AMA Advocacy Insights webinar series: Legislative and regulatory advocacy to support physician wellness

Webinar (series)
Healing the healer: Legislative and regulatory advocacy to support physician wellness
Aug 23, 2023

Physician burnout can lead to devastating consequences for individual physicians, patients, the physician workforce and the U.S. health care system as a whole. Dealing with burnout requires system-level solutions, as well as initiatives and programs that provide protections to help encourage physicians and medical students to seek help when needed and improve their practice environment.

Support for enhancing physician wellness is growing. For example, a number of state medical associations have both successfully enacted laws that provide confidentiality protections for physicians seeking help for burnout, and the AMA has worked closely with state medical associations to urge state medical boards to eliminate or revise stigmatizing mental health related questions on licensing applications to match AMA policy and lower barriers to physicians from seeking help.  

Join the chair of the AMA Board of Trustees Willie Underwood III, MD, MSc, MPH, in conversation with expert panelists who are working with the AMA in advocating for such changes—and implementing them.


  • Willie Underwood III, MD, MSc, MPH, chair, AMA Board of Trustees


Hear from:

  • Mark Staz, management consultant, Regulatory Policy, Federation of State Medical Boards about how FSMB is changing licensing questions to remove stigmatizing questions that often serve as a barrier to care.
  • Barb Smith, chief executive officer, South Dakota State Medical Association, about how South Dakota State Medical Association advocated to have its state board change licensing questions to support physician wellness.
  • Abraham Segres, vice president, Quality and Patient Safety, Virginia Hospital & Healthcare Association about how the Virginia Hospital & Healthcare Association is leading efforts to get all VA hospitals and systems to make positive changes to support physician wellness—and attract new physicians to its workforce.
  • Joel Bundy, MD, vice president, chief quality and safety officer, Sentara Healthcare about how the health system identified changes needed and the steps it took to implement and communicate changes across the system.

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Dr. Underwood: Thank you for joining us today for another AMA Advocacy Insights webinar. I'm Dr. Willie Underwood, chair of the Board of the American Medical Association. And I'm honored to serve as your host this afternoon.

Our Advocacy Insights webinars are designed to keep physicians informed about the important issues affecting them and their patients. Today we'll talk about legislative, regulatory and other advocacy efforts to support physician wellness. We'll do that with a panel of experts who will help us understand where we are, where we're headed and what's next.

Before I introduce them, let me share with you why this topic is key to the AMA's advocacy efforts and why this topic is so important to physicians and the practice of medicine. Physician burnout and the need to support wellness is not new, but the impact is real and growing.

A national survey of U.S. physicians published in September showed an alarming 62.8% of physicians experienced burnout in 2021. Up from 38% the previous year. In my home state of New York and across the country, large number of physicians are reducing their hours or contemplating leaving the profession. If only a fraction of physicians follow through on this decision, it will create an enormous pressure on our already overburdened health care system and further reduce access to care for patients.

In a country with an aging population where far too many people already don't have access to the care they need, the consequences will be dire. There is no doubt that the lingering effects of the pandemic are factors in these numbers. But the root of physician burnout goes much deeper and point to systemic issues in our health care system that have long been ignored.

Ever-growing administrative burden that takes us away from the time with our patients, poorly functional electronic health records, inadequate physician support and practice environment, and a pervasive sense of being powerless to fix the problems we encounter. Deliberate, disinformation campaign meant to undermine trust in science and medicine. And more recently, hostile political attacks and third party interference in the patient-physician relationship.

What's even more challenging is that we spend the bulk of our time on today is that physicians are often reluctant to seek help for their mental health and wellness needs. Many fear that it would jeopardize their license and employment because of outdated and stigmatizing language of medical boards and health systems application forms that ask about past diagnosis or require peer references to give their opinion about an applicant's mental health status. You'll hear from our panel today about efforts to address these issues so that physicians understand that mental wellness is a priority.

We need to act quickly and we need to act now. Four out of 10 physicians in recent Medscape survey said that they have not sought mental health treatment because they were worried about their medical board or employers finding out and potential repercussions. So what's the remedy? As part of our Recovery Plan for America's Physicians, the AMA is pushing for legislative fixes and state legislators and Congress to remove the most common burden physicians encounter such as erroneous prior authorization process and which insurance commonly require hours of paperwork before patients get approved for the care recommended by their physicians.

Another common barrier is the paperwork that physicians have to complete to get licensed and a job. Paperwork that often requires disclosures of past treatment for a mental illness or substance use disorder. State and physicians employers can start by auditing their existing medical licensing and credentialing applications and removing any questions that ask about past diagnosis of mental illness or substance use disorder or past counseling to help with one.

