Steph Weber

As states lift restrictions and practices ease toward a return to full services, maintaining adequate staffing alongside strict safety measures has been challenging. Here's how some practices are doing it.

As many as 97 percent of practices have felt a negative financial impact due to COVID-19, according to a 

new survey from the Medical Group Management Association (MGMA)

. Nearly overnight, canceled and postposed appointments and procedures resulted in average patient volume and revenue decreases of 60 percent and 55 percent, respectively. As a result, 48 percent of practices temporarily furloughed staff while 22 percent permanently laid off at least one employee.

Keeping up with regulatory changes during COVID19

"The week of March 16, 2020, will be etched in everyone's memory," says 

, CEO of MedNetOne Health Solutions, a physician and healthcare management organization located in Rochester, MI. "Active practices came to a complete standstill. Practice staff were being laid off [as] telehealth became the focus of care delivery."

Those with existing telehealth capabilities had the advantage of pivoting more quickly, retaining staff, a source of revenue and continuity of care in the process. "I was fortunate to have lean staffing pre-COVID-19 and did not have to lay off anyone, though I know this was not the case for many of my colleagues," says 

, MD, a board-certified plastic and reconstructive surgeon in Boynton Beach, Fla., and medical director of plastic surgery at Modernizing Medicine, a specialty-specific software company. Rosenthal's in-office patient volume fell 75 percent at one point, but he preserved close to half of pre-COVID patient volume by initiating telehealth visits for consultations and follow-ups and limiting face-to-face appointments for more urgent matters. His staff spent any residual downtime on marketing activities, finetuning practice operations, and reviewing safety protocols.

, MD, FACC, a board-certified electrophysiologist and executive medical director of the Texas Cardiac Arrhythmia Institute in Austin, maintained 60 percent patient volume during state quarantine orders and avoided staff reductions by largely directing efforts toward proactive measures. "[W]e set up a system to avoid any unnecessary [patient] exposure to personnel, visitors, and other hospital environments, along with dedicated pathways to access electrophysiology services and strictly regulated access of family members and vendors," says Natale.

Staff used questionnaires and widespread serology and PCR testing to screen patients prior to elective procedures. Employees underwent the same screening process. "With this strategy, there were no new infections amongst the patients or the healthcare team members," says Natale. "Seronegative physicians and staff interacted freely in the workplace without using significantly restrictive, expensive, non-conventional protective gears and difficult to implement social distancing rules."

As practices resume services, it is critical that everyone is aware of new guidelines and protocols, especially staff that may have been furloughed. "Physicians will need to rely on their teams to disinfect, monitor and track activities in addition to assisting in the provision of clinical services," says Matuszewski, who developed a 

 that outlines a step-by-step approach for safe practice reopening. "Communication is key [and] training and education of teams is crucial." She recommends having an initial meeting via conference call as well as creating a practice checklist that is available for employees to routinely reference and review.

The sooner this happens, the better, since a backlog of patients awaits. "What many are seeing now is what we predicted: that during the easing of restrictions, we are operating over capacity while still trying to be responsible about spacing out patients," says Rosenthal. "We rebounded to about 125-150 percent of volume post-shutdown as the bubble of patients who couldn't be seen during that time came back into the system."

But legislation has hampered some practices' efforts to recall furloughed employees. The 

Coronavirus Aid, Relief and Economic Security (CARES) Act

 expanded unemployment benefits to workers whose hours or jobs were affected by the pandemic, including an additional $600 payment per week. Supplemental initiatives, like the Small Business Administration Paycheck Protection Program, authorized loans to businessowners to cover employee wages and operational expenses. "[A]s the funds hit their checking accounts, practice managers began calling back their staff. [S]taff were often uninterested in returning since they were making more money on unemployment," says Matuszewski. Overcoming this resistance was yet another setback for some practices, slowing their reopening efforts and the provision of timely patient care.

Now weeks into state quarantine lifts, practices are finding their new normal. "The healthcare industry is shifting to the concept of just-in-time delivery versus having patients waiting on us," says Rosenthal. Telehealth services have become part of daily practice, open office spaces have been reconfigured to minimize prolonged exposure and staff are increasingly instrumental in screening both themselves and patients.

The lessons learned over the past several months highlight the necessity of having plans in place to prevent future disruptions in care and shore up staff and patient safety. "Physicians and their teams will need to move beyond clinical expertise to hone in on some basic business skills, such as a developing a business continuity plan," says Matuszewski. "It's not taught in medical school."

is an award-winning freelance journalist hailing from the Midwest. She writes about healthcare, human resources and small business.

Articles

From furloughing employees to implementing strict safety protocols, here's how practices have tackled pandemic staffing.

