Stanford Medcast Episode 48: Physician Distress Mini-Series - Championing Legislation to Prevent Physician Suicide

Ruth Adewuya, MD: Hello, you're listening to Stanford Medcast, Stanford series podcast where we bring you insights from the world's leading physicians and scientists. If you're new here, consider subscribing to listen to more free episodes coming your way. I am your host, Dr Ruth Adewuya.

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Ruth Adewuya, MD: This episode is part of our Physician Distress mini-series, and today's episode is a conversation with Corey Feist. Corey Feist is a co-founder of the Dr Lorna Breen Heroes Foundation. He earned his master's in business administration from the UVA Darden School of Business, his Juris Doctorate from Penn State Dickinson School of Law, and his bachelor's degree from Hamilton College. He has over 20 years of experience in health care leadership and he recently served as the chief executive officer of the University of Virginia Physician Group, the medical group practice of UVA Health, comprised of over 1200 physicians and advanced practice providers.

He has also authored numerous publications on the need to support the wellbeing of the health care workforce and served as an expert in multiple forums, including as a keynote speaker and panelist. Thanks for chatting with me today, Corey.

J. Corey Feist JD, MBA: It's truly my pleasure to be here. Thanks for having me.

Adewuya: We should jump right in and just acknowledge that the practice of medicine involves this hidden culture. Aspects such as clinical pressures and expectations beyond the establishment of wellness programs. What do you believe should be done systematically across health systems or via the legislature to prevent physician suicide rates from increasing?

Feist: Thank you for that question. You have at least two things happening in the health care workforce right now to their well-being, and one is this conversation around burnout, which is an occupational syndrome, and then on the other side you have mental health conditions like depression, things that cause suicide. When you look at the data from the American Medical Association experts on this subject, while burnout can contribute to depression and depression is a risk factor for suicidal ideation, most physicians who experience burnout do not experience depression. I want to make sure that as we go into this conversation, we're super crisp with our language here.

You really have two things here that are two distinct issues. I believe, however, that when we talk about the solutions, there's a Venn diagram. And in that Venn diagram, on the left side you've got the burnout side and on the right side you've got the depression and mental health issues. When you talk about burnout, there are systems solutions and there are individual solutions. On the right side of that, when you look at suicide prevention and you look at what needs to happen, there are at least three things that I'm going to point to. One is removing barriers to accessing mental health care.

We could talk a lot about that because we've been really deeply evolved. Training in suicide prevention, creating pathways to access care free of stigma. In the middle of that Venn diagram, leadership of health systems and the culture of medicine, benefits both the burnout conversation and the depression conversation.

I hope that made sense in terms of just setting a framework here for a conversation around depression and suicide prevention because that to me is the right side of this Venn diagram and it includes prioritizing these issues in health systems, the culture within health care delivery, being supportive of being able to take a break, be supporting yourself and colleagues when they seem to be suffering or even when they look like they're having a fine day, creating a supportive culture where we're just checking in on each other and we're saying, "Hey, Ruth, how was your weekend? No, how was your weekend really? Or how are you doing today really?"

And then there's a lot of very tactical work that we can do here to prevent suicide by removing barriers to mental health access. I'm hearing so many stories about how training on suicide prevention is life saving. If you think about it, or at least as I've thought about it, in one way, leave a safe place to come at the conversation because it gives tools to clinicians who are used to diagnosis treatment. What I'm hearing is that's exactly what's happening. Nurses and doctors who are trained in suicide prevention are looking around and they're seeing symptoms in their colleagues and they're intervening and they're saving lives that way.

Maybe this is an interesting way to get into this very stigma infused conversation by let's give people tools around diagnosis and treatment. You don't even have to talk about the stigma piece. You're just having people who are trained in diagnosis treatment apply their skills in this domain. The byproduct of that is that it saves lives and at the same time elevates and changes the culture to one that's accepting of the recognition that people need to take a break. People who have mental health conditions are people like you and me and they can be and are amazing physicians and clinicians and if treated, just like any other condition, will be thriving in their profession and in their personal life.

