Business of Medicine

What could you do with $18 billion?

I could pay off my mortgage roughly 60,000 times, or take my wife on a never-ending world cruise so we don’t need a mortgage, or at least hire someone to clean my pool regularly so I don’t have to.

A recent report from the OIG found that, in the last 3 years, the Centers for Medicare & Medicaid Services spent $18 billion on drugs for which there’s no proof of significant clinical benefit.

That’s a lot of money on things that may or may not be placebos, some of which are WAY overdue on Food and Drug Administration–mandated efficacy studies. A few have even been on the market so long that they’ve become equally unproven generics.

Now, if you put this in the big picture, that immense amount of money is still only 2% of their total spending in health care. Hell, probably at least 2% of my personal spending is on pointless things, too. So, realistically, you could say 98% of CMS spending is on worthwhile care, which is as it should be.

But the bottom line is that $18 billion is still a lot of money if it’s being spent on fruitless treatments. I’m sure it could be better used in many other programs (refunding it to taxpayers comes out to maybe $55 for each of us, which probably isn’t worth the effort).

As pointed out in the movie “Dave,” shoving that kind of money in even a low-yield savings account would generate at least $180 million in interest each year.

That’s a lot of money, too, that could be used for something. Of course, no one in the government thinks that way. That’s why we all loved the movie.

The problem is that the phrase “no proof of significant clinical benefit” doesn’t mean something doesn’t work. It just means we aren’t sure. Some of those people on one of these drugs may be getting benefit – or not. After all, the placebo effect is remarkably strong. But if they are helping someone, who wants to be the one to tell them “we’re not going to pay for this anymore?”

Another issue is this: Let’s say the drugs only work for 10% of the people who take them ($1.8 billion worth), and for the other 90% it’s iffy ($16.2 billion worth), but the latter want to stay on them anyway, just to be sure. Do we cut them? Or just say that $18 billion is too much money when only 10% are being helped, and cut them all off? I’m sure we could use the money elsewhere (see “Dave” above), so let them find a way to work it out with the manufacturer. The greatest good for the greatest number and all that jazz.

I don’t know, either. Health care dollars are finite, and human suffering is infinite. It’s a balancing act that can’t be won. There are no easy answers.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

What could you do with $18 billion?

I could pay off my mortgage roughly 60,000 times, or take my wife on a never-ending world cruise so we don’t need a mortgage, or at least hire someone to clean my pool regularly so I don’t have to.

A recent report from the OIG found that, in the last 3 years, the Centers for Medicare & Medicaid Services spent $18 billion on drugs for which there’s no proof of significant clinical benefit.

That’s a lot of money on things that may or may not be placebos, some of which are WAY overdue on Food and Drug Administration–mandated efficacy studies. A few have even been on the market so long that they’ve become equally unproven generics.

Now, if you put this in the big picture, that immense amount of money is still only 2% of their total spending in health care. Hell, probably at least 2% of my personal spending is on pointless things, too. So, realistically, you could say 98% of CMS spending is on worthwhile care, which is as it should be.

But the bottom line is that $18 billion is still a lot of money if it’s being spent on fruitless treatments. I’m sure it could be better used in many other programs (refunding it to taxpayers comes out to maybe $55 for each of us, which probably isn’t worth the effort).

As pointed out in the movie “Dave,” shoving that kind of money in even a low-yield savings account would generate at least $180 million in interest each year.

That’s a lot of money, too, that could be used for something. Of course, no one in the government thinks that way. That’s why we all loved the movie.

The problem is that the phrase “no proof of significant clinical benefit” doesn’t mean something doesn’t work. It just means we aren’t sure. Some of those people on one of these drugs may be getting benefit – or not. After all, the placebo effect is remarkably strong. But if they are helping someone, who wants to be the one to tell them “we’re not going to pay for this anymore?”

Another issue is this: Let’s say the drugs only work for 10% of the people who take them ($1.8 billion worth), and for the other 90% it’s iffy ($16.2 billion worth), but the latter want to stay on them anyway, just to be sure. Do we cut them? Or just say that $18 billion is too much money when only 10% are being helped, and cut them all off? I’m sure we could use the money elsewhere (see “Dave” above), so let them find a way to work it out with the manufacturer. The greatest good for the greatest number and all that jazz.

I don’t know, either. Health care dollars are finite, and human suffering is infinite. It’s a balancing act that can’t be won. There are no easy answers.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

What could you do with $18 billion?

I could pay off my mortgage roughly 60,000 times, or take my wife on a never-ending world cruise so we don’t need a mortgage, or at least hire someone to clean my pool regularly so I don’t have to.

A recent report from the OIG found that, in the last 3 years, the Centers for Medicare & Medicaid Services spent $18 billion on drugs for which there’s no proof of significant clinical benefit.

That’s a lot of money on things that may or may not be placebos, some of which are WAY overdue on Food and Drug Administration–mandated efficacy studies. A few have even been on the market so long that they’ve become equally unproven generics.

Now, if you put this in the big picture, that immense amount of money is still only 2% of their total spending in health care. Hell, probably at least 2% of my personal spending is on pointless things, too. So, realistically, you could say 98% of CMS spending is on worthwhile care, which is as it should be.

But the bottom line is that $18 billion is still a lot of money if it’s being spent on fruitless treatments. I’m sure it could be better used in many other programs (refunding it to taxpayers comes out to maybe $55 for each of us, which probably isn’t worth the effort).

As pointed out in the movie “Dave,” shoving that kind of money in even a low-yield savings account would generate at least $180 million in interest each year.

That’s a lot of money, too, that could be used for something. Of course, no one in the government thinks that way. That’s why we all loved the movie.

The problem is that the phrase “no proof of significant clinical benefit” doesn’t mean something doesn’t work. It just means we aren’t sure. Some of those people on one of these drugs may be getting benefit – or not. After all, the placebo effect is remarkably strong. But if they are helping someone, who wants to be the one to tell them “we’re not going to pay for this anymore?”

Another issue is this: Let’s say the drugs only work for 10% of the people who take them ($1.8 billion worth), and for the other 90% it’s iffy ($16.2 billion worth), but the latter want to stay on them anyway, just to be sure. Do we cut them? Or just say that $18 billion is too much money when only 10% are being helped, and cut them all off? I’m sure we could use the money elsewhere (see “Dave” above), so let them find a way to work it out with the manufacturer. The greatest good for the greatest number and all that jazz.

I don’t know, either. Health care dollars are finite, and human suffering is infinite. It’s a balancing act that can’t be won. There are no easy answers.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Incentive bonuses have long been part and parcel of many physicians’ compensation packages. They allow doctors in some specialties to boost their compensation by tens of thousands of dollars.

Often tied to metrics that doctors must hit, incentive bonuses aren’t without controversy. Some physicians welcome them. Others feel burdened by them or think that metrics distract from best patient care.

A recent Medscape poll asked what physicians think about incentive bonuses and whether or not tying metrics to salary is an outdated practice that interferes with the integrity of a physician’s job or contributes to excellence in patient care and increased productivity.

Here is what 406 physicians who answered the poll, which ran from Aug. 17 to Sept. 1, had to say about incentive bonuses:

More than half the physicians polled (58%) received an incentive bonus in 2021. Of those who received a bonus, 44% received up to $25,000. Almost 30% received $25,001-$50,000 in incentive bonus money. Only 14% received more than $100,000.

When we asked physicians which metrics they prefer their bonus to be based on, a large majority (64%) agreed quality of care was most relevant. Other metrics that respondents think appropriate included professionalism (40%), patient outcomes (40%), patient satisfaction (34%), patient volume (26%), market expansion (7%), and other (3%).
 

The problem with bonuses

Once thought to improve quality and consistency of care, incentive bonuses may be falling out of favor. Developing, administrating, and tracking them may be cumbersome for the institutions that advocate for them. For instance, determining who gave quality care and how to measure that care can be difficult.

What’s more, some top health care employers, Mayo Clinic and Kaiser Permanente, have switched from the incentive bonus model to straight salaries. Data show that the number of tests patients have and the number of treatments they try decreases when doctors receive straight salaries. 

In fact, 74% of the polled physicians think that bonuses can result in consequences like unnecessary tests and higher patient costs. Three-fourths of respondents don’t think incentives improve patient care either.

Physicians have long thought incentive bonuses can also have unintended consequences. For example, tying a physician’s monetary reward to metrics such as patient outcomes, like adherence to treatment protocols, may mean that noncompliant patients can jeopardize your metrics and prevent physicians from getting bonuses.

A Merritt Hawkins’ 2019 Review of Physician and Advanced Practitioner Recruiting Incentives found that 56% of bonuses are based in whole or in part on metrics like a patient’s adherence.

Additionally, tying monetary rewards to patient volume encourages some physicians to overbook patients, work more and longer hours, and risk burnout to meet their bonus criteria.

When we asked how hard it was to meet metrics in the Medscape poll, 45% of respondents who receive incentive bonuses said it was somewhat or very difficult. Only 9% consider it very easy. And 71% of physicians say their bonus is at risk because of not meeting their metrics.

Not surprisingly, large pay-for-performance bonuses are only offered to certain specialists and physician specialties in high demand. An orthopedist, for example, can earn up to an average of $126,000 in incentive bonuses, while a pediatrician brings in an average of $28,000, according to the Medscape Physician Compensation Report 2022.

Yet physicians are still torn

Despite these negatives, physicians are split about whether bonuses are good for doctors. The poll shows 51% said no, and 49% said yes. Further, physicians were split 50-50 on whether the bonus makes physicians more productive. Interestingly though, 76% think the bonus compensation method should be phased out in favor of straight salaries.

But many physicians may welcome the “lump sum” nature of receiving large bonuses at certain times of the year to help pay off student loan debt or other expenses, or are just comfortable having a bonus.
 