How practices are tackling pandemic staffing

Originally marketed as a way to discover ethnic and ancestral heritage, direct-to-consumer (DTC) genetic testing kits have expanded into the areas of predictive health and disease susceptibility. The service, offered by companies like 23andMe and AncestryDNA, is increasingly popular. According to a 

, more than 26 million people had taken tests and consented to the inclusion of their DNA in one of four prominent commercial ancestry and genetics databases. If consumer buy-in continues at this rate, boosted by its usual place 

atop the gift-giving list this holiday season

, the databases could hold the DNA of 100 million people by early 2021.

While testing may seem the prudent choice and accumulation of nearly one-third of the nation's genetic makeup promising from a scientific standpoint, the reality isn't so clear-cut. Patients may consent to these tests for fun, but 

unearth long-buried and deeply painful family secrets

. Other patients who are worried about their health, perhaps on the heels of a relative's unexpected and devastating diagnosis, are frantic to discover any and all genetic abnormalities and may be prone to making rash decisions based on flawed or misconstrued data. Still others have grand plans to "biohack" their physiology in an attempt to achieve optimal health and live well past 100. 

Regardless of their reasons, it is likely that physicians will encounter mounting questions from patients, test results in hand, who are worried about their risk factors, expecting treatment, further testing or a referral to a geneticist. Here's how to approach these conversations and what patients deserve to know about DTC genetic testing. 

The ease and affordability of commercial genetic testing kits- typically with no physician order, a noninvasive saliva sample and as little as $99 to screen for several hundred thousand single-nucleotide polymorphisms (SNPs)-has piqued consumer interest, prompting many to view the tests as a sensible way to dive deep into their DNA. Although testing provides pages of information, it doesn't always equate to meaningful or actionable takeaways. 

, a licensed genetic counselor and director of the Genetic Counseling Graduate Program at Ohio State University Wexner Medical Center in Columbus, Ohio, completed a kit herself after seeing a substantial increase in patients requesting consultations to discuss their results. "I [wanted to] understand the complete process and have unfettered access to the [same] services the company provided to individuals," says Allain. 

Her findings were more entertaining than groundbreaking. The test accurately identified her ethnicity and that she was unlikely to have dimples, a cleft chin, and a fear of public speaking-all traits easily verifiable without DNA sampling. Although the testing disclosed that she is a carrier of a common gene variant associated with hereditary hemochromatosis, it wasn't particularly relevant to her own health going forward. "I am only a carrier and not at risk for the disease," says Allain. "Given this is a common condition in the general population, knowing I am a carrier allows for risk assessment for my children and sister." According to the 

Centers for Disease Control and Prevention (CDC)

, most people with hereditary hemochromatosis never develop symptoms or complications, so even if someone has the condition identified via testing, modifications in current medical management or lifestyle are not always useful.  

The ensuing "curse of knowledge" can be devastating for patients with genes that are correlated to illness or disease, even if they are unlikely to ever suffer any ill effects. Physicians should caution patients about the emotional and psychological repercussions and remind them that correlation does not equal causation. "[Patients] learn about the probability of developing various conditions, which is usually low in terms of absolute risk, even if [their] risk relative to the rest of the population is high," says 

, a researcher specializing in social psychology and founding director of the Center for Medical Decision-Making at Ono Academic College in Israel. "[W]hatever information you learn, you cannot unlearn. Every person should ask themselves whether they want to live their healthy years in fear of a condition which may not erupt." 

Unfortunately, the rising consumer interest in genetic testing has led to a market awash with options, little oversight, and gross oversimplification of a complicated topic. "There are many predatory genetic services available today that promise things like an idealized diet for weight loss or risk [quantification] for health conditions that genetic counseling could assess from personal and family history," says 

, a geneticist and technical director of Molecular Pathology at LifeBrite Laboratories in Atlanta, Ga. "There are hundreds of complex traits. For many, it's not a simple 'yes-no' answer." She recommends physicians check in with patients and make sure they are not purchasing unnecessary products and services that have little added value. 

Patient Dismissal: The When, Why, and How

The danger of false negatives of positives

Food and Drug Administration (FDA) authorizing the marketing of 23andMe's Personal Genome Service Genetic Health Risk (GHR) tests

, which look for particular SNPs commonly found in late-onset Alzheimer's, hereditary hemochromatosis and eight other conditions, the agency has warned that DTC tests should not be used for diagnostic or treatment purposes due to the potential for false negatives and positives. 

When false negatives occur and test results seem otherwise unremarkable, patients can be lulled into a sense of security and feel almost genetically invincible, leading to less compliance for existing treatment plans and self-care regimens. It's imperative that physicians have a candid discussion with patients about the validity and scope of DTC testing and establish realistic expectations. "While DNA test kit companies have done good work raising awareness of genetics, it's not going to tell you your predispositions to diseases," says 

, PhD, a board-certified oncologist and director of Cancer Genetics at University of Texas Southwestern Medical Center in Dallas. "[DTC] tests rely on self-reporting. As we know from Dr. House, everybody lies, so the databases are less validated compared to clinical data. The kits are more incomplete than a clinical test [and] false negatives are very common. The results should be taken not with a grain of salt, but a big bag."