Rather, the AMA encourages that medical boards hospitals and health systems to focus on whether a current impairment exists that, if left untreated, would adversely affect patient safety. The next critical step after medical licensing and credentialing language has changed is to communicate these changes to physicians, residents, medical students and the entire health care workforce. Then these changes need to be supported throughout each state and institution with resources to help physicians and other health care professionals seek care, including efforts to reduce the stigma that is too often attached to seeking care.

Changing the language is the first step, but there is far more work to be done. We'll talk more about that with our panel today. So let's get going. With us today we have Mark Staz. He is the management consultant for regulatory policy at the Federation of State Medical Boards. In his capacity he is responsible for organizing organizational strategy and initiatives related to the regulatory best practices, including the FSMB work in ethics and professionalism. Today he'll talk about how the FMSB is changing licensing questions to remove stigmatizing questions that often serve as a barrier to care. Welcome, Mark.

We have Barb Smith, who's the chief executive officer of the South Dakota State Medical Association whose mission is to advance healthy communities through a united voice across the health care continuum. She'll talk about advocacy to change licensing questions to support physician wellness. Welcome, Barb.

Smith: Thank you.

Dr. Underwood: Abraham Segres is vice president of quality and patient safety at Virginia Hospital and Healthcare Association. In his role he provides leadership for the statewide quality and safety and performance improvement activity for Virginia hospital and health systems. He'll talk about changes to support physician wellness and the efforts to attract new physicians into the workforce. Welcome, Abraham.

Joel Bundy is vice president—Dr. Joe Bundy is vice president and chief quality and safety officer for the Sentara Healthcare where he is responsible for all patients and employee initiatives as well as accreditation and regulatory standards. He will talk about Sentara's work to implement and communicate changes across the system. Welcome, Joel.

Our first question is for Mark. Question one. Mark, what led the FSMB to start engaging state medical boards on this issue? And what kind of questions does the FSMB consider to be stigmatizing?

Staz: Well, thanks very much for your question, Dr. Underwood, and thanks also to the AMA for inviting the FSMB to be part of this important discussion. We've certainly appreciated our partnership with the AMA over the years since we've been looking at burnout from a regulatory perspective.

What led us to discuss this issue, to approach this issue, I think we can answer that in a few different ways. First of all, burnout itself we didn't actually intentionally start addressing. We had actually received a request from several state medical boards to provide guidance around the issue of disruptive physician behavior. But as we started talking about what that might look like, what this physician behavior was stemming from, it became clear very early on in our discussions that in many cases it was coming from burnout physicians.

Physicians were burned out as a result of many of the factors that they would deal with either within their clinical practice or from regulatory burdens that may have been imposed by them, on them, by state medical boards, or their employers, or other entities. So this was happening at the same time as a great deal of research at the national level was coming out about burnout about its causes and its effects on not only physicians, but also on patients.

So we pivoted very quickly in response to requests from our state medical boards to look squarely at the issue of burnout. We had looked at the licensing question issue years prior. When the Americans with Disabilities Act passed in the '90s, state medical boards asked us for guidance around what they should be doing with respect to their licensing applications. So that piece wasn't really new for us. But it was clear to us that state medical boards were asking for guidance around what they could be doing to improve the situation regarding burnout.

The second part of your question was about stigmatizing questions. I'm not sure that a question in and of itself is necessarily stigmatizing. I think it's really about what that question does to the person who needs to answer the question. And I think a lot of that comes from the culture.

So if a person is already concerned that there might be negative impacts on their ability to practice medicine or another inhibitor on their autonomy to practice as they see fit or to seek treatment as they see fit, then I think the stigma in the culture is amplified. Fortunately, I don't think we see a lot of stigmatizing questions anymore, but some of the issues that we had identified initially were around—and you mentioned some of them in your introduction, Dr. Underwood, questions that do an infinite look back into a person's treatment history or history with a particular illness.

Questions that don't appropriately deal with not only an illness, but the impairment that could result. So state medical boards don't necessarily need to know whether a physician suffers from a particular illness. It's the impairment that may result and thereby put patients in jeopardy that they need to worry about.

Also, stigmatizing questions could relate to treating physical illnesses differently from mental illnesses spotlighting mental illnesses, including substance use disorders. And so these were some of the areas of focus for the FSMB when we initially provided guidance to our state medical boards.

Dr. Underwood: Great. And you gave a great deal of insight into that as well. So hopefully that was helpful as physicians move forward thinking about this. So the next question is for Barb. First, congratulations on the positive change you were able to secure on the State Board Physicians Licensure applications. Can you tell us how you first realized the need to change the licensing board question? And how did you engage and ultimately convince the medical board to change its questions?

Smith: Great question. Thank you, Dr. Underwood, and also to the AMA. I echo Mark's comments about the value of this webinar. It's a very timely. South Dakota actually began working on licensing questions in 2012. And we looked at those disclosure questions at that time and again in 2020. So as Mark outlined, the timeline for the federation's work on this issue, we were following that work.