Financially speaking

If you have the choice, you may fare better by taking a higher salary and eliminating a bonus. Receiving your pay throughout the year may be preferable to receiving large lump sums only at certain times. Another thing to remember about your incentive bonus is that they are sometimes taxed more heavily based on “supplemental income.” The IRS considers bonuses supplemental to your income, so they may have a higher withholding rate, which can feel penalizing. You may have noticed the extra withholding in your last bonus check.

A version of this article first appeared on Medscape.com.

Incentive bonuses have long been part and parcel of many physicians’ compensation packages. They allow doctors in some specialties to boost their compensation by tens of thousands of dollars.

Often tied to metrics that doctors must hit, incentive bonuses aren’t without controversy. Some physicians welcome them. Others feel burdened by them or think that metrics distract from best patient care.

A recent Medscape poll asked what physicians think about incentive bonuses and whether or not tying metrics to salary is an outdated practice that interferes with the integrity of a physician’s job or contributes to excellence in patient care and increased productivity.

Here is what 406 physicians who answered the poll, which ran from Aug. 17 to Sept. 1, had to say about incentive bonuses:

More than half the physicians polled (58%) received an incentive bonus in 2021. Of those who received a bonus, 44% received up to $25,000. Almost 30% received $25,001-$50,000 in incentive bonus money. Only 14% received more than $100,000.

When we asked physicians which metrics they prefer their bonus to be based on, a large majority (64%) agreed quality of care was most relevant. Other metrics that respondents think appropriate included professionalism (40%), patient outcomes (40%), patient satisfaction (34%), patient volume (26%), market expansion (7%), and other (3%).
 

The problem with bonuses

Once thought to improve quality and consistency of care, incentive bonuses may be falling out of favor. Developing, administrating, and tracking them may be cumbersome for the institutions that advocate for them. For instance, determining who gave quality care and how to measure that care can be difficult.

What’s more, some top health care employers, Mayo Clinic and Kaiser Permanente, have switched from the incentive bonus model to straight salaries. Data show that the number of tests patients have and the number of treatments they try decreases when doctors receive straight salaries. 

In fact, 74% of the polled physicians think that bonuses can result in consequences like unnecessary tests and higher patient costs. Three-fourths of respondents don’t think incentives improve patient care either.

Physicians have long thought incentive bonuses can also have unintended consequences. For example, tying a physician’s monetary reward to metrics such as patient outcomes, like adherence to treatment protocols, may mean that noncompliant patients can jeopardize your metrics and prevent physicians from getting bonuses.

A Merritt Hawkins’ 2019 Review of Physician and Advanced Practitioner Recruiting Incentives found that 56% of bonuses are based in whole or in part on metrics like a patient’s adherence.

Additionally, tying monetary rewards to patient volume encourages some physicians to overbook patients, work more and longer hours, and risk burnout to meet their bonus criteria.

When we asked how hard it was to meet metrics in the Medscape poll, 45% of respondents who receive incentive bonuses said it was somewhat or very difficult. Only 9% consider it very easy. And 71% of physicians say their bonus is at risk because of not meeting their metrics.

Not surprisingly, large pay-for-performance bonuses are only offered to certain specialists and physician specialties in high demand. An orthopedist, for example, can earn up to an average of $126,000 in incentive bonuses, while a pediatrician brings in an average of $28,000, according to the Medscape Physician Compensation Report 2022.

Yet physicians are still torn

Despite these negatives, physicians are split about whether bonuses are good for doctors. The poll shows 51% said no, and 49% said yes. Further, physicians were split 50-50 on whether the bonus makes physicians more productive. Interestingly though, 76% think the bonus compensation method should be phased out in favor of straight salaries.

But many physicians may welcome the “lump sum” nature of receiving large bonuses at certain times of the year to help pay off student loan debt or other expenses, or are just comfortable having a bonus.
 

Financially speaking

If you have the choice, you may fare better by taking a higher salary and eliminating a bonus. Receiving your pay throughout the year may be preferable to receiving large lump sums only at certain times. Another thing to remember about your incentive bonus is that they are sometimes taxed more heavily based on “supplemental income.” The IRS considers bonuses supplemental to your income, so they may have a higher withholding rate, which can feel penalizing. You may have noticed the extra withholding in your last bonus check.

A version of this article first appeared on Medscape.com.

Incentive bonuses have long been part and parcel of many physicians’ compensation packages. They allow doctors in some specialties to boost their compensation by tens of thousands of dollars.

Often tied to metrics that doctors must hit, incentive bonuses aren’t without controversy. Some physicians welcome them. Others feel burdened by them or think that metrics distract from best patient care.

A recent Medscape poll asked what physicians think about incentive bonuses and whether or not tying metrics to salary is an outdated practice that interferes with the integrity of a physician’s job or contributes to excellence in patient care and increased productivity.

Here is what 406 physicians who answered the poll, which ran from Aug. 17 to Sept. 1, had to say about incentive bonuses:

More than half the physicians polled (58%) received an incentive bonus in 2021. Of those who received a bonus, 44% received up to $25,000. Almost 30% received $25,001-$50,000 in incentive bonus money. Only 14% received more than $100,000.

When we asked physicians which metrics they prefer their bonus to be based on, a large majority (64%) agreed quality of care was most relevant. Other metrics that respondents think appropriate included professionalism (40%), patient outcomes (40%), patient satisfaction (34%), patient volume (26%), market expansion (7%), and other (3%).
 

The problem with bonuses

Once thought to improve quality and consistency of care, incentive bonuses may be falling out of favor. Developing, administrating, and tracking them may be cumbersome for the institutions that advocate for them. For instance, determining who gave quality care and how to measure that care can be difficult.

What’s more, some top health care employers, Mayo Clinic and Kaiser Permanente, have switched from the incentive bonus model to straight salaries. Data show that the number of tests patients have and the number of treatments they try decreases when doctors receive straight salaries. 

In fact, 74% of the polled physicians think that bonuses can result in consequences like unnecessary tests and higher patient costs. Three-fourths of respondents don’t think incentives improve patient care either.

Physicians have long thought incentive bonuses can also have unintended consequences. For example, tying a physician’s monetary reward to metrics such as patient outcomes, like adherence to treatment protocols, may mean that noncompliant patients can jeopardize your metrics and prevent physicians from getting bonuses.

A Merritt Hawkins’ 2019 Review of Physician and Advanced Practitioner Recruiting Incentives found that 56% of bonuses are based in whole or in part on metrics like a patient’s adherence.

Additionally, tying monetary rewards to patient volume encourages some physicians to overbook patients, work more and longer hours, and risk burnout to meet their bonus criteria.

When we asked how hard it was to meet metrics in the Medscape poll, 45% of respondents who receive incentive bonuses said it was somewhat or very difficult. Only 9% consider it very easy. And 71% of physicians say their bonus is at risk because of not meeting their metrics.

Not surprisingly, large pay-for-performance bonuses are only offered to certain specialists and physician specialties in high demand. An orthopedist, for example, can earn up to an average of $126,000 in incentive bonuses, while a pediatrician brings in an average of $28,000, according to the Medscape Physician Compensation Report 2022.

Yet physicians are still torn

Despite these negatives, physicians are split about whether bonuses are good for doctors. The poll shows 51% said no, and 49% said yes. Further, physicians were split 50-50 on whether the bonus makes physicians more productive. Interestingly though, 76% think the bonus compensation method should be phased out in favor of straight salaries.

But many physicians may welcome the “lump sum” nature of receiving large bonuses at certain times of the year to help pay off student loan debt or other expenses, or are just comfortable having a bonus.
 

Financially speaking

If you have the choice, you may fare better by taking a higher salary and eliminating a bonus. Receiving your pay throughout the year may be preferable to receiving large lump sums only at certain times. Another thing to remember about your incentive bonus is that they are sometimes taxed more heavily based on “supplemental income.” The IRS considers bonuses supplemental to your income, so they may have a higher withholding rate, which can feel penalizing. You may have noticed the extra withholding in your last bonus check.

A version of this article first appeared on Medscape.com.

Despite money’s central role in our psychic lives, many trainees – and some seasoned practitioners – skirt around financial issues. Some clinicians confess that inquiring about patients’ finances feels “too personal.” They fear that asking about money could suggest that the clinician is primarily concerned with getting paid. Some clinicians feel that looking into patients’ finances might be unprofessional, outside one’s scope of practice. But it is not.

Trainees often receive little guidance concerning money matters in patients’ lives and treatments, considerations we have labeled clinical psychoeconomics. Considerable evidence suggests that financial concerns often provoke emotional distress and dysfunctional behaviors, and directly influence patient’s health care decisions. Financial issues also influence how clinicians view and react to patients.

We have recently reviewed (and illustrated through case vignettes) how money matters might impact psychiatric assessment, case formulation, treatment planning, and ongoing psychiatric treatments including psychotherapies.¹ Consider how money affects people’s lives: Money helps people meet multiple practical, psychological, and social needs by enabling them to obtain food, clothing, shelter, other material goods, services, discretionary time, and opportunities. And money strongly influences relationships. Regardless of poverty or wealth, thoughts and behaviors connected to acquiring, possessing, and disposing of money, and feelings accompanying these processes such as greed, neediness, envy, pride, shame, guilt, and self-satisfaction often underly intrapsychic and interpersonal conflicts.

Individuals constantly engage in numerous simultaneous conscious, preconscious, and unconscious neuro-economic trade-offs that determine goals, efforts, and timing. Many are financially influenced. Money influences how virtually all patients seek, receive, and sustain their mental health care including psychotherapy.

Money problems can be associated with insecurity, impotence, feeling unloved, and lack of freedom or subjugation. Individuals may resent how they’re forced to acquire money, and feel shamed or morally injured by their jobs, financial dependence on other family members, public assistance, or their questionable ways of obtaining money.

Impoverished individuals may face choosing between food, housing, medications, and medical care. Domestically abused individuals may reluctantly remain with their abusers, risking physical harm or death rather than face destitution. Some families tolerate severely disabled individuals at home because they rely on their disability checks and caregiver payments. Suicides may turn on how individuals forecast financial repercussions affecting their families. Desires to avoid debt may lead to treatment avoidance.