Ross, who underwent prophylactic double mastectomy and bilateral salpingo-oophorectomy following clinical confirmation of her risk for breast and ovarian cancers, says that even a negative result provided by licensed geneticists isn't a golden ticket. Future advances in testing methods are probable, for which patients would need to undergo additional screenings to obtain more accurate results. "We ask our patients to remember that genetic testing is a process, not an event, and to check in with us every year just like some people check in with their financial counselor or primary doctor," Ross says. 

False positives come with their own risks and are not rare occurrences either. According to a 

, false positives account for up to 40 percent of gene variants reported in DTC raw data. This becomes more problematic as 

third-party interpretation services like Promethease and GEDmatch gain popularity

, allowing users to upload raw data and generate customized reports about potential disease-associated SNPs not otherwise included in standard DTC summaries. Users must agree that the service is for educational and research purposes only, but there's virtually no way to verify that the results are accurate or interpreted correctly. 

Experts say physicians should encourage patients to share their reasons for seeking genetic screening as well as any results already obtained from commercial kits. "It could be that the individual is concerned about something in their personal or family history and would benefit from a referral to a genetic professional," says Allain. "There may be individuals who have results that they do not understand and may be misinterpreting their risks."

So you no longer want to practice medicine

This was the case for one of Ross' colleagues, a fellow physician who initially feared he had Lynch Syndrome based upon raw data findings. He eventually found his way to Ross and a clinical test confirmed it was a false positive. The trauma of such an event cannot be overstated as it is can create significant psychological stress and pursuit of costly and invasive testing and interventions. 

A patient's interest in genetic testing can serve as leverage for physicians to deepen engagement, fully address concerns and tweak treatment plans. 

, FAAFP, ABOM-BC, a board-certified family medicine physician specializing in nonsurgical weight loss and integrative wellness in Atlanta, Ga., uses it as a conversational jumping off point.  

"It's important to listen carefully to what's keeping them up at night and address their concerns without falling into the 'testing trap,'" says Moore-Ruffin. "I often explain that these tests are better for some things than others and we will use these results along with a careful personal and family history to create a preventive health plan." While Moore-Ruffin utilizes specialty SNP DNA analyses in her practice, she acknowledges the face-to-face review of results as well as the detailed recommendations she provides are instrumental in ensuring the testing is used responsibly and effectively. 

There are additional upsides to pursuing testing under the guidance of a physician or geneticist, especially for patients who have limited access to family history. "[It] makes sense for a person with no idea of their family history (i.e. adopted, estranged, or small family) who could use genetic testing as a starting point to build a health profile," says Umberger. Genetic profiling can be beneficial in optimizing some drug therapies, a process called pharmacogenetics, or for couples planning to conceive, though determinations must still be made on a case-by-case basis.  

If at-home testing identifies certain highly predictive SNPs such as those associated with pancreatic or breast cancers, then more frequent screenings may be advised following confirmation via clinical testing and a geneticist consultation. For many patients, findings can be instrumental in spurring healthful behavior. "[F]or the patient who leads a sedentary lifestyle or smokes, knowing that they specifically have an increased risk for cardiovascular disease or diabetes may be the one thing that convinces them to change their behaviors where previous counseling has not been effective," says Moore-Ruffin. 

4 reasons you should prepare a physician rights and responsibilities document

Ultimately, the mere presence of a SNP doesn't automatically translate to disease. Environmental and lifestyle factors affect gene expression, essentially turning on or off the signals that launch a physiological cascade toward dysfunction. The goal, most experts agree, is to postpone or stop that switch from flipping in the first place. Practicing healthy habits can go a long way toward negating patients' predispositions. "There is no genetic testing, to my knowledge, that would alter my recommendation for healthy eating, exercising, smoking cessation and limiting alcohol," says Ross. 

Direct-to-consumer genetic testing kits are a hot commodity every holiday season, but they often come with strings attached. Here's what patients deserve to know.

Genetic test kits: what patients deserve to know

, transportation challenges prevent a staggering 3.6 million Americans from receiving medical care each year. A 

 found that one-third of Americans frequently or occasionally experience stress over their families' transportation needs. 

While access to a reliable personal vehicle or public transit system can affect virtually any patient at any point in time, it can be persistently problematic for the roughly one-in-five patients residing in rural areas who experience 

commutes 17 minutes longer and 10.5 miles farther

 than their urban and suburban counterparts. Associated travel expenses pose additional barriers, especially for those with mobility-limiting conditions requiring specialized vehicles or with chronic conditions requiring repeated visits.   