In both years, we actually had a physician who brought their concerns to the attention of the State Medical Association. So in 2012 we had a physician who had been involved in mental health treatment. She had actually gone out of state for that treatment and came back and was renewing her license and finding the application to be confusing. A lot of questions on the application she didn't know how to answer.

So she came to the State Association and asked for our help. We reviewed the application and we agreed with her that many of the questions seemed of a different time perhaps. As a result, we worked with physicians health systems here in South Dakota and health insurers to conduct. It was really a comprehensive review of the licensure application as well as all of the disclosure statements that were part of that application.

We made recommendations over a six month period of time actually to our licensing board. Some changes were made and some of our recommendations were before their time. There were a number of changes that were made really related to unclear and overly complex questions. So we made a lot of progress in 2012.

In 2020 we had a physician who came to the medical association. She too was renewing her license and she was experiencing some challenge about responding to some of the questions. Specifically she had experienced postpartum depression, and she had received a diagnosis and she had received treatment. And she found it inappropriate in her mind to have to bring that situation up again in her license renewal. It had nothing to do with her practice behavior or capability at the time she was renewing her license.

We agreed with that. And we reviewed the application and specifically focused this review on the mental health disclosure questions. We engaged our health systems and we then together approached our medical board. The advocacy that we did at that time and, again, it was in mid 2020, resulted in changing the disclosure statement from "Do you have a physical, mental or emotional condition which may adversely affect your practice? And have you ever been treated for or do you have a diagnosis for any mental health condition?" And of course, the answer to both of those questions in her situation would have been yes and yes.

The question has been changed and is now on our licensure application as "Are you currently suffering from any condition for which you are not being treated that impairs your ability to practice your profession in a competent, ethical and professional manner?" So we very much referred to the federation's work on the mental health disclosure statement question wording. We referred to that and used that in advocating with our medical board. And we think that's the reason that we were successful in doing so is because that pathway was there provided by the Federation.

Dr. Underwood: Awesome. So I'm going to go back to Mark, but I think this question will help add insight to everything you just said Barb. So Mark, so how does the FSMB first approach the conversation with the state medical boards regarding their licensing application questions? And if a medical board will not completely remove the questions regarding the past mental illness or substance use, what question does the FSMB recommend?

Staz: Thanks for that. Yeah. First, I should clarify that it's typically the medical boards who approach us about these issues. Yeah. They become aware of them either from their licensees, from the State Medical Association, as was the case in South Dakota, or from the media often. They receive quite a bit of inquiries about physician burnout and its impacts across the nation.

The other thing I should clarify is that we can't really require anything. We don't have authority over our member state medical boards. It's their mission to protect the public, and our role is really to support them in doing that. So one of the chief ways that we can achieve that role is by being purveyors of information. So when we're approached by a state medical board and we engage in a conversation around an issue, we want to tell them you know what we know about that issue, what's happening in other states, what the research says.

And that's exactly what we did with respect to burnout as well. We looked at the issue studied its impacts on physicians and on patients. We tried to make that link for them if it wasn't already made between physician wellness and patient safety. And that was an important conversation starter in a lot of places.

The other thing that we often do is provide best practice models. And so we did face a lot of reluctance initially when the idea of changing medical licensing applications was raised. It was already occurring in some states. And it's occurring to a much greater degree now. But we did face reluctance.

So what we said was, if you can't take the questions off the application altogether here are some model language that we can offer to you. And actually, it's almost identical to what we just heard from Barb. One of the things that we've learned, though, is that it might not be best to remove the questions altogether. One of the things that does is it could shut down the conversation.

So what we've learned and what we've been promoting now actually is an approach that started by the North Carolina Medical Board, which involves an attestation model of addressing these issues. So rather than asking a licensee, do you have a condition that will result in an impairment or do you have an impairment that will impact your medical practice? There's a statement about what the professional expectations are related to taking care of yourself, seeking treatment when necessary, and knowing when to take a break or to seek some help.

And the physician isn't asked a question about whether or not they have a condition or have had previous diagnoses. Rather, they're asked do you understand what your professional expectations are? Yes or no. And they can check a box on many of these applications.

So we've actually seen a lot of momentum behind this approach. And we think that, again, the nice thing is it continues the conversation. It helps reduce stigma because people are talking about burnout. It's clear that the medical board understands that physicians face these issues just as members of the general public would.

Dr. Underwood: Great. So going back to Barb. So what she described in South Dakota those physicians coming forward and raising this issue, they were living up to their ethical standards of professionalism. And the state medical board worked with them to be able to live up to that standard. That's awesome.

So Barb, I'm going to come back to you with another question because I think this again helps this crystallize this concept. So what recommendations do you have for state medical associations who want to engage their prospective medical boards above removing or changing licensing questions to promote physician wellness?