Individuals with enough money to get by face daily financially related choices involving competing needs, desires, values, and loyalties. They may experience conflicts concerning spending on necessities vs. indulgences or spending on oneself vs. significant others.

Whereas some wealthy individuals may assume unwarranted airs of superiority and entitlement, others may feel guilty about wealth, or fearful that others like them only for their money. Individuals on the receiving end of wealth may feel emotionally and behaviorally manipulated by their benefactors.
 

Assessment

Assessments should consider how financial matters have shaped patients’ early psychological development as well their current lives. How do patients’ emotions, thoughts, and behaviors reflect money matters? What money-related pathologies are evident? What aspects of the patient’s “financial world” seem modifiable?

Financial questions should be posed colloquially. Screeners include: “Where do you live?”, “Who’s in the home?”, “How do you (all) manage financially?”, “What do you all do for a living?”, “How do you make ends meet?”, and “What financial problems are you facing?” Clinicians can quickly learn about patients’ financial self-sufficiencies, individuals for whom they bear financial responsibility, and others they rely on for support, for example, relatives. If patients avoid answering such questions forthrightly, particularly when financial arrangements are “complicated,” clinicians will want to revisit these issues later after establishing a firmer alliance but continue to wonder about the meaning of the patient’s reluctance.

Clinically, money matters manifest intrapsychically or interpersonally in three ways: as explicit conflicts, implicit issues, and unequivocal money-related pathologies. When explicit, patients, families, and couples are fully aware of the conflicts but have difficulty resolving financial disputes. When conflicts are implicit, money problems may be unacknowledged, avoided, denied, or minimized. Conflicts concerning money are often transmitted trans-generationally.

Psychopathological conditions unequivocally linked to money include compulsive shopping, gambling disorders, miserly hoarding, impulse buying, and spending sprees during hypomanic and manic states. Mounting debts may create progressively insurmountable sources of distress. Money can be weaponized to sadistically create enticement, envy, or deprivation. Some monetarily antisocial individuals compromise interpersonal relationships as well as treatments. Individuals with alcohol/substance use disorders may spend so much on substances that little is left for necessities. Financially needy individuals may engage in morally questionable behaviors they might otherwise shun.
 

Case formulation and treatment planning

Incorporating money matters into case formulations entails demonstrating how financial concerns influenced maladaptive development and distort current attitudes, perceptions, and behaviors.

Concurrently, clinicians should acknowledge patients’ reality-based fiscal decisions, appreciating cultural and family value differences concerning how money should be acquired and spent. Since money often determines frequency and duration of treatment visits, clinicians are ethically obligated to discuss with patients what they might expect from different medications and psychotherapies, and their comparative costs.
 

Money matters’ impact on psychotherapies

Money matters often affect transference and countertransference reactions. Some reactions stem from how patients and clinicians compare their own financial situations with those of the other.

To help identify and ameliorate money-related countertransference responses, clinicians can reflect on questions such as: “How comfortable are you with people who are much poorer or richer than you are?” “How comfortable are you with impoverished individuals or with multimillionaires or their children?” And “why?” For trainees, all these reactions should be discussed in supervision.
 

Conclusions

To summarize, four clinical psychoeconomic issues should be routinely assessed and factored into psychiatric case formulations and treatment plans: how financial issues 1) have impacted patients’ psychological development; 2) impact patients’ current lives; 3) are likely to impact access, type, intensity, and duration of treatment visits; and 4) might provoke money-related transference and countertransference concerns.

In advising patients about treatment options, clinicians should discuss each treatment’s relative effectiveness and estimated costs of care. Patients’ decisions will likely be heavily influenced by financial considerations.

Dr. Yager is based in the department of psychiatry, University of Colorado at Denver, Aurora. Dr. Kay is based in the department of psychiatry, Wright State University, Dayton, Ohio. No external funds were received for this project, and the authors have no conflicts to disclose.

Reference

1. Yager J and Kay J. Money matters in psychiatric assessment, case formulation, treatment planning, and ongoing psychotherapy: Clinical psychoeconomics. J Nerv Ment Dis. 2022 Jun 10. doi: 10.1097/NMD.0000000000001552.

Despite money’s central role in our psychic lives, many trainees – and some seasoned practitioners – skirt around financial issues. Some clinicians confess that inquiring about patients’ finances feels “too personal.” They fear that asking about money could suggest that the clinician is primarily concerned with getting paid. Some clinicians feel that looking into patients’ finances might be unprofessional, outside one’s scope of practice. But it is not.

Trainees often receive little guidance concerning money matters in patients’ lives and treatments, considerations we have labeled clinical psychoeconomics. Considerable evidence suggests that financial concerns often provoke emotional distress and dysfunctional behaviors, and directly influence patient’s health care decisions. Financial issues also influence how clinicians view and react to patients.

We have recently reviewed (and illustrated through case vignettes) how money matters might impact psychiatric assessment, case formulation, treatment planning, and ongoing psychiatric treatments including psychotherapies.¹ Consider how money affects people’s lives: Money helps people meet multiple practical, psychological, and social needs by enabling them to obtain food, clothing, shelter, other material goods, services, discretionary time, and opportunities. And money strongly influences relationships. Regardless of poverty or wealth, thoughts and behaviors connected to acquiring, possessing, and disposing of money, and feelings accompanying these processes such as greed, neediness, envy, pride, shame, guilt, and self-satisfaction often underly intrapsychic and interpersonal conflicts.

Individuals constantly engage in numerous simultaneous conscious, preconscious, and unconscious neuro-economic trade-offs that determine goals, efforts, and timing. Many are financially influenced. Money influences how virtually all patients seek, receive, and sustain their mental health care including psychotherapy.

Money problems can be associated with insecurity, impotence, feeling unloved, and lack of freedom or subjugation. Individuals may resent how they’re forced to acquire money, and feel shamed or morally injured by their jobs, financial dependence on other family members, public assistance, or their questionable ways of obtaining money.

Impoverished individuals may face choosing between food, housing, medications, and medical care. Domestically abused individuals may reluctantly remain with their abusers, risking physical harm or death rather than face destitution. Some families tolerate severely disabled individuals at home because they rely on their disability checks and caregiver payments. Suicides may turn on how individuals forecast financial repercussions affecting their families. Desires to avoid debt may lead to treatment avoidance.

Individuals with enough money to get by face daily financially related choices involving competing needs, desires, values, and loyalties. They may experience conflicts concerning spending on necessities vs. indulgences or spending on oneself vs. significant others.

Whereas some wealthy individuals may assume unwarranted airs of superiority and entitlement, others may feel guilty about wealth, or fearful that others like them only for their money. Individuals on the receiving end of wealth may feel emotionally and behaviorally manipulated by their benefactors.
 

Assessment

Assessments should consider how financial matters have shaped patients’ early psychological development as well their current lives. How do patients’ emotions, thoughts, and behaviors reflect money matters? What money-related pathologies are evident? What aspects of the patient’s “financial world” seem modifiable?

Financial questions should be posed colloquially. Screeners include: “Where do you live?”, “Who’s in the home?”, “How do you (all) manage financially?”, “What do you all do for a living?”, “How do you make ends meet?”, and “What financial problems are you facing?” Clinicians can quickly learn about patients’ financial self-sufficiencies, individuals for whom they bear financial responsibility, and others they rely on for support, for example, relatives. If patients avoid answering such questions forthrightly, particularly when financial arrangements are “complicated,” clinicians will want to revisit these issues later after establishing a firmer alliance but continue to wonder about the meaning of the patient’s reluctance.

Clinically, money matters manifest intrapsychically or interpersonally in three ways: as explicit conflicts, implicit issues, and unequivocal money-related pathologies. When explicit, patients, families, and couples are fully aware of the conflicts but have difficulty resolving financial disputes. When conflicts are implicit, money problems may be unacknowledged, avoided, denied, or minimized. Conflicts concerning money are often transmitted trans-generationally.

Psychopathological conditions unequivocally linked to money include compulsive shopping, gambling disorders, miserly hoarding, impulse buying, and spending sprees during hypomanic and manic states. Mounting debts may create progressively insurmountable sources of distress. Money can be weaponized to sadistically create enticement, envy, or deprivation. Some monetarily antisocial individuals compromise interpersonal relationships as well as treatments. Individuals with alcohol/substance use disorders may spend so much on substances that little is left for necessities. Financially needy individuals may engage in morally questionable behaviors they might otherwise shun.
 

Case formulation and treatment planning

Incorporating money matters into case formulations entails demonstrating how financial concerns influenced maladaptive development and distort current attitudes, perceptions, and behaviors.

Concurrently, clinicians should acknowledge patients’ reality-based fiscal decisions, appreciating cultural and family value differences concerning how money should be acquired and spent. Since money often determines frequency and duration of treatment visits, clinicians are ethically obligated to discuss with patients what they might expect from different medications and psychotherapies, and their comparative costs.
 

Money matters’ impact on psychotherapies

Money matters often affect transference and countertransference reactions. Some reactions stem from how patients and clinicians compare their own financial situations with those of the other.

To help identify and ameliorate money-related countertransference responses, clinicians can reflect on questions such as: “How comfortable are you with people who are much poorer or richer than you are?” “How comfortable are you with impoverished individuals or with multimillionaires or their children?” And “why?” For trainees, all these reactions should be discussed in supervision.
 

Conclusions

To summarize, four clinical psychoeconomic issues should be routinely assessed and factored into psychiatric case formulations and treatment plans: how financial issues 1) have impacted patients’ psychological development; 2) impact patients’ current lives; 3) are likely to impact access, type, intensity, and duration of treatment visits; and 4) might provoke money-related transference and countertransference concerns.

In advising patients about treatment options, clinicians should discuss each treatment’s relative effectiveness and estimated costs of care. Patients’ decisions will likely be heavily influenced by financial considerations.