When lack of transportation leads to missed, canceled, or delayed appointments, the impact on patients and providers is significant, interrupting continuity of care and compromising patient outcomes as well as the successful management of complex comorbidities. The rise in such scenarios has prompted the creation and implementation of targeted solutions. "Addressing social needs [like transportation] is the next frontier in healthcare," says Edward Lee, MD, executive vice president of information technology and chief information officer at the Permanente Federation in Oakland, Calif. "An individual's social needs can have a huge impact on their health; physicians are often the first professionals working in a community to identify those needs."

6 considerations for outsourcing at your medical practice

Social determinants of health (SDOH)-where patients are born, live, learn, and work-are increasingly being studied as a way to stymie existing health inequities, improve access to both acute and preventive care, and address modifiable risk factors. According to the 

, genetic, biologic, and personal behaviors account for just 25 per cent of an individual's wellness. The remaining 75 per cent is attributed to SDOH factors like housing, safe neighborhoods, food insecurity, and access to transportation and healthcare services. 

When patients cannot attend appointments, regardless of the reason, it creates a cascade of consequences for all involved. An interruption in the continuity of care and access to critical support services can leave patients struggling to independently maintain treatment regimens and make healthful decisions that advance their care plans. 

Journal of Primary Care and Community Health 

, patients with a history of missed appointments are nearly five times more likely to miss subsequent appointments. 

 determined that patients with higher rates of no-shows are significantly more likely to have incomplete preventive cancer screenings, worse chronic disease control, and increased rates of acute care utilization for hospitalization and emergency department visits, adding to healthcare costs in an already overburdened system. Missed appointments are a risk factor for all-cause mortality, according to a 

, with mental health patients experiencing an eightfold increase in risk. 

Healthcare organizations and providers feel the strain too. In the current healthcare environment where physician shortages are rampant, last-minute scheduling changes may result in unfilled timeslots, underutilization of valuable finite resources, and increased wait times for other patients. A secondary effect is the potential loss of revenues. While it is difficult to determine the economic repercussions, 

 suggests that no-shows or last-minute cancellations result in an industry loss of $150 billion per year, compounding at an average rate of $200 per unused timeslot. When patient visits are infrequent or sporadic, quality metrics can suffer, resulting in financial penalties under emerging value-based reimbursement models. 

 have reported no-show rates from three per cent up to 80 per cent, they vary broadly among providers and even within an institution's own departments. "No-show rates average 15 percent for appointments across our system and around 50 per cent for behavioral health appointments," says 

, vice president of population health for Indiana University Health Physicians group in Indianapolis, Ind. 

When care managers contacted emergency room patients post-discharge to ensure care plan adherence, a common theme quickly became evident. "We would often find out they had no social support to bring them to their appointments," says Brandt. When patients inevitably became ill or required further treatment, they would resort to visiting the emergency room instead. 

Missed appointments due to a lack of transportation also tend to point to a patient's overall socioeconomic status. Patients residing in communities with poor SDOH factors tend to face more barriers to care including less social support, fewer financial resources, and greater travel distances. "Lack of transportation is a significant barrier when accessing care, especially for patients that are low-income, disabled and/or suffer from a chronic condition," says 

, president and CEO of the California Chronic Care Coalition in Sacramento. 

Although Medicaid frequently covers non-emergency medical transportation (NEMT) services, prior authorization requirements and varying coverage from state to state can undermine the program's reach. If patients are forced to pay out-of-pocket for NEMT services, the expense may simply be too great. "These added costs are especially significant for patients who need to receive treatment at a certified clinic only a couple of minutes away from their home, but are [sometimes sent] to [centers in] other states their insurance will cover," says Helms. "Costs include time away from work, accommodations, paying for a professional caregiver or having a family member provide transportation."

 found that transportation challenges disproportionately affect the elderly, children, minorities, and veterans, as well as patients who are low income, less educated, or chronically ill. To bridge the gap for the most vulnerable populations, Indiana University Health recently formed new ride-sharing partnerships to provide transportation to eligible patients. The initial focus is on the elderly, those with chronic diseases such as heart failure and diabetes, and Medicare Advantage and ACO health plan participants. High utilizers of emergency services and patients without social support or who have SDOH needs are also included.

"To avoid patients paying out of pocket, we are paying for transportation services if they meet our regulatory criteria and have financial need, based on information provided to our care managers and social workers," says Brandt. While the program is still in its early stages, feedback has been positive and promising for reducing total no-shows. At an average per ride cost of less than $30, it's significantly less than an emergency room visit and may likely prove more sustainable.

, cofounder and CEO of Envoy America, a senior transportation provider headquartered in Tempe, AZ, has seen a shift in client demographics and needs. "Even though most of our marketing is focused on serving the elderly, we have clients as young as 20 years old," says Kanaan, who estimates the organization has provided more than 100,000 NEMT rides through its network of medical partners which includes the Mayo Clinic as well as dentists, rehabilitation facilities, and kidney dialysis centers. His employees have also assisted parents traveling with young children, who may have otherwise struggled to find a way to easily and safely commute as a family. 

