Richard Payerchin is associate editor of Medical Economics.

Richard Payerchin

Physician burnout is a problem. So is physician suicide. But often, the way we conflate these two crises are not accurate, and do damage to efforts to confront the problems. Medical World News® sat down with Christine Yu Moutier, MD, chief medical officer for the American Foundation for Suicide Prevention, to discuss these topics. The transcript below was edited for length and clarity.

Can you discuss some of the key differences between physician burnout, depression and suicide? Sometimes those get lumped together, but they’re not necessarily the same thing. Can you explain?

 I’m really glad that you’re asking the question in that way. As a national suicide prevention expert … I actually got my start and my interest in suicide prevention more broadly, in my own personal and professional experiences as a medical student or resident, and then a dean in the medical school at University of California, San Diego, where I was really doing my best at that local institution level to address well-being, as well as suicide prevention for the medical students, residents and faculty physicians. And I think there has been a lot of conflation of any form of distress. The research is very weakly linked … . We’ve just published some data that show that among health workers and trainees who have burnout alone, depression alone, or the combination of burnout and depression, it’s really only the group that has depression present, whether burnout is present or not, that has those higher risk factors for suicide such as suicidal ideation.

MWN: Do you think it’s helpful? Or is it harming the conversation to sometimes group these together?

 I think the main thing that we worry about when it’s all lumped into one big, conflated grouping is that the key difference between depression and burnout is that depression is a very serious medical illness that has potentially life-threatening consequences, if not addressed, and well-researched treatments that can be used to bring depression to bear. And so, what we worry about is that if, say, a physician who is truly severely depressed is only being recognized by himself or herself or by someone who is trying to support that person as being burned out, they may or may not make a referral to actual treatment. …

Self-care strategies and peer to peer, and debriefing — all of those things are essential … for all of us. But we wouldn’t want to miss the opportunity to effectively address and treat the medical illness of depression.

MWN: Just how powerful is that stigma attached to mental health care in relation to ability to practice medicine?

I think the stigma is still alive. And there’s a lot of confusion. And there are a lot of current and historical reasons that those barriers are still in place. … The bottom line is that mental health is a part of human health, just like physical health is. And we would never [assume] that a physician with diabetes or hypertension, or cancer or other physical health problems, produce an absolute 100% of the time. We know that there are gradations of symptoms and different ways that different types of symptoms might affect a physician’s performance, depending on their scope of practice. And that is a very … nuanced thing. And in fact, most physicians, especially the older we are … the more likely we all are to be managing one or more medical and/or psychiatric conditions. And there should not be an assumption of impairment unless there’s evidence of that. I think that’s … one great misunderstanding that we need to really reframe and correct.

MWN: What would you like to say to primary care physicians about this topic?

 Anyone who is a physician and front-line health worker, especially in primary care, you know better than anyone that you and all of your colleagues are human beings, that mental health is very dynamic, depending on a whole set of factors that relate to things like your genetic loading, your early childhood experiences, all of the things that we know are multifactorial determinants of a complex health outcome, like any of the mental health conditions. … . We can become much more proactive, and it’s not that it’s all on the individual. We need institutional change; we need those questions in the medical licensing and hospital privileging boards to be changed. We need access to treatment that’s confidential and appropriate, all of that. But it also does take our own effort as individuals, not only for ourselves, but to be on the lookout for colleagues whom you might be noticing, who are struggling, and to really take the mindset that we are part of a community together; we can make a difference. We don’t need to be their doctor or therapist, only a colleague and a friend; if we approach someone … we notice isn’t in their usual state of health, to just ask the caring questions, to let them know that you’re there to support them. It should be normal to get the help and support that we need.

Articles

Burnout, depression, and suicide among physicians

Primary care physicians should be on the lookout for 

 (RSV) as infections increase around the country.

In recent days, news outlets have been reporting on increasing RSV case counts at children’s hospitals. RSV infects the lungs and breathing passages and usually causes mild, cold-like symptoms, with most people recovering in a week or two, according to the U.S. Centers for Disease Control and Prevention (CDC).

However, “RSV can be serious, especially for infants and older adults,” causing bronchiolitis and pneumonia in children younger than a year old, according to CDC.

 (AAP), and other experts have published resources to help recognize RSV and treat patients with it.