Smith: Well, one of the things that resulted from our medical boards changing the disclosure questions related to mental health is the Lorna Breen Foundation recently recognized our medical board as a champion. And that made a difference to our medical board for being recognized for making the change.

And we have as a result of that approached all our health systems and health plans and asked them to look at their license and renewal applications for credentialing they do in hospitals or for health plans to make similar changes to the questions that they're using on their applications. So we're trying to spread the word from the good work that was done in 2020 and as recognized by the Lorna Breen Foundation.

I would recommend to any state medical society to first of all review the licensing and renewal applications that your medical board uses to determine what should be changed. Focus on those mental health questions, be very specific in the changes that you would recommend. Access the Federation's model language, which was very helpful to us.

And then look for a physician who can give a real life story about the change you want to make. It made a difference to have a physician telling a story about their struggle and concern with the confusion of the questions that were being asked of them. Amplify your voice. We engaged other partners who represent physicians, including our health systems and health plans. Amplifying your voice just makes that advocacy road a little easier to travel. So those would be my thoughts.

Dr. Underwood: Thank you. So tying the two together, this is an opportunity for us to not just solve a problem, but actually enhance our profession, and enhance our ability to come together, work together, and create an environment that will lead to increased quality of care, increased patient engagement and increased physician productivity. So this is extremely important for all of us to be a part of this.

And now I'm going to ask Abraham a couple of questions. So as you and the Virginia Hospital and Healthcare Association have done a tremendous job getting Virginia hospitals and the health systems motivated to make changes that will support physician wellness and address the workforce issues. How were you able to do this?

Segres: Well, Dr. Underwood, as my colleagues have said, first of all, thanks very much for the opportunity to participate in this very important discussion dialogue. It's been a joy to work with the folks at the AMA. So we really appreciate the leadership you all have taken on this particular issue.

I would say actually in Virginia our work on this started 12 years ago. And actually it started by a very visionary board chair we had at the time that was very appreciative of the advocacy work that the Association was doing, but really felt that the Association could become a leader in statewide quality and safety improvement. And he said, you know why the advocacy work is good. We're all doing quality and safety improvement within our own organizations.

Now we recognize that hospitals compete on a number of different fronts. But he said, when it comes to the quality and safety of the care that Virginians receive it is a joint imperative for the field and not a competitive differentiator. And so that was a principle that the board adopted.

Secondly, he said and the board agreed that to make the improvements we want to make it's going to take leadership and creativity. We can't agree to do it and simply delegate it. We've got to be involved as leaders. And then finally, while we can all improve by ourselves, if we come together and do it together, we can improve much faster. So our board really leaned into a joint quality and safety vision for the association.

And that really provided this foundation that we've been able to build on. About five years ago, we went to a more population health triple aim focus, and really started using those concepts for our work around population health. While we knew the workforce was important, honestly, I'm not sure we actually leaned into that sphere. But as we came together through doing COVID, it clearly exacerbated an issue that was already there. And so given the strides we made with quality and safety and population health, it was an easy next step for our board to say we need to lean into the workforce issues and specifically wellness and burnout the way that we've leaned into our quality and safety work.

So we simply moved into what's been referred to as a quadruple aim focus. We're doing quality and safety. Making great strides. We believe we're reducing the cost of care. We're improving population health. Now we really need to improve provider satisfaction and remove barriers to them receiving mental health. And so it was a natural next step for us, given the work we started 12 years ago around quality and safety.

Dr. Underwood: Great. And you tie all that together as we step by step looking at the Federation of State Medical Boards, looking at how medical associations are now looking at that and having health systems involved in that, and seeing how that we're a family. And how we work together and come together, we can improve health outcomes, reduce costs, increase quality.

So if a medical association wants to follow your example and engage hospitals and health systems the way that the VHAS has done, what recommendations do you have? What kind of evidence or argument would be helpful in persuading hospitals and health systems and state hospital associations to do what you guys have done?

Segres: Well I think as you just summarized and articulated, using that quadruple aim as a North Star. We're all in this work because we want to improve individuals' experience of care. We want to improve the health of our communities. We want to reduce the cost of care. And we need satisfied stable workforce participants in order to do that. So make sure that everyone understands that those core concepts are key to why we all got into this business, number one.

Number two, I think Barbara referenced the Dr. Lorna Breen Heroes Foundation, but they have become a real clearinghouse for the abundance of literature and research that's been done that's documented the extent of this as a real issue in our health care industry and the impact it's having. So the AMA has lots of research as well, but there is a significant amount of research that's been done that can be brought to bear in those conversations.

If you're talking to hospital CEOs, it's all about the bottom line, and keeping operations going, and making payroll, and meeting the needs of your community and clearly having a high functioning workforce is key to simple good hospital operations 101. And then I think as Barb referenced as well, whenever you can find a champion everybody will come along, but we've been very fortunate in Virginia to have Dr. Joel Bundy and Sentara Healthcare. They're one of our largest providers, but they're often out in front on some issues. And this is the one that they are out.