Although formal data isn't yet available for Envoy America's program, demand has grown. "We estimate that our services are making a difference, because we are seeing our business grow," says Kanaan. "Anecdotally, we have heard from some of our partners that our services help them in their overall goal to lower readmission rates."

7 things to do to start your 2020 planning

Once the impact of ride-sharing programs can be more fully measured, it's possible the scope could be expanded into a modern version of the house call. "In the future, it could be used to send a healthcare provider to the patient's home if that is a more efficient and cost-effective option," says Brandt. 

When physical commutes prove challenging, mobile may be the answer, especially now that cellphone ownership has reached an all-time high. According to 

, 96 per cent of Americans own a cellphone and 81 per cent own a smartphone. Tapping into that technology can keep providers and patients connected for follow-ups, and perhaps even more importantly, create opportunities to access first-line care.

"Because many people have time and transportation barriers to their 

 visit with a medical provider, virtual healthcare options speed time to initial evaluation," says 

, cofounder and chief medical officer at CirrusMD, a text-based virtual care platform located in Denver, Colo. "[CirrusMD is] instantly available from any mobile or web device." 

Through partnerships with employers, payers, and integrated delivery networks, the service is offered at no cost to most patients, completely bypassing three of the most commonly cited barriers to care – transportation, distance, and money. Users of the platform, including more than 200,000 veterans, connect with a physician in less than 60 seconds. Avoidable emergency room visits have been reduced by as much as 40 per cent and utilization rates are three times that of national telehealth averages.

"Management of chronic diseases, such as heart failure, require a high touch clinical workflow. Currently, most hospitals and medical groups have programs staffed by highly trained nurse practitioners following evidence-based protocols who stay in touch and manage patients over the telephone – which these days means voicemail and can lead to many lost conversations," says McKinney. "We live in a world where everyone texts, so it makes sense to use medical-grade texting capabilities for the management of chronic disease." 

Other telehealth services like patient portals and secure messaging partially circumvent the transportation gap and have slowly gained traction alongside EHRs. Unfortunately, rollouts are often clunky and interfaces not particularly intuitive, essentially trading one barrier for another. The key, experts say, is to offer patients accessible resources at every turn.

That's exactly what Kaiser Permanente hopes to accomplish through their Thrive Local initiative, a comprehensive social health network designed to connect patients with SDOH needs to appropriate services. "A network of community resources will be integrated into Kaiser Permanente's electronic health record. By doing so, our members with unmet social needs will be more efficiently connected to community services by our clinicians and staff," says Lee.

Ultimately, the most effective solutions must focus on ease of use and streamlined access to providers. "Some believe that doctors need a bunch of information inputted before they can talk to you – that's the paradigm of the office clipboard, right?" says McKinney. "What I prefer, and what I believe patients prefer, is to just let us connect and communicate as quickly and as personally as possible. A doctor you can communicate with is more relevant to your care than a doctor you have to wait weeks to see."

When patients do not have reliable transportation, the effects ripple through the entire healthcare system. Here's a look at the fallout as well as innovative solutions.

Overcoming patient transportation barriers to care

 by the American Medical Association (AMA), September  was spent celebrating the trailblazing achievements of female physicians.

As we look ahead, though, the momentum of these gains is stymied by lingering roadblocks preventing women from achieving true gender equality across all specialties, roles, and geographic locations. Although 

women matriculants now regularly exceed males

 and representation in the upper echelons of academia and leadership has slowly climbed – the AMA's three consecutive female presidents is one example of the latter – troubling gender imbalances continue to plague graduates as they move beyond medical school.

Only 36 percent of the nation's professionally active physicians are women,  and at the local level, females account for less than 40 percent of the physician workforces in 44 states, dropping as low as 24 percent in Idaho, a 2019 report from the 

In academia and leadership, the gender imbalance is even more prominent and points to enduring systemic issues.

"With each academic rank jump, we lose approximately 10 percent women. Only 20 percent  [of departments chairs] are held by women [and] specialties like surgery [have] less than five percent women chairs. The number is similarly low at the Dean level," says Jennifer Hunt, MD, a board-certified pathologist in Little Rock, Arkansas, Fellow of the College of American Pathologists, and chair of the Department of Pathology and Laboratory Services at the University of Arkansas for Medical Sciences. "There has been a slow increase, but nowhere close to where it should be for the demographics of practicing physicians. We continue to have a significant gap." 

Shortly after medical school enrollment, experts say women physicians encounter unique barriers to success that derail continuation into long-term clinical, leadership, and academic careers. From restrictive parenting roles rooted in an outdated societal structure to an undercurrent of implicit gender bias that discourages the pursuit of certain specialties and propagates hierarchical divisions, widespread disparities exist alongside the incremental improvements. Here's a rundown of barriers faced by female physicians and how to bridge the expanse. 