Adewuya: I am so glad that you responded to my question with the framework. There's so much to unpack with what you said, and I know that we'll touch on a few of them as we have our conversation, but one of the things that I'll start with is when you said addressing stigma of the conversation. When we think about the factors that prevent health care workers from seeking help, I think you would agree that the stigma is one of those. How do we mitigate the factors that prevent health care workers from seeking help?

Feist: I'm going to come back to culture. There are barriers to seeking mental health treatment that are real for doctors and nurses across this country and other health care professionals. Six of those barriers we identified in 2021 in an article published in U.S. News & World Report because based on our work as a foundation we just heard, the first four are exactly the same issue, which means the solution is exactly the same. Those are questions that appear on different kinds of applications that doctors and nurses have to fill out to get a job in a hospital, to get paid by an insurance company, to get covered by malpractice insurance, to getting license to practice medicine or nursing.

There are questions that exist in those applications which go far beyond the bounds of the Americans with Disabilities Act and ask questions beyond what is acceptable frankly. Another way to say that is you have a lot of questions out there that are literally violating the law and therefore could be addressed and mitigated. What we've done on our website at drlornabreen.org is we've created a free toolkit which can be used by anyone and ask people to do three things. First, audit questions that appear in any of these applications. The second, change them and we've given some criteria for what's successful.

And then the third and importantly, we need to communicate to the workforce that these barriers are now removed, because they're perceived very highly as barriers. That's a cluster of four. And then the other two, I'll quickly touch on, in many states, a doctor's own mental health medical record can be subpoenaed when that doctor's being sued for malpractice, which to me is unbelievable, mind-boggling, and perverse. There are programs like in Virginia that are called Safe Haven programs where that record is maintained confidentially. The final I'll point out as a barrier is brought to our attention by the widow of a physician who died by suicide in the last year and a half.

This physician named Dr Scott Jolley was limited by his own health plan that he had on his insurance card. He could only use the services of the hospital that he worked at. A lot of hospitals in this country for business purposes either incent their workforce to use their own services or they require it. And that makes a lot of sense from a business perspective. However, when you talk to the widow of Scott Jolley, she would say that limiting Scott's ability to only go to get mental health care at his own hospital was really what contributed to his decision to take his own life because he was literally wheeled by his colleagues when he was discharged and it was just too much to bear.

Health plan design and changing the health plan design is that sixth barrier. I've just given you some real tactical things that we need to address. From a culture perspective, this is one that the workforce needs to own. And to me, what needs to happen here is that behavior needs to be modeled at all levels. This needs to be top down and bottom up. If I've heard it once, I've heard it literally a thousand times, that when medical students become residents, all of a sudden have this big wake up call, they call it the shadow curriculum, where all of a sudden they see behavior modeled that is I'll just say not healthy.

That is something that is actionable by the workforce. To me, it starts in small steps where the health care workforce just starts to check in on each other and creates a culture of acceptance, of just I have permission to ask you if you're okay and if you need help and you have permission to answer me that you're not doing perfectly well today. And that is a sign of strength. I think it's little steps like that. When I look at any of these problems, I look at trying to get upstream of the problem.

Another very important tactic that I think we need to implore here when it comes to preventing suicide is getting into the curriculum of medical schools, nursing schools and all health care professional schools the training on how to appropriately, and by that I mean in a healthy way, manage the adverse events and issues that you're going to see in your career. And that is, one, again, at a very tactical level, if there are curriculum out there where that is being trained on, that is another one here where we focus on it and we train on it.

Adewuya: The things that I keep hearing you say, removing the stigma, asking for help is strength, which in some ways cuts against some of the perfectionism, whether it's a standard that physicians make for themselves or a standard that the institutions make for physicians, and that you layer on top of that the pandemic and its impact on physician distress, physician mental health issues. What were some of the learnings that you're seeing that has come out from this pandemic about physician distress, physician wellness, physician suicide prevention?