Dr. Yager is based in the department of psychiatry, University of Colorado at Denver, Aurora. Dr. Kay is based in the department of psychiatry, Wright State University, Dayton, Ohio. No external funds were received for this project, and the authors have no conflicts to disclose.

Reference

1. Yager J and Kay J. Money matters in psychiatric assessment, case formulation, treatment planning, and ongoing psychotherapy: Clinical psychoeconomics. J Nerv Ment Dis. 2022 Jun 10. doi: 10.1097/NMD.0000000000001552.

Despite money’s central role in our psychic lives, many trainees – and some seasoned practitioners – skirt around financial issues. Some clinicians confess that inquiring about patients’ finances feels “too personal.” They fear that asking about money could suggest that the clinician is primarily concerned with getting paid. Some clinicians feel that looking into patients’ finances might be unprofessional, outside one’s scope of practice. But it is not.

Trainees often receive little guidance concerning money matters in patients’ lives and treatments, considerations we have labeled clinical psychoeconomics. Considerable evidence suggests that financial concerns often provoke emotional distress and dysfunctional behaviors, and directly influence patient’s health care decisions. Financial issues also influence how clinicians view and react to patients.

We have recently reviewed (and illustrated through case vignettes) how money matters might impact psychiatric assessment, case formulation, treatment planning, and ongoing psychiatric treatments including psychotherapies.¹ Consider how money affects people’s lives: Money helps people meet multiple practical, psychological, and social needs by enabling them to obtain food, clothing, shelter, other material goods, services, discretionary time, and opportunities. And money strongly influences relationships. Regardless of poverty or wealth, thoughts and behaviors connected to acquiring, possessing, and disposing of money, and feelings accompanying these processes such as greed, neediness, envy, pride, shame, guilt, and self-satisfaction often underly intrapsychic and interpersonal conflicts.

Individuals constantly engage in numerous simultaneous conscious, preconscious, and unconscious neuro-economic trade-offs that determine goals, efforts, and timing. Many are financially influenced. Money influences how virtually all patients seek, receive, and sustain their mental health care including psychotherapy.

Money problems can be associated with insecurity, impotence, feeling unloved, and lack of freedom or subjugation. Individuals may resent how they’re forced to acquire money, and feel shamed or morally injured by their jobs, financial dependence on other family members, public assistance, or their questionable ways of obtaining money.

Impoverished individuals may face choosing between food, housing, medications, and medical care. Domestically abused individuals may reluctantly remain with their abusers, risking physical harm or death rather than face destitution. Some families tolerate severely disabled individuals at home because they rely on their disability checks and caregiver payments. Suicides may turn on how individuals forecast financial repercussions affecting their families. Desires to avoid debt may lead to treatment avoidance.

Individuals with enough money to get by face daily financially related choices involving competing needs, desires, values, and loyalties. They may experience conflicts concerning spending on necessities vs. indulgences or spending on oneself vs. significant others.

Whereas some wealthy individuals may assume unwarranted airs of superiority and entitlement, others may feel guilty about wealth, or fearful that others like them only for their money. Individuals on the receiving end of wealth may feel emotionally and behaviorally manipulated by their benefactors.
 

Assessment

Assessments should consider how financial matters have shaped patients’ early psychological development as well their current lives. How do patients’ emotions, thoughts, and behaviors reflect money matters? What money-related pathologies are evident? What aspects of the patient’s “financial world” seem modifiable?

Financial questions should be posed colloquially. Screeners include: “Where do you live?”, “Who’s in the home?”, “How do you (all) manage financially?”, “What do you all do for a living?”, “How do you make ends meet?”, and “What financial problems are you facing?” Clinicians can quickly learn about patients’ financial self-sufficiencies, individuals for whom they bear financial responsibility, and others they rely on for support, for example, relatives. If patients avoid answering such questions forthrightly, particularly when financial arrangements are “complicated,” clinicians will want to revisit these issues later after establishing a firmer alliance but continue to wonder about the meaning of the patient’s reluctance.

Clinically, money matters manifest intrapsychically or interpersonally in three ways: as explicit conflicts, implicit issues, and unequivocal money-related pathologies. When explicit, patients, families, and couples are fully aware of the conflicts but have difficulty resolving financial disputes. When conflicts are implicit, money problems may be unacknowledged, avoided, denied, or minimized. Conflicts concerning money are often transmitted trans-generationally.

Psychopathological conditions unequivocally linked to money include compulsive shopping, gambling disorders, miserly hoarding, impulse buying, and spending sprees during hypomanic and manic states. Mounting debts may create progressively insurmountable sources of distress. Money can be weaponized to sadistically create enticement, envy, or deprivation. Some monetarily antisocial individuals compromise interpersonal relationships as well as treatments. Individuals with alcohol/substance use disorders may spend so much on substances that little is left for necessities. Financially needy individuals may engage in morally questionable behaviors they might otherwise shun.
 

Case formulation and treatment planning

Incorporating money matters into case formulations entails demonstrating how financial concerns influenced maladaptive development and distort current attitudes, perceptions, and behaviors.

Concurrently, clinicians should acknowledge patients’ reality-based fiscal decisions, appreciating cultural and family value differences concerning how money should be acquired and spent. Since money often determines frequency and duration of treatment visits, clinicians are ethically obligated to discuss with patients what they might expect from different medications and psychotherapies, and their comparative costs.
 

Money matters’ impact on psychotherapies

Money matters often affect transference and countertransference reactions. Some reactions stem from how patients and clinicians compare their own financial situations with those of the other.

To help identify and ameliorate money-related countertransference responses, clinicians can reflect on questions such as: “How comfortable are you with people who are much poorer or richer than you are?” “How comfortable are you with impoverished individuals or with multimillionaires or their children?” And “why?” For trainees, all these reactions should be discussed in supervision.
 

Conclusions

To summarize, four clinical psychoeconomic issues should be routinely assessed and factored into psychiatric case formulations and treatment plans: how financial issues 1) have impacted patients’ psychological development; 2) impact patients’ current lives; 3) are likely to impact access, type, intensity, and duration of treatment visits; and 4) might provoke money-related transference and countertransference concerns.

In advising patients about treatment options, clinicians should discuss each treatment’s relative effectiveness and estimated costs of care. Patients’ decisions will likely be heavily influenced by financial considerations.

Dr. Yager is based in the department of psychiatry, University of Colorado at Denver, Aurora. Dr. Kay is based in the department of psychiatry, Wright State University, Dayton, Ohio. No external funds were received for this project, and the authors have no conflicts to disclose.

Reference

1. Yager J and Kay J. Money matters in psychiatric assessment, case formulation, treatment planning, and ongoing psychotherapy: Clinical psychoeconomics. J Nerv Ment Dis. 2022 Jun 10. doi: 10.1097/NMD.0000000000001552.

A provider-only patient care protocol was safe and efficient for delivery of emergency department care in response to pandemic-related staff shortages, based on data from nearly 3,000 patients.

The COVID-19 pandemic sparked a shortage of health care personnel, according to Tanveer Gaibi, MD, of INOVA Fairfax Hospital, Falls Church, Va., and colleagues. To help manage these challenges, the INOVA emergency department developed a Provider-Only Patients (POP) protocol for patients who required minimal nursing care.

In a study presented at the American College of Emergency Physicians 2022 Scientific Assembly, the researchers reported the outcomes of a cohort of patients with suspected COVID-19 who were treated in the emergency department using the POP protocol between Dec. 1, 2021, and Jan. 15, 2022. The patients ranged in age from 21 to 64, and all presented with COVID-19-related complaints, with an Emergency Severity Index (ESI) of 4 or 5, with 1 being the most urgent and 5 being the least urgent.

Patients were triaged by a physician or nurse to determine POP status. Those deemed POP were seen and discharged directly by a physician or advanced-practice provider (APP). The researchers reviewed data from a total of 640 patients treated via the POP protocol and 2,386 patients who were not POP with ESI of 4 or 5.

Overall, the mean time from when a patient was initially seen by a provider to the discharge disposition was 48 minutes shorter for POP, and the mean time from discharge disposition placement to leaving the ED was 66 minutes shorter. None of the POP-protocol patients were readmitted within 72 hours of discharge. The researchers estimated that the 640 patients in the POP protocol saved approximately 1892.27 hours of nursing and 705.1 provider hours during the study period, and no additional physician hours or advanced-practice provider hours were needed.

The study findings suggest that POP holds up as a safe, efficient, and effective process that can reduce discharge length of stay and provider to disposition times. Although more research is needed, the POP model also may be considered to address staffing challenges unrelated to the pandemic, the researchers concluded.

“This study was conducted at [a] time when our emergency department was experiencing a sudden and disproportionate increase in volume related to the Omicron variant of COVID-19,” Dr. Gaibi told this news organization. “This novel process was developed by brainstorming untested ways of managing this increased demand. The research study was a natural outcome once the process was implemented,” he said.

“Once barriers to implementing this process were overcome, we were not surprised by the results,” Dr. Gaibi said. “Subtracting at the time for nursing process was anticipated to shorten cycle times.”

The clinical implications of POP relate to generalizability outside of the pandemic setting, Dr. Gaibi noted. “We anticipate that POP could be used for patients with minor complaints to greatly shorten their time in the emergency department,” he said.

“Potential barriers to the generalized use of POP relate, in part, to local administrative barriers related to nursing assessments,” Dr. Gaibi explained. “Further, POP patients should be simple and require little or no testing. Keeping to this strict definition of the provider-only patient may be a pitfall in terms of its hard wiring,” he added.

Looking ahead, more research is needed to study POP in ED patients with minor complaints not necessarily related to COVID-19, Dr. Gaibi said.

The study received no outside funding. The researchers disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A provider-only patient care protocol was safe and efficient for delivery of emergency department care in response to pandemic-related staff shortages, based on data from nearly 3,000 patients.