Roughly 40 percent of physicians express plans to have children during graduate medical education (GME) programs, according to a 

. The cost of childbearing during this period, however, weighs considerably heavier on females, ultimately impacting the depth and trajectory of their training and careers.

"The pressure around the decision to have [and care for] children is a real thing. Women have been asked explicitly about their plans [and] definitely 'mommy tracked' if an interested is expressed," says LaTasha S. Perkins, MD, a board-certified family medicine physician in Washington, DC, and student health staff physician and director of outreach & engagement at Georgetown University. "This is done not only by others (i.e. attends, supervisors, directors, colleagues), but also by women themselves."

 study discovered females pregnant during GME are more likely than their male counterparts to revise career plans both while pregnant and following childbirth, suffer from loss of research productivity, alter on-call and rotation schedules, and complete the program later than originally planned.

"Traditionally, women are still seen as the primary caregivers and the burden of raising a family and children is often seen as their responsibilities," says Evi Abada, MD, MS, a pathology resident physician in Detroit, Michigan, and member of the 500 Women Scientists and 500 Women in Medicine leadership teams. "Toward the end of their medical education, female students may find themselves grappling with specialty career choices. The act of balancing clinical responsibilities with caring for a family is often shoved in the faces of women, as though it is a crime to be both a caretaker/mother and physician at the same time."

AMA urges residency programs to establish written family and parental leave policies

 covering birth, adoption, a six-week minimum leave allowance, and accommodations like modified rotations and permanent part-time scheduling, the availability of such offerings is inconsistent.

 found just eight of 15 GME-sponsoring institutions affiliated with 12 prominent U.S.-based medical schools have paid childbearing or family leave provisions for residents. Even more troubling, the 

 reports a mere 28.9 percent of physician contracts provide maternity coverage and taking leave results in an estimated $10,000 in lost income, disincentivizing this as a viable option for many females.

Women physicians are then forced to make tough decisions in an effort to achieve work-life balance.

"Many women choose to work part-time, which affects their productivity and ultimately their ability to be promoted," says Kate Killoran, MD, a board-certified OB/GYN in Camden, Maine.

Reduced work hours also limit access to leadership opportunities and curtails representation in the more competitive, time-intensive, and historically male-dominated specialties like orthopedics and neurosurgery.

The solution, Killoran says, is threefold and widely supported by physician organizations like the AMA and ACP. "[Stop] penalizing physicians who work less, [provide] universal access to paid medical and family leave, [and] expand paid leave to more than 6 weeks."

Unfortunately, pregnancy and parenting barriers and the lack of equitable leave policies are simply the workplace manifestation of a broader societal belief system – implicit gender bias.

 found 41 percent of women physicians experience gender bias compared to six percent of males. Female physicians regularly operate in less welcoming and supportive environments, which compromises their authority, promotes marginalization, and overshadows relationships with colleagues and patients.

"Women experience profound microaggressions on a daily basis," Hunt says. "There is one committee that I attend where the chair regularly refers to male committee members as 'Dr. [Last name]' while referring to each woman doctor only by her first name. This erodes the creditability and validity of the women at the table."

Hunt's experience aligns with the findings of a 

 in which Grand Rounds speaker introductions were assessed for possible gender bias. Formal titles were used less than half of the time when males introduced female speakers versus 95 percent when the roles were reversed.

"I call this form of covert discrimination the 'fallacy of familiarity,'" says Hunt, who is also an Executive Leadership Coach and works with female physicians to overcome the self-limiting beliefs of Impostor Syndrome – a condition that often occurs as a result of ongoing gender bias. "The person talking thinks that they are demonstrating rapport and friendship with the woman they are introducing, but in fact they are just invalidating them as experts and specialists. When that happens day after day, the time [females] spent in training and their level of expertise feels diminished."

Patients may also proliferate gender bias. A 

 evaluated hundreds of Press Ganey patient satisfaction surveys, and after accounting for other variables, found female OB/GYNs were 47 percent less likely to receive top satisfaction scores than their male counterparts. The inferior scores are surprising given research that patients under the care of female physicians tend to receive 

face-to-face time and enhanced patient-centered communications

lower patient mortality and readmission rates

The constant onslaught of gender bias from seemingly all directions can push women into less desirable and fulfilling roles or out of the workforce completely, potentially to the detriment of patients who miss out not only on arguably better care, but on unique perspectives too.

 "Women bring skills and viewpoints that are different, but equal to men, and for that reason our presence is essential. A practical example would be a pelvic exam," Perkins says. "A woman who has experienced that sensitive exam can be more empathetic when performing [it]."

These are intricate, complex problems with no simple solutions. The way forward, experts agree, is to expose the barriers and work toward a better balance. Actively and intentionally rooting out bias is a meaningful and critical first step, but it requires action from all sides and throughout the lifespan.