So we the association can talk the game, but what we've got are providers actually in the work, and doing the work, and can speak to the benefit of the work. It's always good to have a living example that's fairly close to home to be able to speak to that work. So those are some of the recommendations I would make for folks that are trying to encourage others to get in the game.

Dr. Underwood: And thinking about that, you just led right into the questions for Dr. Joel Bundy. Thank you very much. I think we're working together. Our minds were in sync there. So Joel.

Dr. Bundy: Yes, sir.

Dr. Underwood: OK. So what led you and Sentara Healthcare to want to identify and change current practices, i.e. asking potentially stigmatizing questions on credentialing applications that might pose obstacles to physician wellness?

Dr. Bundy: Dr. Underwood, that's a great question. We have been working on a lot of different wellness initiatives. We're trying to improve efficiency and individual resiliency, resiliency of the system, trying to make the workplace a happier place. And as Abraham alluded to, making sure the workforce was better.

But as Barb said, some of these things have been set in place for years and years. And so these credentialing questions were put in place long, long time ago. And so when Corey Feist with the Lorna Green Foundation came and he said, "Hey, have you looked at your credentialing questions?" So it really was awareness.

So I went back and looked at him and said, "Oh my gosh. These are terrible questions." So why are we asking these questions of people? And we're integrated delivery network so we have a fairly large health plan. We have employed physicians. We have our affiliated physicians and APPs.

And so there were a lot of places where we could be asking questions. And so when we looked at those questions we said, we don't need to be asking these questions. These are questions, have you ever had x, y or z? And so when we looked at those we realized that we could get to the same place by changing the questions. And Mark talked about having an attestation type of thing.

So now I don't ask people, do you have diabetes? Or do you have mental health issues? Do you have this or that? I want to know can you competently practice to your profession today? Period. Full stop. And so we work on that. We made changes where we needed to.

In Virginia, we have a task force. And we were talking about this and one of the physician leaders said, hey, we found similar questions in peer review. So we went back and looked at our peer review questions. And is it in there? And I looked at our employment agreements. I looked at our health plan.

And so we worked really hard to remove all of those questions. And Simon Sinek says, well, start with why. And the why for me was when Corey Feist talked about his sister-in-law Lorna Breen and said, she didn't want to seek help because she was worried she was going to lose her license. When I read our questions to Sentara Health, I said, well, people aren't going to answer these questions truthfully anyway. So I think all of those things work together from an awareness standpoint that we needed to make some changes.

Dr. Underwood: Great. So I'm going to ask one final question to the panelists. And then we're going to open up to chat questions from the virtual audience. Submit questions through the chat for the panelists. But this question the final question for me is for Joel. So what if any internal challenges or obstacles did you face in your efforts to identify needed changes, actually make those changes, and make sure that all those who needed to know about and implement those changes were actually informed?

Dr. Bundy: Yeah. That's another great question. I think that the first part of the question was we have to find out who is in the position to do the work. And for my system, that was me. I oversee credentialing and privileging. So I mean, once I was convinced, once I realized that there was a need, it was pretty easy to go back to the team and say, hey team, this is the why. This is what we wanted to do. The questions had good intentions in the past. But really those intentions weren't born out. We need to make changes.

So I was the champion as Abraham said in Sentara Healthcare to make those changes. Now the harder part was communication back. So we worked really hard to make these changes, but like so many things that we do we just we don't tell people or we tell them but we don't tell them effectively. So we used a myriad of communication techniques. A lot of one on ones. A lot of meeting with physician leaders, medical executive committees, emails, which are not very effective.

But a lot of those things to try to communicate back to the physicians and the APPs working in Sentara Health. Hey, we've made these changes and we're doing it for you. And it also gave us the opportunity to say, hey, and we're also doing these other things. We're working on Epic to try to make Epic better for you and this is how we're doing it.

So there's a lot of efforts, but you're right. I think that one of the things that we just don't do very well is communicate and make other people aware. I wasn't thinking about changing these questions until Corey Feist brought it to my attention. So we've worked really hard then to cascade that down to the physician leaders and the physicians at the bedside throughout our health system.

Dr. Underwood: Awesome. So just to recap before we go into some questions from the participants. So we've seen starting at the Federation of Medical Boards, we saw how an impact that they were able to have. Again, working with the states of medical boards and working with the state medical associations. And how when a group of hospital systems as far as Virginia looked at this and now individual systems looked at it, they all came to the same opinion that this needed to be resolved now. Not later.

And the impact was not only to the physician workforce, but is actually to the quality of care that would be able to deliver it to the patients and to our citizens. So this is an extremely important process. And I thank all of you for the direct impact that you have had on this for the physicians themselves as being chair of the Board of AMA, but also for your community and the patients that have been significantly in quality of care improved in their outcomes because of your work. Thank you very much.