RSV in common – so much that in the United States, nearly all children have been infected by age 2. Each year, it causes about 58,000 hospitalizations among children aged 5 years and younger, and is estimated to cause about 14,000 deaths a year in U.S. adults aged 65 years and older, according to the 

National Institute of Allergy and Infectious Diseases

In the United States, peak RSV season tends to be fall, winter, and spring. But there was a surge in summer 2021 and the Cleveland Clinic noted 

Most healthy infants and young children with RSV do not need hospitalization, but 

 are considered at high risk, according to CDC:

Very young infants, especially those 6 months and younger

Children younger than 2 years old with chronic lung disease or congenital heart disease

Children who have neuromuscular disorders, including those who have difficulty swallowing or clearing mucus secretions

Cold-like symptoms could indicate an upper respiratory tract infection and may include:

With bronchiolitis, lower respiratory tract infection symptoms may include cold symptoms, along with:

Belly breathing, tugging between their ribs, and/or tugging at the lower neck

Adults infected with RSV may have no symptoms, or may show symptoms consistent with an upper respiratory tract infection which can include rhinorrhea, pharyngitis, cough, headache, fatigue, and fever. Adults may show more severe symptoms consistent with a lower respiratory tract infection, such as pneumonia.

According to CDC, those at high risk for severe illness include:

Older adults, especially those 65 years and older

Adults with chronic lung or heart disease

In children, symptoms generally last five to seven days, according to AAP. In adults, the disease usually lasts less than five days, according to CDC.

Clinical symptoms of RSV are nonspecific and can overlap with other viral or bacterial respiratory infections. Several tests are available to confirm RSV infections, according to CDC.

“Both rRT-PCR and antigen detection tests are effective methods for diagnosing RSV infection in infants and young children,” according to CDC.

For older children, adolescents, and adults, highly sensitive rRT-PCR assays are commercially available for RSV. In all instances, healthcare providers should consult experienced laboratorians for more information on interpretation of results.

There is no vaccine against RSV and there is no cure for it. Acetaminophen or ibuprofen (for children older than 6 months) may help low-grade fevers, according to AAP.

The U.S. Food and Drug Administration has licensed palivizumab for reduction of serious lower respiratory tract infection caused by RSV. CDC cited the 

Direct contact, such as kissing a child with RSV

Touching an object or surface with the virus on it, then touching your mouth, nose, or eyes

CDC notes many of the measures that slow the spread of other contagious viruses also work against RSV. Tell your patients and staff to:

Wash your hands often with soap and water for at least 20 seconds. If those are not available, use an alcohol-based hand sanitizer.

Avoid touching your eyes, nose, and mouth with unwashed hands.

Avoid close contact, such as kissing, and don’t share cups or eating utensils with people who have cold-like symptoms.

Cover your mouth and nose with a tissue or your upper shirt sleeve when coughing or sneezing. Throw the tissue in the trash afterward.

Clean and disinfect surfaces and objects that people frequently touch, such as toys, doorknobs, and mobile devices.

CDC, other experts are tracking increases in respiratory syncytial virus cases in infants.

What your practice needs to know about RSV

Physician burnout and suicide are serious issues that need addressing — but dealing with them can call for very different approaches.

Sept. 17 is National Physician Suicide Awareness Day, billed as a reminder and a call to action. Last year the awareness campaign reached 1.2 million people and received support from 54 medical and other organizations, resulting in 26,000 actions taken to prevent suicide, according to sponsors The Physicians Foundation, the Dr. Lorna Breen Heroes’ Foundation and FirstRespondersFirst.

Although there may be overlap between the two in symptoms and distress that people feel, focusing solely on burnout can create a risk of missing depression, a serious medical illness with potentially life-threatening consequences if left unaddressed, says Christine Yu Moutier, M.D., chief medical officer of the American Foundation for Suicide Prevention (AFSP).

Moutier was co-author of a study on feelings of depression and burnout in 2,281 medical trainees, staff and faculty at University of California San Diego Health, where the Healer Education and Assessment and Referral Program has been heralded as a model system for physician and medical staff suicide prevention efforts. The findings “suggest depression is a much more serious condition” with indicators of distress and suicide risk, including intense affective states, alcohol and drug use and suicidal thoughts and behaviors. Burnout without cooccurring depression was not associated with higher rates of suicidal thoughts or behaviors or with substance use, compared with respondents who screened negative for burnout and depression.