"It has to be multifaceted, [starting by acknowledging] implicit bias as early as elementary school, with special and specific training for parents [and] educators," says Perkins.

For Abada, postsecondary education is a prime time to address these sensitive topics.

"Curricula on career development and leadership should be incorporated into medical student's education [and] the notion that some specialties are well suited to males [instead of] females should be discouraged in training."

Initiatives by medical associations, accrediting bodies, employers–essentially 

 stakeholders–will be necessary to remedy the imbalance and increase retention of female talent. Introducing women by their hard-earned titles is just the start.

"Support programs for negotiation and leadership development, improve the visibility of female physicians' speaking and panel discussions [and] include women in search committees," Killoran says.

Male physicians may play the most pivotal role, Hunt says, based on a dynamic exchange she witnessed during a medical society meeting.

"A white middle-aged male, and good friend of mine, stood up and said, 'You all look pretty much the same to me. What are you going to do in your term to increase the diversity of the board? And more importantly, how are you going to support and promote people who don't look like you?' It electrified the room and [prompted us] to carefully examine the barriers to board diversity. Men of good conscious exercise their privilege to speak on behalf of those who are not speaking."

Steph Weber is an award-winning freelance journalist hailing from the Midwest. She writes about healthcare, human resources and small business.

Parental, Family and Medical Necessity Leave H-405.960

Principles for Advancing Gender Equity in Medicine

Wondering which specialties have the biggest gender imbalances? 

An Infographic: Achieving Gender Equity in Physician Compensation + Career Advancement

ACP's Top 10 Things You Can Do to Impact Gender Equity in Medicine

"Women are regularly addressed more casually and have their orders and decisions questioned by other staff or colleagues," says Killoran. "This persistent challenge to knowledge and authority adds up over time, certainly eroding confidence and potentially resulting in earlier burnout." This 

 paper elaborates on why female physicians are at higher risk for burnout.

 Pay disparities continue to plague female physicians. According to the 

, male physicians earn $1.25 for every $1 earned by female physicians, resulting in a salary difference of $90,490. Although this is an improvement over previous years, the gap still stings. "Women are paid less and get smaller bonuses even when they have more experience and better credentials," says Killoran, who advocates for pay transparency to ensure equal compensation for physicians with similar skills and credentials. The 

, discouraging financial penalties for physicians who work less than full time and recommending "

routine assessment of the equity of physician compensation arrangements by all organizations that employ physicians."  

Resources and support for female physicians 

American Academy of Family Physicians: Medical School and Residency

Executive Leadership in Academic Medicine

Executive Leadership Coaching – Dr. Jennifer Hunt

Despite promising surges in the number of female medical students, active physicians remain predominantly male. Here are insiders' thoughts on why gender inequity persists and how to find a better balance.

The systemic barriers preventing physician workforce equality 

Legislative proposals restricting abortion access have dominated the headlines this year. From a near outright abortion ban in Alabama that seeks to 

 against participating physicians to "heartbeat" bills that have been 

, abortion and reproductive rights have been at the center of a constitutional firestorm.  

The American Medical Association (AMA) has recently intervened by 

filing a lawsuit that challenges two North Dakota laws

, alleging they are politically motivated and force physicians to "provide patients with false, misleading, non-medical information about reproductive health." The laws require physicians to inform patients that abortions performed via the administration of medications are reversible - a claim for which there is no scientific backing - and that abortion terminates "the life of a whole, separate, unique, living human being," which crosses into forbidden ideological territory.

While most of these proposals will endure months, if not years, of litigation and appeals before they can fully impact patients, they represent an opportunity for primary care physicians (PCPs), regardless of geographic location and opinions on abortion, to transform a deeply polarizing issue into a commitment to provide extensive, evidence-based reproductive health education to patients - a move that preserves patient autonomy and reduces the likelihood patients will ever face a difficult abortion decision or fall prey to reckless misinformation campaigns.

With nearly half of all pregnancies unintended, according to research by 

, the scope of reproductive rights and access to associated services like abortion and birth control remain prominent public health issues. A renewed and focused push for earlier, targeted interventions as well as wide accessibility to family planning and sexual well-being tools, resources and education could potentially shift the entire dynamic of care.  

Here's how PCPs can adopt a comprehensive, nonjudgmental and patient-centered approach to sexual health, conception and even abortion - independent of political influences.

As cradle-to-grave caregivers, PCPs are arguably the most influential healthcare provider over the course of patients’ lifespan. This ongoing relationship is ideal for identifying the wide-ranging reproductive care needs of patients, with pregnancy prevention accounting for only a portion of those services.     

"In order to truly provide comprehensive care, primary care physicians must recognize the importance of meeting patients' sexual and reproductive health needs across the reproductive life course, from sex education to family planning to infertility to menopause," says Christine Dehlendorf, MD, MAS, a board-certified family medicine physician, member of the 

Person-Centered Reproductive Health Program

. "While some of these services may be provided by obstetrician/gynecologist colleagues, it is still the responsibility of the primary care physician to make sure that these needs are being met holistically."