The COVID-19 pandemic sparked a shortage of health care personnel, according to Tanveer Gaibi, MD, of INOVA Fairfax Hospital, Falls Church, Va., and colleagues. To help manage these challenges, the INOVA emergency department developed a Provider-Only Patients (POP) protocol for patients who required minimal nursing care.

In a study presented at the American College of Emergency Physicians 2022 Scientific Assembly, the researchers reported the outcomes of a cohort of patients with suspected COVID-19 who were treated in the emergency department using the POP protocol between Dec. 1, 2021, and Jan. 15, 2022. The patients ranged in age from 21 to 64, and all presented with COVID-19-related complaints, with an Emergency Severity Index (ESI) of 4 or 5, with 1 being the most urgent and 5 being the least urgent.

Patients were triaged by a physician or nurse to determine POP status. Those deemed POP were seen and discharged directly by a physician or advanced-practice provider (APP). The researchers reviewed data from a total of 640 patients treated via the POP protocol and 2,386 patients who were not POP with ESI of 4 or 5.

Overall, the mean time from when a patient was initially seen by a provider to the discharge disposition was 48 minutes shorter for POP, and the mean time from discharge disposition placement to leaving the ED was 66 minutes shorter. None of the POP-protocol patients were readmitted within 72 hours of discharge. The researchers estimated that the 640 patients in the POP protocol saved approximately 1892.27 hours of nursing and 705.1 provider hours during the study period, and no additional physician hours or advanced-practice provider hours were needed.

The study findings suggest that POP holds up as a safe, efficient, and effective process that can reduce discharge length of stay and provider to disposition times. Although more research is needed, the POP model also may be considered to address staffing challenges unrelated to the pandemic, the researchers concluded.

“This study was conducted at [a] time when our emergency department was experiencing a sudden and disproportionate increase in volume related to the Omicron variant of COVID-19,” Dr. Gaibi told this news organization. “This novel process was developed by brainstorming untested ways of managing this increased demand. The research study was a natural outcome once the process was implemented,” he said.

“Once barriers to implementing this process were overcome, we were not surprised by the results,” Dr. Gaibi said. “Subtracting at the time for nursing process was anticipated to shorten cycle times.”

The clinical implications of POP relate to generalizability outside of the pandemic setting, Dr. Gaibi noted. “We anticipate that POP could be used for patients with minor complaints to greatly shorten their time in the emergency department,” he said.

“Potential barriers to the generalized use of POP relate, in part, to local administrative barriers related to nursing assessments,” Dr. Gaibi explained. “Further, POP patients should be simple and require little or no testing. Keeping to this strict definition of the provider-only patient may be a pitfall in terms of its hard wiring,” he added.

Looking ahead, more research is needed to study POP in ED patients with minor complaints not necessarily related to COVID-19, Dr. Gaibi said.

The study received no outside funding. The researchers disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A provider-only patient care protocol was safe and efficient for delivery of emergency department care in response to pandemic-related staff shortages, based on data from nearly 3,000 patients.

The COVID-19 pandemic sparked a shortage of health care personnel, according to Tanveer Gaibi, MD, of INOVA Fairfax Hospital, Falls Church, Va., and colleagues. To help manage these challenges, the INOVA emergency department developed a Provider-Only Patients (POP) protocol for patients who required minimal nursing care.

In a study presented at the American College of Emergency Physicians 2022 Scientific Assembly, the researchers reported the outcomes of a cohort of patients with suspected COVID-19 who were treated in the emergency department using the POP protocol between Dec. 1, 2021, and Jan. 15, 2022. The patients ranged in age from 21 to 64, and all presented with COVID-19-related complaints, with an Emergency Severity Index (ESI) of 4 or 5, with 1 being the most urgent and 5 being the least urgent.

Patients were triaged by a physician or nurse to determine POP status. Those deemed POP were seen and discharged directly by a physician or advanced-practice provider (APP). The researchers reviewed data from a total of 640 patients treated via the POP protocol and 2,386 patients who were not POP with ESI of 4 or 5.

Overall, the mean time from when a patient was initially seen by a provider to the discharge disposition was 48 minutes shorter for POP, and the mean time from discharge disposition placement to leaving the ED was 66 minutes shorter. None of the POP-protocol patients were readmitted within 72 hours of discharge. The researchers estimated that the 640 patients in the POP protocol saved approximately 1892.27 hours of nursing and 705.1 provider hours during the study period, and no additional physician hours or advanced-practice provider hours were needed.

The study findings suggest that POP holds up as a safe, efficient, and effective process that can reduce discharge length of stay and provider to disposition times. Although more research is needed, the POP model also may be considered to address staffing challenges unrelated to the pandemic, the researchers concluded.

“This study was conducted at [a] time when our emergency department was experiencing a sudden and disproportionate increase in volume related to the Omicron variant of COVID-19,” Dr. Gaibi told this news organization. “This novel process was developed by brainstorming untested ways of managing this increased demand. The research study was a natural outcome once the process was implemented,” he said.

“Once barriers to implementing this process were overcome, we were not surprised by the results,” Dr. Gaibi said. “Subtracting at the time for nursing process was anticipated to shorten cycle times.”

The clinical implications of POP relate to generalizability outside of the pandemic setting, Dr. Gaibi noted. “We anticipate that POP could be used for patients with minor complaints to greatly shorten their time in the emergency department,” he said.

“Potential barriers to the generalized use of POP relate, in part, to local administrative barriers related to nursing assessments,” Dr. Gaibi explained. “Further, POP patients should be simple and require little or no testing. Keeping to this strict definition of the provider-only patient may be a pitfall in terms of its hard wiring,” he added.

Looking ahead, more research is needed to study POP in ED patients with minor complaints not necessarily related to COVID-19, Dr. Gaibi said.

The study received no outside funding. The researchers disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A chain of primary care clinics in Minneapolis is likely the first of its kind to be staffed entirely by nurse practitioners (NPs). The Good Clinic offers patients 40-minute exams, as opposed to the 10- to 15-minute appointments typically allotted for physician-staffed clinics, as well as a 1-day wait time instead of 2 weeks.

The chain of six primary care clinics, owned by health care holding company Mitesco, seeks to address the shortage of doctors, particularly among primary care physicians, which results in longer wait times, delayed care, and shorter patient visits.

“As the nation seeks solutions to the challenges of health care access and the rising incidence of chronic disease, it is no surprise that NPs are increasingly the provider of choice for patients,” said April Kapu, DNP, APRN, president of the American Association of Nurse Practitioners.

NPs are in a prime position to address health care disparities and ensure quality and equitable health care access for millions of people in the United States, she said.

According to 2021 data from the U.S. Bureau of Labor Statistics, a 40% increase in the number of NPs is expected over the next 10 years.

Currently, 26 states and Washington, have given full-practice authority (FPA) to NPs, according to the AANP. FPA, as defined by the organization, gives NPs the authority to evaluate, diagnose, and treat patients, as well as order and interpret diagnostic tests under the state board of nursing. This eliminates the need of a collaborative practice agreement between an NP and a physician to provide care.

NPs in Minnesota have FPA, which allows them to see patients and prescribe without doctor oversight.

In a report released last year by the Association of American Medical Colleges, it is projected that there will be a shortage of between 37,800 and 124,000 physicians within 12 years.

Not only is there a dearth of qualified providers, but also there is a significant lack of primary care providers, said Kishlay Anand, MD, founder of Apricus Health in Arizona, which manages health systems. With more physicians choosing to specialize, there are not going to be enough primary care providers, he said. “We have definitely compensated specialty care, but we have not paid adequate compensation for primary prevention,” Dr. Anand told this news organization.

The pandemic has accelerated this shortage by causing physician burnout, said Peter Hahn, MD, CEO of the University of Michigan Health–West. Health care systems, especially in rural areas, are already experiencing this severe shortage, he said. It results in delayed patient care, and as a result, more significant health care needs that trickle down.

It’s what makes primary care, with an emphasis on health promotion and prevention, a great niche for NP-led clinics to address the physician shortage, Dr. Hahn told this news organization. NPs can optimize patient outcomes with fewer resources compared to a physician, he said.
 

Growth of NP field

Improving patient experience and making health care less transactional were priorities for The Good Clinic founder and chief nurse practitioner officer Kevin Lee Smith, DNP.

“The bottom line is we truly wanted to take that nursing perspective where you look at the bio-psycho-social-spiritual being. What is unique [about NPs] is the patient education focus, experience, and holistic care. And NPs are more inclined to take that time because that’s part of our education,” he said.

Nurse practitioner Teal Foster owns Refine Wellness, an independent practice in Stillwater, Minn., which is not affiliated with Mitesco clinics. One reason she started her company was that she was seeing that patients couldn’t get an appointment to see their provider, sometimes for weeks to months. Ms. Foster said she sets her own appointment times, spends more time with patients, and has a greater opportunity to take a more holistic approach to care.

“As nurse practitioners, our education is largely based on prevention and chronic disease management. With that being the focus, it’s seeing the big picture, rather than individual parts of the patient,” Ms. Foster said in an interview.
 

Doctors see need for NPs – with caution

“Nursing education is focused more on health promotion and prevention – tenets that prevent ED costs specifically in underserved populations,” said Dr. Hahn. “In these rural areas or medically underserved communities, NP-led clinics support positive patient experience scores, a sense of security, feelings of trust and respect, and have been shown to help patients gain insights into their own health.”

With the physician shortage, advanced practice providers are a crucial part of the solution for patients, as well as health care systems, Dr. Hahn said. But one challenge to NP-led clinics is the variability in practice regulations from state to state. “Standardization should be considered a high priority to utilize these advanced practice providers effectively and to enable them to consistently practice at the top of their license,” said Dr. Hahn.

The concern of many physicians is that not having physician supervision for early-career NPs can lead to problems, Dr. Anand said. Physicians train much longer than NPs, and it’s what lends to their credibility and their qualification to deliver quality care, he explained. “Patients in rural communities can be very complex and have multiple comorbidities. Sometimes that quick training is not able to do justice to that.”