So I think we do have a few questions. So how can we put teeth into efforts to solve systemic problems that drive burnout? And would open that up to any member of the panel.

Dr. Bundy: Well, this is Joel. I'll just say that as Abraham alluded to really for hospital systems and for large groups, it's the efficiency of the workforce. And to have an efficient workforce, they have to be a happy workforce. So it's truly incumbent upon us to do everything we can to make our teams incredibly happy, have purpose and joy in their work. It's something that's been lost I believe.

And so I think that to get people to recognize that joy in the practice of medicine, or joy in the practice of nursing, or joy in the kitchen or joy in the facilities group, that has to be brought back. And if we do that I think that it clearly will make people more engaged and more efficient. Ergo then the operations will improve as well. So it is incumbent upon us to do that because it's to our own best interest.

Dr. Underwood: Yeah. I mean, you raised an interesting point. You said employee engagement. We know that no matter what industry you're in that the more engaged employees have greater productivity and better outcomes, and they reduce cost to the system. So that's extremely important. Unless there's someone else who wants to add to a comment regarding that question, I have another question I think ties into that.

Staz: Yeah. I just want to add something very brief picking up on Dr. Bundy's comments about communication. I think, again, keeping the conversation going and bringing as many people into the conversation as possible will have a massive effect. That's how you find out about what resources are available.

That's how people start to feel liberated to actually speak about these certain things. That's how about what your state Medical Association can do, what your state physician health program can do. The fact that you can anonymously enter some of these programs and seek support is of extreme importance. So communicating and keeping the conversation going would be my response to that question.

Dr. Underwood: And that's an excellent point. And this is going to lead into the next question so tying these things together. So it said, why are physician wellness programs always focused on how the physician should do more self care and not on problems of poor workplace management and outdated workflow?

Staz: Sorry to jump in again. I'm not sure that's completely true. I think that there are a lot of things that physician wellness programs and state physician health programs can do beyond asking the physician to heal thyself. I think that they can help with navigation and they do help as coordinators of an ecosystem that can contribute to the wellness of that profession.

So we've already kind of addressed several myths over the course of this panel. That's another myth. People need to understand and the role of those programs needs to be communicated effectively. The AMA is a partner in that sphere and so is the FSMB.

Dr. Bundy: And this is how I'll add to that, Abraham's put together a task force in Virginia where we have lots of different kinds of people, wellness, we have physician leaders, we have nursing leaders. We have people who work on Epic. And so we are working very, very diligently to do more than just self resiliency. We're trying to make things much more effective so that it's not just about doing rounds at 10:00 at night after the kids went to bed. But you can get all your work done during the day because we made everything much more efficient.

Burnout is secondary to a system issue. So we have to improve the system if we're going to improve burnout.

Segres: And I would—

Dr. Underwood: Go ahead. I'm sorry, Abraham.

Segres: And I think as Mark said, I think it's both and. I do think that we as health systems, we have an obligation to provide workforces that are encouraging that lift people up and help them be the best that they can be. But the workforce can't do that for your entire. I think there is still some responsibility for self care and self resilience.

And some of you may be familiar with the work of Dr. Brian Sexton out of Duke. But he really talks about a lot of those tools that can help you be really resilient in your job, but also very resilient in your marriage, very resilient as a parent. I mean, those skills help us before and after we come to work.

And so actually our first foray into this work was engaging with Dr. Brian Sexton to provide those skills and those tools to everybody to make sure they're resilient at work, at home, wherever they're be. Now with that said, we clearly recognize the way we structure the work, the policies, the procedures, the evidence is clear that those are also major drivers of burnout, which is why we have decided as an association we're going to focus our statewide work on those initiatives.

While we recognize folks taking care of themselves, we're not going to repeat that message. We're going to support that message, but our work is going to be on what do we as leaders need to do to improve the workforce environment and to advocate for things such as streamline prior authorization or working with vendors of electronic health records to design better. We have the power to do that and others can't. And we need to bring that power to bear to address some of these systemic issues. So it's been a myth, but I hope that we're myth busters on this call today there's no longer the case.

Dr. Underwood: So great point. But however, we do know that it may be easier for a system to say, hey, listen you need to do self care. Because it's harder to begin to make those kind of changes to improve. And I don't want to call it just the workflow, but the culture of the institutions. How things interact.

Years ago I gave a talk on the business model for creating a great workplace, which the employees love but the administration didn't. And that leads into a question that was asked. And it said, and this is for you Abraham, so do you have any economic data, such as turnover rates, showing that there's a return on investment when implementing a just culture?

Segres: So do I have any economic data showing the return on the investment? I can't quote a specific research article that I can point to at this time, but I do know that when you look at quality and safety, and specifically on just culture, when people are thriving in their work, they're much more likely to stay with that employer. I mean, we know that salary adjustments and those other things help, but they're not the things that really bring joy to people and to why they stay in a job.