Yet burnout and depression are real problems that must be addressed with systemic change in medicine, say Moutier and Kristen Kim, M.D., corresponding author of a recent study on contributing factors to physician suicides across the country from 2003 to 2018.

Burnout is characterized by chronic workplace stress that can lead to a sense of emotional exhaustion, depersonalization or difficulty seeing others as human, and a low sense of personal accomplishment. Depression and suicide are clinical diagnoses requiring therapy and medications if appropriate, Kim says.

Solutions start with recognizing physician suicide is a serious problem and physicians must prioritize self-care in their everyday practices, Kim says. “I think medicine still, as a field, embraces this outdated sense that we need to sacrifice everything as a physician, including our own well-being,” she says. “And that is just simply wrong. At this point, it’s time to move beyond that and to really prioritize our own well-being in order to best care for our patients.”

In the study of physician suicides, one stressor was incapacity to work due to deteriorating physical health. Physicians tell their patients to stay healthy and they need to do the same, Kim says.

When scheduling appointments, physicians face the same barriers patients do. Primary care and specialist physicians often have office hours that overlap with work schedules, so physicians as patients sometimes must wait days, weeks or months for appointments. Flexibility in scheduling and telehealth could offer solutions, although telehealth limits physical examinations, Kim says.

AFSP notes primary care providers are “in a unique position to identify patients at risk of suicide and enact appropriate intervention methods,” including for fellow physicians. The foundation advocates increased training for physicians to better understand suicide assessment, treatment or risk management.

Even without added training, talking and listening can be a start. Physicians must be on the lookout for colleagues who are struggling and embrace the mindset that, as a community, “we can make a difference,” Moutier says.

“We don’t need to be their doctor or therapist; we’re being a colleague and a friend,” she says.

If physicians sought therapy or psychiatric treatment, Moutier suggests sharing that information with a colleague in distress.

“Give them permission to take those steps themselves by showing and modeling that that can be done safely and without any negative repercussions on your career,” Moutier says. “I’ve seen it happen innumerable times; there is so much more fear about that harm that will come from seeking treatment than there is. And the truth is that the true source of fear, and sort of danger, is actually from unaddressed mental health conditions when they’re left to go unaddressed because of the barriers that are in the way.”

Depression, burnout, and suicide among physicians

COVID-19 pandemic conditions are getting better, but red tape and paperwork are getting worse in the last year, according to a survey of physician practices and health care system leaders around the nation.

The Medical Group Management Association published its 

“2022 Annual Regulatory Burden Report,”

 a survey of more than 500 group practices, including 64% with fewer than 20 physicians, and more than 75% in independent practices.

If the poll was an election, increasing overall regulatory burden would win in a landslide, with 89% of respondents reporting it got worse in the last 12 months. If that burden was reduced, 97% of respondents said that would allow them to reallocate resources toward patient care.

“In a time of runaway inflation and unprecedented workforce shortages, the federal government is layering on additional regulatory burdens that, while in theory are beneficial to patients, act more as an impediment to delivering care,” said Anders Gilberg, MGMA’s senior vice president of government affairs, said in a news release. “From longstanding challenges associated with the Quality Payment Program, to new obstacles related to the No Surprises Act, it is evident that policymakers must consider the totality of these burdens and their ultimate impact on patient care.”

The results were published on Oct. 11, the day when MGMA was concluding its 2022 Medical Practice Excellence Leaders Conference.

The top contenders for consuming the most time and effort in physicians’ practices, with percentages of respondents reporting it very or extremely burdensome:

Surprise billing and good faith estimates, 70.45%.

Medicare Quality Payment Program, 64.56%.

Translation and interpretation requirements, 50.75%.

Lack of electronic health record interoperability, 50.44%.

Medicare and Medicaid credentialing, 41.17%.

The COVID-19 pandemic has not yet dropped out of sight, with 42.38% of respondents calling the very or extremely burdensome.

Getting prior authorizations from payers has caused 89% of practices to hire additional staff or redistribute current staffing resources to process prior authorizations due to the increased number of requests, according to the survey.

Along with an expense to physician practice resources, doctors, patients, and their advocates argue the processes delay patient care unnecessarily, according to MGMA.