It’s why Dr. Anand said meeting qualifications and having physician mentorship opportunities would bring a “much-needed safeguard” and regulatory aspects to delivering care in those settings. Even experienced physicians can improve their skills if they have a good coach and mentor, he said.
 

Continuing to collaborate

At The Good Clinic, collaboration operates similarly to at an MD-led clinic, Dr. Smith said. Computer messaging between the six clinics puts NPs in touch with each other instantly.

“Curbside consults” are common. “For example, we’ll have someone who has 20 years of women’s health experience, and the person who has 5 years as an NP might run into a case where they need that person. We’ll do a lot of consulting internally,” explained Dr. Smith.

A partnership with a nearby radiology group lends radiologists who are happy to consult with an NP over the phone about what type of x-ray would be most beneficial, he said. For cases that require a higher level of care, The Good Clinic maintains an extensive referral list.

“We are here to advocate for our patients,” said Dr. Smith. “We have best-practice guidelines in-house, and there’s also that professional accountability and ethics, that you’re not going to go into the territory of managing something that you’re not comfortable with. It takes a village to provide the appropriate care for an individual.”

A version of this article first appeared on Medscape.com.

A chain of primary care clinics in Minneapolis is likely the first of its kind to be staffed entirely by nurse practitioners (NPs). The Good Clinic offers patients 40-minute exams, as opposed to the 10- to 15-minute appointments typically allotted for physician-staffed clinics, as well as a 1-day wait time instead of 2 weeks.

The chain of six primary care clinics, owned by health care holding company Mitesco, seeks to address the shortage of doctors, particularly among primary care physicians, which results in longer wait times, delayed care, and shorter patient visits.

“As the nation seeks solutions to the challenges of health care access and the rising incidence of chronic disease, it is no surprise that NPs are increasingly the provider of choice for patients,” said April Kapu, DNP, APRN, president of the American Association of Nurse Practitioners.

NPs are in a prime position to address health care disparities and ensure quality and equitable health care access for millions of people in the United States, she said.

According to 2021 data from the U.S. Bureau of Labor Statistics, a 40% increase in the number of NPs is expected over the next 10 years.

Currently, 26 states and Washington, have given full-practice authority (FPA) to NPs, according to the AANP. FPA, as defined by the organization, gives NPs the authority to evaluate, diagnose, and treat patients, as well as order and interpret diagnostic tests under the state board of nursing. This eliminates the need of a collaborative practice agreement between an NP and a physician to provide care.

NPs in Minnesota have FPA, which allows them to see patients and prescribe without doctor oversight.

In a report released last year by the Association of American Medical Colleges, it is projected that there will be a shortage of between 37,800 and 124,000 physicians within 12 years.

Not only is there a dearth of qualified providers, but also there is a significant lack of primary care providers, said Kishlay Anand, MD, founder of Apricus Health in Arizona, which manages health systems. With more physicians choosing to specialize, there are not going to be enough primary care providers, he said. “We have definitely compensated specialty care, but we have not paid adequate compensation for primary prevention,” Dr. Anand told this news organization.

The pandemic has accelerated this shortage by causing physician burnout, said Peter Hahn, MD, CEO of the University of Michigan Health–West. Health care systems, especially in rural areas, are already experiencing this severe shortage, he said. It results in delayed patient care, and as a result, more significant health care needs that trickle down.

It’s what makes primary care, with an emphasis on health promotion and prevention, a great niche for NP-led clinics to address the physician shortage, Dr. Hahn told this news organization. NPs can optimize patient outcomes with fewer resources compared to a physician, he said.
 

Growth of NP field

Improving patient experience and making health care less transactional were priorities for The Good Clinic founder and chief nurse practitioner officer Kevin Lee Smith, DNP.

“The bottom line is we truly wanted to take that nursing perspective where you look at the bio-psycho-social-spiritual being. What is unique [about NPs] is the patient education focus, experience, and holistic care. And NPs are more inclined to take that time because that’s part of our education,” he said.

Nurse practitioner Teal Foster owns Refine Wellness, an independent practice in Stillwater, Minn., which is not affiliated with Mitesco clinics. One reason she started her company was that she was seeing that patients couldn’t get an appointment to see their provider, sometimes for weeks to months. Ms. Foster said she sets her own appointment times, spends more time with patients, and has a greater opportunity to take a more holistic approach to care.

“As nurse practitioners, our education is largely based on prevention and chronic disease management. With that being the focus, it’s seeing the big picture, rather than individual parts of the patient,” Ms. Foster said in an interview.
 

Doctors see need for NPs – with caution

“Nursing education is focused more on health promotion and prevention – tenets that prevent ED costs specifically in underserved populations,” said Dr. Hahn. “In these rural areas or medically underserved communities, NP-led clinics support positive patient experience scores, a sense of security, feelings of trust and respect, and have been shown to help patients gain insights into their own health.”

With the physician shortage, advanced practice providers are a crucial part of the solution for patients, as well as health care systems, Dr. Hahn said. But one challenge to NP-led clinics is the variability in practice regulations from state to state. “Standardization should be considered a high priority to utilize these advanced practice providers effectively and to enable them to consistently practice at the top of their license,” said Dr. Hahn.

The concern of many physicians is that not having physician supervision for early-career NPs can lead to problems, Dr. Anand said. Physicians train much longer than NPs, and it’s what lends to their credibility and their qualification to deliver quality care, he explained. “Patients in rural communities can be very complex and have multiple comorbidities. Sometimes that quick training is not able to do justice to that.”

It’s why Dr. Anand said meeting qualifications and having physician mentorship opportunities would bring a “much-needed safeguard” and regulatory aspects to delivering care in those settings. Even experienced physicians can improve their skills if they have a good coach and mentor, he said.
 

Continuing to collaborate

At The Good Clinic, collaboration operates similarly to at an MD-led clinic, Dr. Smith said. Computer messaging between the six clinics puts NPs in touch with each other instantly.

“Curbside consults” are common. “For example, we’ll have someone who has 20 years of women’s health experience, and the person who has 5 years as an NP might run into a case where they need that person. We’ll do a lot of consulting internally,” explained Dr. Smith.

A partnership with a nearby radiology group lends radiologists who are happy to consult with an NP over the phone about what type of x-ray would be most beneficial, he said. For cases that require a higher level of care, The Good Clinic maintains an extensive referral list.

“We are here to advocate for our patients,” said Dr. Smith. “We have best-practice guidelines in-house, and there’s also that professional accountability and ethics, that you’re not going to go into the territory of managing something that you’re not comfortable with. It takes a village to provide the appropriate care for an individual.”

A version of this article first appeared on Medscape.com.

A chain of primary care clinics in Minneapolis is likely the first of its kind to be staffed entirely by nurse practitioners (NPs). The Good Clinic offers patients 40-minute exams, as opposed to the 10- to 15-minute appointments typically allotted for physician-staffed clinics, as well as a 1-day wait time instead of 2 weeks.

The chain of six primary care clinics, owned by health care holding company Mitesco, seeks to address the shortage of doctors, particularly among primary care physicians, which results in longer wait times, delayed care, and shorter patient visits.

“As the nation seeks solutions to the challenges of health care access and the rising incidence of chronic disease, it is no surprise that NPs are increasingly the provider of choice for patients,” said April Kapu, DNP, APRN, president of the American Association of Nurse Practitioners.

NPs are in a prime position to address health care disparities and ensure quality and equitable health care access for millions of people in the United States, she said.

According to 2021 data from the U.S. Bureau of Labor Statistics, a 40% increase in the number of NPs is expected over the next 10 years.

Currently, 26 states and Washington, have given full-practice authority (FPA) to NPs, according to the AANP. FPA, as defined by the organization, gives NPs the authority to evaluate, diagnose, and treat patients, as well as order and interpret diagnostic tests under the state board of nursing. This eliminates the need of a collaborative practice agreement between an NP and a physician to provide care.

NPs in Minnesota have FPA, which allows them to see patients and prescribe without doctor oversight.

In a report released last year by the Association of American Medical Colleges, it is projected that there will be a shortage of between 37,800 and 124,000 physicians within 12 years.

Not only is there a dearth of qualified providers, but also there is a significant lack of primary care providers, said Kishlay Anand, MD, founder of Apricus Health in Arizona, which manages health systems. With more physicians choosing to specialize, there are not going to be enough primary care providers, he said. “We have definitely compensated specialty care, but we have not paid adequate compensation for primary prevention,” Dr. Anand told this news organization.

The pandemic has accelerated this shortage by causing physician burnout, said Peter Hahn, MD, CEO of the University of Michigan Health–West. Health care systems, especially in rural areas, are already experiencing this severe shortage, he said. It results in delayed patient care, and as a result, more significant health care needs that trickle down.

It’s what makes primary care, with an emphasis on health promotion and prevention, a great niche for NP-led clinics to address the physician shortage, Dr. Hahn told this news organization. NPs can optimize patient outcomes with fewer resources compared to a physician, he said.
 

Growth of NP field

Improving patient experience and making health care less transactional were priorities for The Good Clinic founder and chief nurse practitioner officer Kevin Lee Smith, DNP.

“The bottom line is we truly wanted to take that nursing perspective where you look at the bio-psycho-social-spiritual being. What is unique [about NPs] is the patient education focus, experience, and holistic care. And NPs are more inclined to take that time because that’s part of our education,” he said.

Nurse practitioner Teal Foster owns Refine Wellness, an independent practice in Stillwater, Minn., which is not affiliated with Mitesco clinics. One reason she started her company was that she was seeing that patients couldn’t get an appointment to see their provider, sometimes for weeks to months. Ms. Foster said she sets her own appointment times, spends more time with patients, and has a greater opportunity to take a more holistic approach to care.

“As nurse practitioners, our education is largely based on prevention and chronic disease management. With that being the focus, it’s seeing the big picture, rather than individual parts of the patient,” Ms. Foster said in an interview.
 