And when people stay in a job, you see less turnover. And we know from employee engagement surveys when engagement goes up, turnover goes down. And we know that there are a number of studies that show the economic impact of a turnover rate. The cost of replacing and onboarding and orienting a new employee, there is a clear dollar value to that.

So to the extent that, you can implement these programs, see improved employee engagement results, lower turnover and then putting the cost of turnover on that number I think that economic data exists. So I can't produce a report, but I know that data is out there. And those are the elements that would be used to be able to document that return on the investment.

Dr. Underwood: So that's important because there's a lot of data in other industries beyond health care. Right? So I guess the real question is, how do we get that data in health care so we can help all health systems allow them to see the need and the benefit of doing these things? Another question because they said, well, what obstacles? Real or perceived exists in a hospital system and other employers on changing these questions, changing the culture, changing the environment. And I'll throw that out there for anyone.

Segres: Well, I'll start. I think one of the obstacles we encounter is that you talk to any hospital executive, their list of top priorities is 10 things long. There are no number of folks coming at them with a priority whether it's the governor, whether it's the mayor of the town, whether it's the nursing staff, whether it's the community in which the facility exists that don't like the new parking. I mean, there's always something.

And so getting this on the priority list. I think our board readily agreed to do this work in concept. Getting them all to actually do it is still a work in progress. We had a leader like Sentara. Joel was already there and so they leaned in. There were others that said, yes, we're doing it. But our CMO just left. We are recruiting a new CMO and the CEO is not sure whether he's going to stay or not.

So can you allow us to at least get those seats filled before we get into this? And then on the licensing and on the credentialing questions, there are people that spent their careers putting those questions in there. And so the process of culturally making a mind shift because they view those questions as their way of ensuring safe care. And the cultural shift that's required is more significant at some organizations than others. So those are some of the obstacles and barriers that might make it a little bit more challenging for some organizations to lean in this and get it done than others.

Dr. Bundy: And Abraham, I would just add to that, it was really important for me to hear from the Lorna Green Foundation that there really was no data demonstrating that those questions led to improved public safety. I mean, that's why we put it in there to protect the public from physicians who had issues in the past. But there was no data to show that they really worked.

In fact they were driving people to either lie on their applications or just to avoid it altogether. So really wasn't good for the physician and APP community. And they don't work anyway.

Smith: I would add also one of the things we found just recently as we're working with our health systems and health plans on changing their credentialing forms and the questions on those forms is that a number of them have a physician network in multiple states. And they are concerned about not making a change on a form without doing that for all of their—they use their form for all of their entire health system across their footprint.

So we actually found we needed to go to the source of what their credentialing form is. In our case, a number of our health systems use the Minnesota uniform credentialing application. So if we go to the Minnesota uniform credentialing application and get their form changed, it will automatically change the forms used by the majority of health systems and health plans in South Dakota. So you got to do the research and get into where the source is for the questions.

Staz: Yeah, I would say that these barriers are identical on the licensing side. To use Abraham's words, there is a sense of personal responsibility that members of State Medical Boards have to ask these questions, to ask about impairment that might be meaningful in a physician's ability to provide safe care. What we see our job is doing is saying, well, that's fine and that's completely normal. In fact, I might even say it's human to feel the need to ask those questions when your mission is one of patient protection.

But it's also important to know what the result's going to be. And I that's what Joel hit on very well. Is if you ask those questions, the result is going to be that you drive people away from care. And so we've tried to bring research into our conversations that says exactly that. I thought the study that Dr. Underwood cited at the beginning saying that 4 in 10 individuals have decided not to seek care for fear that there would be a consequence to their ability to practice medicine.

There's a great study out of Michigan from a researcher named Katie Gould that provides similar conclusions. And that's actually been fairly eye opening to a lot of people in our community.

Dr. Underwood: So let's see if we can tie this to some of the health equity stuff as well. So I want you to please address racial, ethnic and intersectionality considerations, and how do you manage physician burnout in marginalized communities? And that's for anyone and everyone.

Staz: I'm happy to start if that's all right. We've gone through a few years of work in diversity, equity and inclusion research and data collection from the state medical board level, but we've also really tried to follow the lead of some of the other partner organizations we have. And the AMA has been very high on that list of organizations from your strategic plan that helped inform some of our own efforts.

You mentioned intersectionality, but even if there is no intersectionality involved, there are multiple balls in the air for any physician, especially if you have to face issues related to discrimination either from your patients, from your employer or from elsewhere in the field. So the fact that these balls are all in the air at the same time can obviously contribute to burnout.

And I think it's important to factor in as many considerations as you can when you're looking at the ecosystem within which any practitioner lives. So when issues related to discrimination, whether it's based on race or any other feature, come into the picture, I think that can absolutely exacerbate burnout conditions and need to be looked at.