“The increase in prior authorization requirements year after year is simply unsustainable,” Gilberg said. “Practices are being forced to divert resources away from delivering care to contend with these onerous and ever-changing requirements. It is time that Congress acts to put commonsense guardrails around prior authorization programs. We urge the expedient passage of the 

Improving Seniors’ Timely Access to Care Act

That act has been approved in the U.S. House of Representatives and has strong support in the Senate, along with backing by numerous medical associations.

 aims to protect patients from malicious balance billing practices and ensure patients have cost estimates to make informed decisions about their care – positions that MGMA supports. But the association members remain concerned the policies, as implemented, create undue burden without improving care, the report said.

In the survey, 82% of respondents said the required uninsured or self-pay good faith estimates have increased administrative burdens on their practices.

 are growing, along with government scrutiny of that consolidation. The MGMA survey found 90% of medical group leaders believe health care consolidation is increasing, and 76% of medical groups indicated the increasing regulatory burdens have been a major contributor to that.

COVID-19 pandemic conditions get better, but more red tape blocks care for patients.

MGMA 2022: Regulatory burdens growing for physicians, survey says

Physicians can get paid by educating their patients about their medical bills and making it easy for patients to pay them.

Some patients avoid going to their physicians at least partly out of fear of huge medical bills – or just not knowing how medical bills work. One poll found 50% of Americans avoid medical care due to cost, said Taya Gordon, MBA, CMPE, CMOM, and chief revenue cycle officer at H4 Technology LLC, a health care support company.

When that happens, underlying health problems can grow worse, leading to emergency department visits that add to costs, said Gordon. She presented “Reduce Revenue Cycle Pain Points by Improving the Patient Financial Experience,” during the 2022 Medical Practice Excellence Leaders Conference of the Medical Group Management Association, and is coauthor of the association’s publication “Revenue Cycle Management: Don’t Get Lost in the Financial Maze.”

Gordon challenged physicians and administrators to reconsider medical care from the perspective of patients worried about costs, health insurance benefits, fear of health conditions, or maybe afraid of getting stuck by a needle that day.

While financial education may not alleviate all those fears, physicians and health care leaders who want to keep patients – and keep getting paid – should make the financial transactions as smooth as possible, Gordon said. She outlined samples of hurdles to patients accessing their health, billing and insurance information, with solutions to improve their understanding – and, ideally, their willingness to pay for physicians’ services.

 Patients are only told about the portal at the check-in. There are no signup instructions. Patients don’t see value to enrollment.

 Make it easy to locate patient portal links or login windows on websites. Allow patients to pay bills with or without logging in. Make it easy for patients to find social media accounts.

 Physicians should encourage patients to access online health records because patients feel like it is “prescribed” for them, Gordon said, citing her own family experience, along with a finding that patients are almost twice as likely to log on when encouraged by a health care provider.

Patients don’t understand why they owe what they owe because statements use health care terms instead of user-friendly terms, contact information is not helpful, and statements are not clear about what is due, when, or how to pay.

 Include pertinent information with clear messaging. Minimize use of complex codes and code descriptions. Consolidate the most important components quickly: Amount due, due date, payment methods.

 If a patient files for bankruptcy, traditional collections must cease immediately. Do call your legal counsel for guidance on next steps, but don’t send statements or make phone calls attempting to collect.

Are your patient bills easy to read and understand? Here’s an example of one that clearly shows how much a patient owes, when it is due, how they can pay it, and contact information if they have questions. This example was part of the presentation “Reduce Revenue Cycle Pain Points by Improving the Patient Financial Experience,” during the 2022 Medical Practice Excellence Leaders Conference of the Medical Group Management Association. Presenter Taya Gordon, MBA, CMPE, CMOM, and chief revenue cycle officer at H4 Technology LLC, a health care support company, offered tips on making it easy for patients to pay their physicians.

Bills have minimal payment options available. Accessing payment options requires a login. Patients don’t have access to payment plans to recall terms.

 Instead of a login, require a form with fields such as name, date of birth, and other identifiers to match patients to payments. Offer multiple forms of payment such as Venmo, PayPal, CashApp, or Apple Pay.

 Print, or have printed, a sign listing the forms of payment you accept and post it where patients can see it in the office.

Insurance explanation of benefits (EOBs) and reimbursement rules are complex. Patients have high expectations with minimal support. Patients with unpaid balances may avoid care.

Have patients bring in complicated EOB forms to interpret and set up payment plans. Be sure to collect something when setting up a payment plan. Create a patient financial literacy program using your patient portal, social media, hold times, and wait times to engage patients about wellness, prevention, and financial literacy.