Feist: As I've spoken with addiction experts across the country, what I've heard is that during the pandemic, the health care workforce really had a significant rise in addiction and substance abuse. When you realize that they've experienced repetitive trauma basically for now the last couple years and have these barriers to getting mental health access, they can't go to a therapist, they can't do that stuff, what are they going to do? I mean, they're human, right? I think that there are so many known triggers for trauma that doctors and nurses are going to see in their career. Let's recognize it and let's train people on how to deal with it in an appropriate and a healthy way.

I think it's important to contrast this with a professional athlete for a minute. When a professional athlete plays a sport, they are playing at the highest level of their game. And when they're doing that, errors are really not well received and they are literally on television for millions to watch. Before an athlete plays in a game at a professional level, that athlete is well trained. They're well fed. They're well-nourished. Hopefully they've slept. They are looking out for their physical and mental health so that they can perform a technical task under extreme pressure and get it right 99.9% of the time.

In contrast to that model, we asked an already burnt out workforce to run a marathon on one leg without a clear finish line, without the appropriate sustenance. We have to approach this entire answer by saying that there is nothing wrong with seeking perfection. There is nothing wrong with trying to be the best at your game. What the pandemic has shined a light on is that the circumstances by which we hold physicians and nurses and other health care professionals to that standard, their work environment, their conditions, do not actually allow them to do that on a regular basis.

What you've seen is this massive walkout now, heavily on the nursing side, but you're seeing it also on the physician side too, which is that the environmental factors are not keeping up with just human needs to be able to perform at a high level. I would say as an overarching statement, that is a fundamental issue here is that you have a malnourished, if you will, fully depleted workforce who you're still holding to standards that are not reasonably achievable if we were to think about them as professional athletes. In contrast, you have someone who's in a human's brain in a microsurgery, I don't know what's more high performance than that.

That person should be well fed, that person needs sleep, but we've created an environment where you're guaranteed to fail. Holding them to an unrealistic expectation is an attitudinal adjustment that we need to make. If the workforce is not taken care of, how can they take care of patients in a highly compassionate, high quality manner? The answer is they can't do it consistent. And that's been my big revelation. The other piece, which is becoming increasingly aware, is while these health systems are putting support in place, mostly on the individual level, there is still a gap in understanding by the workforce as to what's being done.

Even if they're doing a systems change, or they're trying to optimize an electronic medical record, or they're actually offering services that the workforce will use to support themselves, there's a big gap in understanding that these things are in process and exist.

Adewuya: I think this is a great place in our conversation to talk about the Lorna Breen Foundation and to talk about the work that your foundation is doing with grassroots advocacy. What are some of the policy initiatives that your foundation is involved in that addresses this topic?

Feist: We've been working at a federal and state level to bring resources to this issue and to eliminate barriers to mental health access. Prior to March 18th, 2022, there wasn't this thing called the Dr Lorna Breen Health Care Provider Protection Act. But luckily on March 18th, 2022, President Biden signed into law the first ever law that's focused on supporting the well-being of the health care workforce. And what it's doing is it's building the first few steps of an entire staircase of health policy that I think needs to come into play to support the well-being of the health care workforce. It's doing that by creating programs at training institutions and at non-training institutions to support the workforce.

It's doing that by creating a national awareness campaign focused on employers and on individuals on what they need to do to be supported from a systems perspective. It's creating a study to help us build further steps on this staircase. That's at a federal level. At a state level, what we're really focusing on are removing these barriers to mental health access, first and foremost. In the 50 states that we have and territories and then, as I said earlier, with that Safe Haven law, there are states that make available to a plaintiff the mental health medical record of a physician who's being sued for malpractice.

There are different protections that can be plugged in place so that those interests are protected there. From a policy perspective, it is scaling those safe haven laws. It is eliminating those barriers to mental health access, and it is building this federal staircase of support and a nationwide community of sharing of best practices and really then scaling those best practices and incorporating those best practices into hospital operations so that the workforce can thrive.

Adewuya: I want to take a step back before I continue talking about the work of your foundation. You've talked about the questions. Can you elaborate, what are these questions that you've been referring to?

