tory cuts began to bite deep into the NHS.

Today victims’ families call for vital early mental health training and support for young nurses – and an end to a “bullying and toxic culture” in the health service which leaves them afraid to ask for help in their darkest moments.

One mum – whose trainee nurse daughter Lucy de Oliveira killed herself while juggling other jobs to make ends meet – told us: “They’re working all hours God sends doing a really important job. Most of them would be better off working in McDonald’s. That can’t be right.”

Shadow Health Secretary Jonathan Ashworth has called for a government inquiry into the “alarming” figures – 23 per cent higher than the national average – from 2011 to 2017, the latest year on record.

“Every life lost is a desperate tragedy,” he said. “The health and wellbeing of NHS staff must never be compromised.”

The info is here.

Moral Distress: A Call to Action

The Editor
AMA Journal of Ethics. June 2017, Volume 19, Number 6: 533-536.

During medical school, I was exposed for the first time to ethical considerations that stemmed from my new role in the direct provision of patient care. Ethical obligations were now both personal and professional, and I had to navigate conflicts between my own values and those of patients, their families, and other members of the health care team. However, I felt paralyzed by factors such as my relative lack of medical experience, low position in the hospital hierarchy, and concerns about evaluation. I experienced a profound and new feeling of futility and exhaustion, one that my peers also often described.

I have since realized that this experience was likely “moral distress,” a phenomenon originally described by Andrew Jameton in 1984. For this issue, the following definition, adapted from Jameton, will be used: moral distress occurs when a clinician makes a moral judgment about a case in which he or she is involved and an external constraint makes it difficult or impossible to act on that judgment, resulting in “painful feelings and/or psychological disequilibrium”. Moral distress has subsequently been shown to be associated with burnout, which includes poor coping mechanisms such as moral disengagement, blunting, denial, and interpersonal conflict.

Moral distress as originally conceived by Jameton pertained to nurses and has been extensively studied in the nursing literature. However, until a few years ago, the literature has been silent on the moral distress of medical students and physicians.

The article is here.

Moral distress in physicians and nurses: Impact on professional quality of life and turnover

Austin, Cindy L.; Saylor, Robert; Finley, Phillip J.
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 9(4), Jul 2017, 399-406.

Abstract

Objective: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital.

Method: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale–Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one’s professional quality of life. Relationships between these constructs and clinicians’ years in health care, critical care patient load, and professional discipline were explored.

Results: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%.

Conclusion: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

The article is here.

Physicians, Not Conscripts — Conscientious Objection in Health Care

Ronit Y. Stahl and Ezekiel J. Emanuel
N Engl J Med 2017; 376:1380-1385

“Conscience clause” legislation has proliferated in recent years, extending the legal rights of health care professionals to cite their personal religious or moral beliefs as a reason to opt out of performing specific procedures or caring for particular patients. Physicians can refuse to perform abortions or in vitro fertilization. Nurses can refuse to aid in end-of-life care. Pharmacists can refuse to fill prescriptions for contraception. More recently, state legislation has enabled counselors and therapists to refuse to treat lesbian, gay, bisexual, and transgender (LGBT) patients, and in December, a federal judge issued a nationwide injunction against Section 1557 of the Affordable Care Act, which forbids discrimination on the basis of gender identity or termination of a pregnancy.

The article is here, and you need a subscription.

Here is an excerpt:

Objection to providing patients interventions that are at the core of medical practice – interventions that the profession deems to be effective, ethical, and standard treatments – is unjustifiable (AMA Code of Medical Ethics [Opinion 11.2.2]10).

Making the patient paramount means offering and providing accepted medical interventions in accordance with patients’ reasoned decisions. Thus, a health care professional cannot deny patients access to medications for mental health conditions, sexual dysfunction, or contraception on the basis of their conscience, since these drugs are professionally accepted as appropriate medical interventions.

Moral Distress in Physicians and Nurses: Impact on Professional Quality of Life and Turnover.

C. L. Austin, R. Saylor, and P. J. Finley
Psychological Trauma: Theory, Research, Practice, and Policy, 2016

Abstract

Objective: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital.

Method: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale–Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one’s professional quality of life. Relationships between these constructs and clinicians’ years in health care, critical care patient load, and professional discipline were explored.

Results: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%.

Conclusion: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

The article is here.

Calling the Nurse ‘Doctor,’ a Title Physicians Oppose

By Gardiner Harris

The New York Times

Originally published October 2, 2011

With pain in her right ear, Sue Cassidy went to a clinic. The doctor, wearing a white lab coat with a stethoscope in one pocket, introduced herself.

“Hi. I’m Dr. Patti McCarver, and I’m your nurse,” she said. And with that, Dr. McCarver stuck a scope in Ms. Cassidy’s ear, noticed a buildup of fluid and prescribed an allergy medicine.

It was something that will become increasingly routine for patients: a someone who is not a physician using the title of doctor.

Dr. McCarver calls herself a doctor because she returned to school to earn a doctorate last year, one of thousands of nurses doing the same recently. Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title “doctor,” but also the money, power and prestige that often comes with it.

As more nurses, pharmacists and physical therapists claim this honorific, physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. But so far, the new degrees have not brought higher fees from insurers for seeing patients or greater authority from states to prescribe medicines.

Nursing leaders say that their push to have more nurses earn doctorates has nothing to do with their fight of several decades in state legislatures to give nurses more autonomy, money and prescriptive power.

But many physicians are suspicious and say that once tens of thousands of nurses have doctorates, they will invariably seek more prescribing authority and more money. Otherwise, they ask, what is the point?

Dr. Roland Goertz, the board chairman of the American Academy of Family Physicians, says that physicians are worried that losing control over “doctor,” a word that has defined their profession for centuries, will be followed by the loss of control over the profession itself. He said that patients could be confused about the roles of various health professionals who all call themselves doctors.

“There is real concern that the use of the word ‘doctor’ will not be clear to patients,” he said.

So physicians and their allies are pushing legislative efforts to restrict who gets to use the title of doctor. A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession.

The entire story can be read here.