Create a glossary of health care financial terms. Print copies to give patients at the office and post it on your website and social media sites.

Offering financial education helps patients understand what they owe, why, and when.

MGMA 2022: Collect more revenue by making it easier for patients to pay

Working from home offers flexibility for medical staff and a new avenue for hackers to compromise data from physicians’ offices and health care systems.

Employees remain the weakest link in the cyber security chain that protects computer networks and patient information that by law must remain confidential, said Jeffery Daigrepont, senior vice president for health information technology for Coker Group, physician advisory group based in Alpharetta, Georgia.

Daigrepont presented “Confessions of a Hacker: How Cyberattackers Have Targeted Remote Workers,” as part of 2022 Medical Practice Excellence Leaders Conference of the Medical Group Management Association. He noted he is not a real computer hacker – but there are plenty out there targeting physician offices and health systems seeking money and personal details about patients.

The bad news is that cyberattackers are unrelenting and are good at what they do.

“Individuals, us, even the most savviest of IT individuals can be tricked into being compromised,” Daigrepont said. But there are hints and signs that staff can recognize, and steps to take, to guard against cyber breaches, he said.

Many physicians and health care workers are familiar with rules governing patient privacy protections of the Health Insurance Portability Accountability Act.

But there is a difference between privacy and security, Daigrepont said. Security is a process or set of actions, comparable to a lock on a door: It must be activated to ensure privacy, and without it, there is no privacy.

In information technology, 10% of the safeguards are technical, while 90% of the safeguards rely on users. Meanwhile, data is spread out over a number of electronic devices, including copy machines, Daigrepont said.

One easy tip to avoid compromised data is, when upgrading to new computer hardware, ensure the old equipment is destroyed, he said.

The COVID-19 pandemic was a once-in-a-lifetime opportunity for hackers because office information went with employees working from home, but some office cybersecurity measures did not.

Now attackers are using social engineering, including emails and queries that include personal details about the recipients, taken from social media websites where people openly share information without thinking about it.

“The weakest link is our entire cybersecurity efforts is the individual, us in this room,” Daigrepont said. “You might think, I would never fall for any of these gimmicks, I’m too smart, I know this stuff. A lot of the social engineering is getting to the point where they are dialing into you at a very personal level.”

He used the example of a Facebook post asking for prayers for a family members diagnosed with cancer. In a case study, Daigrepont described a hacker who created a phony fundraising document sent to the sister of a woman diagnosed with cancer.

“Do you think she clicked on that? Absolutely she did, absolutely. Well, why would she click on it? Well, they knew personal information about her,” he said.

Practice-based computer security measures don’t necessarily transfer to home-based computers that remote staff are using. Daigrepont described various cyberattacks that can fool people into offering personal information or allowing hackers access to computers:

Phishing is relatively well-known. Hackers pose as trusted entities to extract sensitive information via email.Perhaps the best known is the example of an email from a Nigerian royal asking for a recipient’s bank account information to transfer money. But phishing takes many forms and can be convincing. To avoid phishing, look for awkward phrasing, unofficial website and email addresses, and don’t click on links in the email.

Drive-by downloads happen when users visit a compromised website that can infect the user’s computer with a virus.

The lost jump drive hack happens when a hacker deliberately drops an infected jump drive, also called a thumb drive, in a parking lot or waiting room. Studies show curious staff will insert the drive into their computers 60% of the time, launching an automatic virus attack.

Practices should run vulnerability scans on their networks at least once a year.

Do everything you can to filter emails with potential threats, before they get to workers’ inboxes.

Back up data and be obsessive with software updates.

Have unique user IDs and passwords. Daigremont compared passwords to toothbrushes: Choose a good one, don’t share it with anyone, and change it occasionally.

The laptop privacy sweater may cover a user’s computer screen but it won’t protect against the latest methods that cyberattackers are using against physician offices and health care systems, said Jeffery Daigrepont, senior vice president for health information technology for Coker Group, physician advisory group based in Alpharetta, Georgia. Daigrepont used the illustration in his presentation “Confessions of a Hacker: How Cyberattackers Have Targeted Remote Workers,” as part of 2022 Medical Practice Excellence Leaders Conference of the Medical Group Management Association.

Working from home offers flexibility for staff, gateway for cyberattacks.