Feist: Absolutely. In September of 2021, we published an article in U.S. News & World Report which identifies six barriers to mental health access. The first four are questions that ask about any prior mental health treatment or go beyond anything that is currently impairing an individual, whether that be a physical impairment or a mental impairment. The fact that those questions exist, that are a barrier to doctors and nurses obtaining mental health care. To put in a much finer point on it, in January of 2022, Medscape released a physician burnout and depression report and they asked physicians, "Why have you not sought help for burnout or depression?"

The number one barrier that those individuals identified is they do not want to risk disclosure to a medical board. They also identified concerns about being on their insurance record, concerns about then colleagues finding out culturally. But the workforce has identified this as an issue. In my sister-in-law's case, these barriers did not exist in the State of New York, but she was so convinced because culturally, everyone knows if you're a doctor, you can't do this. She got mental health treatment one time in her whole life.

And after she got it, when we got her out of New York, she told us now she was going to lose her job and her license and all these other things, and then she decided to die by suicide very closely after she told us about that. Because she was incorrect, one of the big pieces of this, as you're going to hear me say over and over again, is we have to communicate what the rules are, particularly when the rules are fine, like they were on Lorna's case. She wasn't going to have any of that, but she was convinced she was.

There are so many doctors out there that are convinced, which is why we created a toolkit, which is on our website at drlornabreen.org, which walks organizations through how to do this in that three step process that I was talking about before. We know that it's taking hold. States are adopting this toolkit. Organizations are adopting the toolkit. It's amazing to watch how many downloads of this toolkit are happening.

Adewuya: Thank you for sharing your story and your sister-in-law story. I hope by the time the listeners finish this episode, that they are hearing the message that you're sending. The theme is the culture from medical school to when you're in your organization and your private practice and for health systems to be able to communicate what can and cannot happen when you seek help. And then for the barriers, the questions that shouldn't be asked and all of that and knocking down those ones so that it's not a barrier to clinicians to seek help.

I think that's phenomenal. I want to also talk about the documentary, The First Wave. In what ways do you think that documentary has educated the general public, and how did the Dr Lorna Breen Foundation play a role in that documentary?

Feist: The documentary is an unbelievable window into what the health care workforce has experienced during the pandemic. They didn't just experience that on one day. They experienced it every day for years. When Participant Media and National Geographic came to us before they released the film, they told us that they always have an impact campaign associated with their films. They were looking for some advice about what that impact campaign should be. We said after we looked at the film and heard about... Actually at that point, I'd only seen the trailer because it was really hard to watch it for our family.

My sister-in-law had trained in the hospital that the movie was in and she was in New York in a different hospital, but it was just too hard and it was too soon. Nonetheless, after just looking at the trailer, speaking with Participant Media, what we said was this is a movie about the impact of the pandemic on the workforce. We suggest two things. The first is the workforce needs to be able to process this. They need to be able to process openly what they've seen or privately in small groups, but they need an outlet and they need some help doing it.

One of the things that we did with their help was we developed a curated discussion guide that could be utilized by any organization and viewing rights for any individual organization who wants to take a look at the movie. Now it's on Hulu and a lot of people have subscriptions to Hulu. But for those who don't and for organizations who don't, they can go on our website and they can fill out a form and they can get screening rights for this movie for free. They can use this discussion guide. That was an impact of our work and that was partnership. The other thing that they did was they used their resources to help us knock out these licensure questions.

I give them a tremendous amount of credit for helping us work through the process to go through all these state applications and get them and make freedom of information requests for them and do all that work. In fact, on this year's National Physician Suicide Awareness Day, we're going to be publishing a new map of the country that they helped us implement. The First Wave as a movie is an unbelievable view of what happened. I think everybody needs to know what has happened to the workforce to get the perspective that we need to take care of them.

Adewuya: It sounds like your foundation is really tapping into much needed areas from the federal, the state level. I'm curious, as you look into the future of your foundation, what's a plan to continue this? What's next for the foundation?