Doctors see need for NPs – with caution

“Nursing education is focused more on health promotion and prevention – tenets that prevent ED costs specifically in underserved populations,” said Dr. Hahn. “In these rural areas or medically underserved communities, NP-led clinics support positive patient experience scores, a sense of security, feelings of trust and respect, and have been shown to help patients gain insights into their own health.”

With the physician shortage, advanced practice providers are a crucial part of the solution for patients, as well as health care systems, Dr. Hahn said. But one challenge to NP-led clinics is the variability in practice regulations from state to state. “Standardization should be considered a high priority to utilize these advanced practice providers effectively and to enable them to consistently practice at the top of their license,” said Dr. Hahn.

The concern of many physicians is that not having physician supervision for early-career NPs can lead to problems, Dr. Anand said. Physicians train much longer than NPs, and it’s what lends to their credibility and their qualification to deliver quality care, he explained. “Patients in rural communities can be very complex and have multiple comorbidities. Sometimes that quick training is not able to do justice to that.”

It’s why Dr. Anand said meeting qualifications and having physician mentorship opportunities would bring a “much-needed safeguard” and regulatory aspects to delivering care in those settings. Even experienced physicians can improve their skills if they have a good coach and mentor, he said.
 

Continuing to collaborate

At The Good Clinic, collaboration operates similarly to at an MD-led clinic, Dr. Smith said. Computer messaging between the six clinics puts NPs in touch with each other instantly.

“Curbside consults” are common. “For example, we’ll have someone who has 20 years of women’s health experience, and the person who has 5 years as an NP might run into a case where they need that person. We’ll do a lot of consulting internally,” explained Dr. Smith.

A partnership with a nearby radiology group lends radiologists who are happy to consult with an NP over the phone about what type of x-ray would be most beneficial, he said. For cases that require a higher level of care, The Good Clinic maintains an extensive referral list.

“We are here to advocate for our patients,” said Dr. Smith. “We have best-practice guidelines in-house, and there’s also that professional accountability and ethics, that you’re not going to go into the territory of managing something that you’re not comfortable with. It takes a village to provide the appropriate care for an individual.”

A version of this article first appeared on Medscape.com.

Acts of violence targeting the professionals who staff America’s emergency departments have gotten significantly worse since the COVID pandemic’s onset – with serious implications for the future provision of emergency medicine. Those are among the conclusions from a new poll conducted for the American College of Emergency Physicians and reported Sept. 22 in a virtual press briefing.

Among 2,712 physicians responding to the ACEP poll conducted from July 25 to Aug. 1, 45% said that violence in the ED has increased greatly and 40% said it has increased somewhat over the past 5 years, while 89% said they believe this violence has harmed patient care. And 55% reported that they personally had been assaulted in the ED – some of them on a weekly or more frequent basis.

That number is up from 49% in a similar poll conducted for ACEP in 2018. One-third (33%) of respondents said they were injured on the job from a workplace assault, up from 27% in 2018. Reported incidents include verbal assaults with the threat of violence as well as being hit, slapped, spit on, punched, kicked, scratched or bit, sexual assaults, and assaults with a weapon like a knife or gun.

Doctors often describe personal encounters that illustrate the survey results. Alex Skog, MD, an emergency physician in Oregon City and president-elect of ACEP’s Oregon state chapter, said that when he was asked to speak at the press briefing, he started reviewing past violent incidents from his own career. But in the weeks leading up to the briefing, two more horrific incidents occurred, highlighting how dire the situation has become for emergency personnel.

“Few memories are more painful to me than an evening about a month ago when an intoxicated patient started roaming down the halls, out of sight of nursing staff due to overcrowding,” Dr. Skog related at the press briefing. “I heard a scream. I was the second person into the room next door. I saw the male patient on the ground straddling a nurse I work with and repeatedly punching her in the head. I wrestled him off and was quickly joined by other staff,” he said.

“I consider the staff I work with not just colleagues but close friends. ... Emergency medicine is hemorrhaging doctors, nurses, and techs who can no longer accept the violence they experience daily. I fear we will lose these frontline medical professionals unless action is taken to increase accountability and add protections for staff.” Violent incidents like these contribute to increased rates of burnout, turnover, and mental health issues for ED professionals.
 

A paralyzed ED

Dr. Skog described another very recent incident where an agitated patient, brought in by ambulance after an intervention involving multiple police and restraints to prevent him from attacking the paramedics transporting him, charged an ED technician, tearing his shirt and wrestling him to the ground.

While the physical trauma that results from events like this is unacceptable, other effects may be less obvious, Dr. Skog said. His department was essentially paralyzed by the turmoil in its ability to care for other emergency patients and had to go on ambulance diversion for several hours, causing delays in the treatment of other critically ill patients.

“The average emergency department clinician is well aware that violence today is completely different than it was 5 years ago, and this survey quantifies that,” Dr. Skog said. Clinicians need to understand how important it is to share their stories and get the word out. ED professionals often fail to report violent incidents because of the belief that nothing will be done about it.

“But without us making it known to everyone, it will be harder to call stakeholders to account to address the problem.” Those stakeholders include hospital administrators, law enforcement, and legislators, Dr. Skog added. “We need to find appropriate venues for holding the people who knowingly assault health care workers accountable.”
 

Legislative solutions proposed

Two bills now in Congress are designed to address the problem of ED violence. While it is late in the legislative season of an election year, ACEP is encouraging legislators to include ED violence as a component of any larger conversation about mental health, patients, and physicians.

The Workplace Violence Prevention Act for Health Care and Social Service Workers, H.R. 1195, which passed the House in 2021 and was introduced in the Senate by Sen. Tammy Baldwin (D-Wisc.), was highlighted in a press conference on the Senate lawn in May, cosponsored by ACEP and the Emergency Nurses Association (ED nurses may have even higher rates of violence on the job). It calls on the Occupational Safety and Health Administration to require employers in health care and social services to establish workplace violence prevention plans in accordance with OSHA’s 2016 “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.”

This bill is supported by the American Public Health Association, although the American Hospital Association opposes it based on increased costs for hospitals. AHA has stated that hospitals already strive to prevent violence in the workplace, although ACEP’s new study reinforces how this is not sufficient.

A recent article in Security suggests that hospitals could start implementing the features of H.R. 1195 even before it becomes law, given its important implications for hospital bottom lines, absenteeism, turnover, and morale.

A second bill, the Safety from Violence for Healthcare Employees Act, H.R. 7961, introduced in June by Rep. Madeleine Dean (D-Pa.) and Rep. Larry Bucshon, MD, (R-Ind.), would create federal penalties for violence against health care workers, similar to protections now in place for airport and airline personnel.
 

Violence’s vicious cycle

“This type of legislation is urgently needed to ensure the safety of all health care providers,” said Robert Glatter, MD, an emergency physician at Lenox Hill Hospital, New York.

“ED violence creates a vicious cycle affecting not only the long-term mental and physical health, but overall well-being and security of health care workers,” Dr. Glatter said in an interview. “It ultimately impacts their ability to perform their jobs in a confident and competent manner. The bottom line is that much more needs to be done to ensure that every member of the team in the ED can make patient care a priority, as opposed to worry and concerns about their own safety.”

The pandemic seriously eroded trust between patients and providers, Dr. Glatter said. This loss of trust is harmful not only to patient care, but to the long-term health and compliance of patients overall. It makes addressing the epidemic of ED violence crucial to all stakeholders, healthcare providers and patients alike.”

Experienced clinicians have a sense of what triggers patients to an act of violence, although that understanding may not help in a fast-moving crisis, Dr. Skog said. In addition to the lack of trust between patients and clinicians, frustrations over delays in treatment, obvious agitation, intoxication, and drug-seeking behavior may be warning signs. “I can see patients’ past violent behavior red-flagged in their chart, but they are still assaulting us.”

What else could help? More use of metal detectors and the 24-hour presence of security personnel able to rapidly respond to escalating situations can be great tools in specific situations, he said. But EDs vary widely in size and setting. Another tool is an emergency device that can alert the entire department in a crisis.

But for Dr. Skog, one of the most important responses is to actually hold patients accountable for their acts of violence – to report them to the police and the criminal justice system. According to the new poll, hospital security departments pressed charges for such incidents a mere 2% of the time.

In Oregon, it now is merely a misdemeanor to assault a hospital worker, he said. A bill proposing to change that just died in the state legislature.

ACEP engaged Marketing General Incorporated to replicate a brief polling survey originally conducted in 2018. Dr. Skog and Dr. Glatter disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Acts of violence targeting the professionals who staff America’s emergency departments have gotten significantly worse since the COVID pandemic’s onset – with serious implications for the future provision of emergency medicine. Those are among the conclusions from a new poll conducted for the American College of Emergency Physicians and reported Sept. 22 in a virtual press briefing.

Among 2,712 physicians responding to the ACEP poll conducted from July 25 to Aug. 1, 45% said that violence in the ED has increased greatly and 40% said it has increased somewhat over the past 5 years, while 89% said they believe this violence has harmed patient care. And 55% reported that they personally had been assaulted in the ED – some of them on a weekly or more frequent basis.

That number is up from 49% in a similar poll conducted for ACEP in 2018. One-third (33%) of respondents said they were injured on the job from a workplace assault, up from 27% in 2018. Reported incidents include verbal assaults with the threat of violence as well as being hit, slapped, spit on, punched, kicked, scratched or bit, sexual assaults, and assaults with a weapon like a knife or gun.

Doctors often describe personal encounters that illustrate the survey results. Alex Skog, MD, an emergency physician in Oregon City and president-elect of ACEP’s Oregon state chapter, said that when he was asked to speak at the press briefing, he started reviewing past violent incidents from his own career. But in the weeks leading up to the briefing, two more horrific incidents occurred, highlighting how dire the situation has become for emergency personnel.

“Few memories are more painful to me than an evening about a month ago when an intoxicated patient started roaming down the halls, out of sight of nursing staff due to overcrowding,” Dr. Skog related at the press briefing. “I heard a scream. I was the second person into the room next door. I saw the male patient on the ground straddling a nurse I work with and repeatedly punching her in the head. I wrestled him off and was quickly joined by other staff,” he said.