To that point, many family physicians are already operating within their full scope of practice by prescribing birth control, providing family planning support, performing pelvic exams and vasectomies and screening for and treating sexually transmitted infections (STIs). This follows the guidelines from the 

American Academy of Family Physicians (AAFP)

, which encourage a well-rounded approach to patient education, encompassing everything from contraception and abstinence to sterilization, counseling and emergency contraception care. 

Despite such efforts, PCPs may still underestimate the need for clear and targeted conversations with their patients about reproduction.

"I'll be honest. I don't always think about [family planning and reproductive health] as a discrete entity," says Jennifer Caudle, DO, a board-certified osteopathic family medicine physician in Sewell, N.J., and associate professor in the department of family medicine at 

Rowan University-School of Osteopathic Medicine

. "[Reproductive health] is an important life stage for our patients, [so we need to] make sure that we're [having] this conversation, providing options and supporting them through their journey - not ignoring the issue or failing to bring it up. [This] is a good reminder for us to be engaged and do more [for our patients]."

Experts say that early intervention starting in adolescence and continuing through adulthood can be key to establishing more favorable outcomes, particularly when physicians find ways to check in with patients frequently. "These conversations take less time than we think because our patients know a lot already," says Glenna Martin, MD, a board-certified family medicine physician in Seattle, Wash., and fellow with 

 (PRH). "Primary care providers are creative problem-solvers, so whether [it's] adding a question on the intake form, putting more posters in your office to remind you and patients to talk about reproductive health or a flag in the EHR, everyone can find the solution that works best for them."

Starting this dialogue early with adolescents and young adults can drastically decrease unintended pregnancy rates, as demonstrated by the success of the 

. The initiative, launched in 2009, made low- and no-cost long-acting reversible contraceptives (LARCs) along with additional educational and health services available to low-income women throughout the state via Title X family planning clinics. By 2014, both birth and abortion rates declined by nearly 50 percent for participants aged 15-19 and 20 percent among those aged 20-24.

While such a program may be difficult to mimic in day-to-day primary care practice, annual well child visits offer built-in face-to-face encounters ideal for the provision of sexual health and contraceptive education. The 

 suggests using motivational interviewing to help young patients talk through their feelings on sexuality, brainstorm solutions that suit their lifestyle and deepen engagement and trust along the way. For those patients who do not wish to practice abstinence, the AAP recommends using LARCS as the first-line contraceptive choice.

The level of parental involvement during these encounters varies. "It's very, very individual [and] goes both ways," Caudle says. "Often, I'll ask the parents to step out, so I can have a private conversation with the child." Other times, parents are the ones inquiring about contraceptives on the child's behalf.

Since birth control does not provide adequate protection against sexually transmitted infections, reiterating condom usage and benefits as part of any contraceptive conversations is warranted as well. Regardless, physicians must carefully navigate these situations and follow their state's confidentiality laws to ensure the preservation of minor patients' privacy.

By and large, females of reproductive age have typically been the core focus of pregnancy risk screenings and reproductive health initiatives. "Primary care physicians have been encouraged to ask any reproductive aged woman they see: Do you plan to get pregnant in the coming year?" says Ingrid Skop, MD, an OB/GYN in San Antonio and chairman-elect of the 

American Association of Pro-Life Obstetricians & Gynecologists

 (AAPLOG). While these efforts shouldn't be abandoned, this type of narrow approach may only address one subset of patients, leaving others without access to critical services and counseling.

One often underserved demographic is male patients. "I think it would be useful for PCPs to ask a variation of the pregnancy question to men: Are you in a relationship? Do you and your partner desire pregnancy this year? Are you using effective contraception? Are you having sexual intercourse outside of a relationship?" Skop says. Discussing the risks associated with sexual activity such as unintended partner pregnancy and STIs can be empowering. "As a society, we need to help men feel included and engaged, [especially] in the event a woman becomes pregnant."

September 2016 position paper by the AAFP

 expa nded previous practice guidelines and preconception interventions for men with a goal "to ensure positive outcomes of their reproductive and sexual behaviors while minimizing negative consequences of unhealthy lifestyle choices." Male counseling and care should cover contraceptive methods, fertility issues and overall wellness. It should also offer guidance on how to support partners during pregnancy and postpartum recovery as well as the impact smoking and STIs may have on a partner's health.  

An even more expansive approach, one that requires a shift in clinical theory and practice, is to address the specific reproductive health of 

 patients, regardless of gender and orientation. To encourage this transition, the 

The surge in restrictive abortion legislation is a timely reminder that physician-led reproductive health and family planning education can significantly impact patient decisions and outcomes. Here's how to start the conversation.