Feist: Oh, we have a great plan. Thank you for that question. It was like I wrote it for you, but I didn't. I promise audience, I didn't. During this work, we have found a number of really amazing partners, and one of our greatest partnerships has been with The Schwartz Center for Compassionate Healthcare, which is based in Boston. It's a global nonprofit. Many people are aware of Schwartz Rounds is part of their programming. The Schwartz Center came to us in the last six months and said, "Why don't we partner?" We are very excited that starting in the fall of 2022, we will be partnered with them. Both organizations will come together.

We are going to be doing this work around the globe and really focusing of those areas of individual health care worker support, systems change. In addition to that, let me just say one other thing, and this has been a real differentiator for us. We have had conversations in the general public about topics that have never been in the general public or have rarely been in the general public. We have partnered with the entertainment industry in Hollywood. We will continue to do that work. As a direct result of our work with the entertainment industry, we will continue to try to incorporate into popular culture the needs of the health care workforce.

Because thus far, all you know is what you see on television about doctors. You're never really in there, unless you watch The First Wave with these show creators so that they can prioritize into these television shows so that a lot of other people need to understand this. We're not just speaking within health care, but we're speaking about health care outside of the traditional health care domain.

Adewuya: I think that's very important and that's why we're having this conversation here in this platform, reaching the audience in multiple ways. Some people are podcast listeners. Some people watch shows. Some people read, and some people watch movies. Wherever the word can be spread about this important topic, that's such a great idea. I want to wrap up our conversation by focusing on some practical ways and things that clinicians can think about. For clinicians who might understand that they need help, but are afraid of job repercussions or things like that, what are some resources or what is a path of action that you would recommend?

Feist: It depends a little bit on what type of health care worker we're talking about. The first thing I think people need to recognize is that your local institution is going to be well positioned to provide very timely resources. Employee Assistance Programs are underutilized by physicians in particular. They're not so much other parts of the health care workforce. I would go to your local EAP program. There are a number of free resources that are out there. The National Alliance on Mental Illness, NAMI, has a whole health care workforce page of resources.

There are a number of organizations like Therapy Aid and the Physician Support Line, which are virtual basically counseling sessions and services. I should say, one of the things this country is very lucky to have now is the National Suicide Prevention number that's just like 911, but it's 988. And that launched this summer. If somebody's worried about another person and you're not really sure what to do, just call 988. You just pick up the phone, you call, and they can help you navigate it, because it's not always clear where to go.

The last thing I would say is that in order to do your best, you've got to take care of yourself. You've got to get sleep. You've got to be fed. You've got to do all of those other things on a personal level. Try to do those.

Adewuya: What a great way to end this conversation. I just want to say thank you so much for chatting with me. Thank you for sharing your insights, your story, and really thank you for the work that you're doing, that you're continuing to do. It's just been a pleasure being able to amplify the work that you're already doing and to encourage others to also consider doing the same.

Feist: We are so grateful and it's really a pleasure. If folks are interested in more information, our contact information is on our website, drlornabreen.org. If folks want to get involved, we welcome all individuals who are interested in helping. Even if we never hear you, use that toolkit, get it out there, and make the landscape a different one for your colleagues and the future generations.

Adewuya: Thanks for tuning in. This episode was brought to you by Stanford CME. To claim CME for listening to this episode, click on the claim CME link below, or visit medcast.stanford.edu. Check back for new episodes by subscribing to Stanford Medcast wherever you listen to podcasts.

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Ruth Adewuya, MD, CHCP

Managing Director, Center for Continuing Medical Education

Stanford University School of Medicine

Course Director

J. Corey Feist, JD

Faculty

Jayzona Alberto, EdD

Assistant Director, Center for Continuing Medical Education

Stanford University School of Medicine

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Magna Patel, MD

RSS Manager, Center for Continuing Medical Education

Stanford University School of Medicine

Planner

Ishita Verma

Student

Stanford University

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Rokeena Williams, CHCP, CMP

eLearning Manager, Center for Continuing Medical Education

Stanford University School of Medicine

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