Dr. Bundy: Yeah. I think that it's important to have a champion. We talked about having position champions on some of these. But I think it's also important to have a champion when it comes to that. So Dr. Underwood, at Sentara, we recently just several years ago hired a vice president for diversity and inclusion. And then a separate executive leader for health equity.

So that's their job. And because sometimes when you have it as other duties as assigned and we talked about priorities, it gets lost on the priority list. So having someone who says, this is my job. I'm going to own this and do this work. It's very important because I'll routinely get a call and say, "Hey Joel, did you know x, y and z?" And so then we can work together on that. So I think having a champion, whether it's a defined champion or someone who's just passionate about that is incredibly important as well to keep us honest.

Segres: And maybe just building on Mark's point, I think as organizations assess their culture and some of the contributing systemic drivers of burnout in their unique culture if that's one of the drivers, the organization I think is obligated to address it. And the type of discrimination could vary from one population to another.

But if it's clear that—in South Dakota, it's Native Americans. If that subset of the population has a greater degree of burnout contributed and that's one of the contributing factor. I think the organization has an obligation from a systemic standpoint to acknowledge, recognize and lean into that if they're going to fulfill their commitment to addressing the system drivers of burnout and not simply give them another yoga app and say, do yoga twice.

Dr. Underwood: So I'm coming down to the last two questions here. And this has been a great, wonderful discussion. So I'm going to go from to a policy level, a federal policy. So what are some additional actions or items that can be done to help improve physician wellness from at a federal level? That's for anyone.

Staz: Well, we work under a sort of a Federated system. Our state medical board members of the Federation of State Medical Boards are from across the country. And we see our role as one of coordination in a lot of ways. So sharing information from boards that are making great progress in this area, but also bringing folks together to have those conversations.

I think the AMA by holding this webinar and by a lot of its initiatives in the area of physician burnout is doing the same thing. Sending messages that can be transmitted across the country and making space for those conversations to happen.

Smith: I would add that like politics all burnout is local. It really is the physicians in South Dakota or Virginia or New York who are feeling that sense of burnout and experiencing those difficult work cultures that are contributing to that. However, I do think there are things that can set the standard at the I don't know if it's federal government level, but at the national level. I'll just say that.

And I think the Breen Foundation is doing just that. It almost reminds me of—this will date me, but the good housekeeping seal of approval. So we're going to do a good housekeeping seal of approval for medical boards on applications because we want to see mental health questions changed.

That's a very specific deliverable and a very nationally driven opportunity, I guess, for all of us to use. And that is very helpful at the local level for us to have that available in our tool kit when we go to our medical board, and our health systems, and our health plans to advocate for change. So that's just a kind of a small example.

Segres: And while not regulatory in nature, I think the work the surgeon general has done about in regards to raising this as a top priority at a national level has been very impressive. Some talk about why is it taking so long to fix these issues? In the grand scheme of things, this conversation really has only been going on for maybe a couple of years.

And I'm actually cautiously impressed with how extensive and how widespread this conversation is actually occurring. And so I think the work the surgeon general has done to pull together a task force and to issue federal statements on the importance of this is just an example of some things that are already occurring at the federal level to raise the awareness of this issue.

Dr. Bundy: And this is all I'll just say in answer to the question, at the federal level and I've seen it in the chat a lot of the things we look at are all the metrics. And we have hundreds and hundreds and hundreds of quality metrics to keep up with. And those things cascade down to the physicians at the bedside. And we build our EHRs to capture a lot of those things.

And so I think that by consolidating those types of metrics to what's really important and changing the way our EHRs work, I think those things at the federal level certainly would make an impact on all the physicians and APPs across the country.

Dr. Underwood: Awesome. So that was our final question this afternoon. So I want to thank our audience for your questions. And want to thank you, our wonderful panel, for sharing their solutions. We've heard a lot today from our experts. And through your questions, we have learned a great deal more about our collective efforts to address burnout at the state and federal levels, and hospitals, health systems and in our own practices in patient care.

As we return to our roles, let us be mindful of this truth. Seeking care for wellness or mental illness or substance use disorder is a sign of strength. It is an act that takes courage that deserves our health system's unconditional support. As physicians, we need to be leaders to deliver and model that message and behavior in our practice every day and within the systems in which we work.

As you heard today, the factors that drive burnout are complex and not easy to solve. But the AMA advocacy is addressing it at every level. We know it and the long term process. We urge state policy makers, hospitals and health systems to work with us every step of the way. The health of the patients, physicians and our nation's health care system depends on it.

I'd like to thank all of you today for participating. And as you heard, teamwork makes the dream work. You've heard how people come together, work together to make changes in their states. Now let's do this across the nation. Thank you for your time today and everyone have a wonderful day. Thank you.

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