“I consider the staff I work with not just colleagues but close friends. ... Emergency medicine is hemorrhaging doctors, nurses, and techs who can no longer accept the violence they experience daily. I fear we will lose these frontline medical professionals unless action is taken to increase accountability and add protections for staff.” Violent incidents like these contribute to increased rates of burnout, turnover, and mental health issues for ED professionals.
 

A paralyzed ED

Dr. Skog described another very recent incident where an agitated patient, brought in by ambulance after an intervention involving multiple police and restraints to prevent him from attacking the paramedics transporting him, charged an ED technician, tearing his shirt and wrestling him to the ground.

While the physical trauma that results from events like this is unacceptable, other effects may be less obvious, Dr. Skog said. His department was essentially paralyzed by the turmoil in its ability to care for other emergency patients and had to go on ambulance diversion for several hours, causing delays in the treatment of other critically ill patients.

“The average emergency department clinician is well aware that violence today is completely different than it was 5 years ago, and this survey quantifies that,” Dr. Skog said. Clinicians need to understand how important it is to share their stories and get the word out. ED professionals often fail to report violent incidents because of the belief that nothing will be done about it.

“But without us making it known to everyone, it will be harder to call stakeholders to account to address the problem.” Those stakeholders include hospital administrators, law enforcement, and legislators, Dr. Skog added. “We need to find appropriate venues for holding the people who knowingly assault health care workers accountable.”
 

Legislative solutions proposed

Two bills now in Congress are designed to address the problem of ED violence. While it is late in the legislative season of an election year, ACEP is encouraging legislators to include ED violence as a component of any larger conversation about mental health, patients, and physicians.

The Workplace Violence Prevention Act for Health Care and Social Service Workers, H.R. 1195, which passed the House in 2021 and was introduced in the Senate by Sen. Tammy Baldwin (D-Wisc.), was highlighted in a press conference on the Senate lawn in May, cosponsored by ACEP and the Emergency Nurses Association (ED nurses may have even higher rates of violence on the job). It calls on the Occupational Safety and Health Administration to require employers in health care and social services to establish workplace violence prevention plans in accordance with OSHA’s 2016 “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.”

This bill is supported by the American Public Health Association, although the American Hospital Association opposes it based on increased costs for hospitals. AHA has stated that hospitals already strive to prevent violence in the workplace, although ACEP’s new study reinforces how this is not sufficient.

A recent article in Security suggests that hospitals could start implementing the features of H.R. 1195 even before it becomes law, given its important implications for hospital bottom lines, absenteeism, turnover, and morale.

A second bill, the Safety from Violence for Healthcare Employees Act, H.R. 7961, introduced in June by Rep. Madeleine Dean (D-Pa.) and Rep. Larry Bucshon, MD, (R-Ind.), would create federal penalties for violence against health care workers, similar to protections now in place for airport and airline personnel.
 

Violence’s vicious cycle

“This type of legislation is urgently needed to ensure the safety of all health care providers,” said Robert Glatter, MD, an emergency physician at Lenox Hill Hospital, New York.

“ED violence creates a vicious cycle affecting not only the long-term mental and physical health, but overall well-being and security of health care workers,” Dr. Glatter said in an interview. “It ultimately impacts their ability to perform their jobs in a confident and competent manner. The bottom line is that much more needs to be done to ensure that every member of the team in the ED can make patient care a priority, as opposed to worry and concerns about their own safety.”

The pandemic seriously eroded trust between patients and providers, Dr. Glatter said. This loss of trust is harmful not only to patient care, but to the long-term health and compliance of patients overall. It makes addressing the epidemic of ED violence crucial to all stakeholders, healthcare providers and patients alike.”

Experienced clinicians have a sense of what triggers patients to an act of violence, although that understanding may not help in a fast-moving crisis, Dr. Skog said. In addition to the lack of trust between patients and clinicians, frustrations over delays in treatment, obvious agitation, intoxication, and drug-seeking behavior may be warning signs. “I can see patients’ past violent behavior red-flagged in their chart, but they are still assaulting us.”

What else could help? More use of metal detectors and the 24-hour presence of security personnel able to rapidly respond to escalating situations can be great tools in specific situations, he said. But EDs vary widely in size and setting. Another tool is an emergency device that can alert the entire department in a crisis.

But for Dr. Skog, one of the most important responses is to actually hold patients accountable for their acts of violence – to report them to the police and the criminal justice system. According to the new poll, hospital security departments pressed charges for such incidents a mere 2% of the time.

In Oregon, it now is merely a misdemeanor to assault a hospital worker, he said. A bill proposing to change that just died in the state legislature.

ACEP engaged Marketing General Incorporated to replicate a brief polling survey originally conducted in 2018. Dr. Skog and Dr. Glatter disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Acts of violence targeting the professionals who staff America’s emergency departments have gotten significantly worse since the COVID pandemic’s onset – with serious implications for the future provision of emergency medicine. Those are among the conclusions from a new poll conducted for the American College of Emergency Physicians and reported Sept. 22 in a virtual press briefing.

Among 2,712 physicians responding to the ACEP poll conducted from July 25 to Aug. 1, 45% said that violence in the ED has increased greatly and 40% said it has increased somewhat over the past 5 years, while 89% said they believe this violence has harmed patient care. And 55% reported that they personally had been assaulted in the ED – some of them on a weekly or more frequent basis.

That number is up from 49% in a similar poll conducted for ACEP in 2018. One-third (33%) of respondents said they were injured on the job from a workplace assault, up from 27% in 2018. Reported incidents include verbal assaults with the threat of violence as well as being hit, slapped, spit on, punched, kicked, scratched or bit, sexual assaults, and assaults with a weapon like a knife or gun.

Doctors often describe personal encounters that illustrate the survey results. Alex Skog, MD, an emergency physician in Oregon City and president-elect of ACEP’s Oregon state chapter, said that when he was asked to speak at the press briefing, he started reviewing past violent incidents from his own career. But in the weeks leading up to the briefing, two more horrific incidents occurred, highlighting how dire the situation has become for emergency personnel.

“Few memories are more painful to me than an evening about a month ago when an intoxicated patient started roaming down the halls, out of sight of nursing staff due to overcrowding,” Dr. Skog related at the press briefing. “I heard a scream. I was the second person into the room next door. I saw the male patient on the ground straddling a nurse I work with and repeatedly punching her in the head. I wrestled him off and was quickly joined by other staff,” he said.

“I consider the staff I work with not just colleagues but close friends. ... Emergency medicine is hemorrhaging doctors, nurses, and techs who can no longer accept the violence they experience daily. I fear we will lose these frontline medical professionals unless action is taken to increase accountability and add protections for staff.” Violent incidents like these contribute to increased rates of burnout, turnover, and mental health issues for ED professionals.
 

A paralyzed ED

Dr. Skog described another very recent incident where an agitated patient, brought in by ambulance after an intervention involving multiple police and restraints to prevent him from attacking the paramedics transporting him, charged an ED technician, tearing his shirt and wrestling him to the ground.

While the physical trauma that results from events like this is unacceptable, other effects may be less obvious, Dr. Skog said. His department was essentially paralyzed by the turmoil in its ability to care for other emergency patients and had to go on ambulance diversion for several hours, causing delays in the treatment of other critically ill patients.

“The average emergency department clinician is well aware that violence today is completely different than it was 5 years ago, and this survey quantifies that,” Dr. Skog said. Clinicians need to understand how important it is to share their stories and get the word out. ED professionals often fail to report violent incidents because of the belief that nothing will be done about it.

“But without us making it known to everyone, it will be harder to call stakeholders to account to address the problem.” Those stakeholders include hospital administrators, law enforcement, and legislators, Dr. Skog added. “We need to find appropriate venues for holding the people who knowingly assault health care workers accountable.”
 

Legislative solutions proposed

Two bills now in Congress are designed to address the problem of ED violence. While it is late in the legislative season of an election year, ACEP is encouraging legislators to include ED violence as a component of any larger conversation about mental health, patients, and physicians.

The Workplace Violence Prevention Act for Health Care and Social Service Workers, H.R. 1195, which passed the House in 2021 and was introduced in the Senate by Sen. Tammy Baldwin (D-Wisc.), was highlighted in a press conference on the Senate lawn in May, cosponsored by ACEP and the Emergency Nurses Association (ED nurses may have even higher rates of violence on the job). It calls on the Occupational Safety and Health Administration to require employers in health care and social services to establish workplace violence prevention plans in accordance with OSHA’s 2016 “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.”

This bill is supported by the American Public Health Association, although the American Hospital Association opposes it based on increased costs for hospitals. AHA has stated that hospitals already strive to prevent violence in the workplace, although ACEP’s new study reinforces how this is not sufficient.

A recent article in Security suggests that hospitals could start implementing the features of H.R. 1195 even before it becomes law, given its important implications for hospital bottom lines, absenteeism, turnover, and morale.

A second bill, the Safety from Violence for Healthcare Employees Act, H.R. 7961, introduced in June by Rep. Madeleine Dean (D-Pa.) and Rep. Larry Bucshon, MD, (R-Ind.), would create federal penalties for violence against health care workers, similar to protections now in place for airport and airline personnel.
 

Violence’s vicious cycle

“This type of legislation is urgently needed to ensure the safety of all health care providers,” said Robert Glatter, MD, an emergency physician at Lenox Hill Hospital, New York.

“ED violence creates a vicious cycle affecting not only the long-term mental and physical health, but overall well-being and security of health care workers,” Dr. Glatter said in an interview. “It ultimately impacts their ability to perform their jobs in a confident and competent manner. The bottom line is that much more needs to be done to ensure that every member of the team in the ED can make patient care a priority, as opposed to worry and concerns about their own safety.”

The pandemic seriously eroded trust between patients and providers, Dr. Glatter said. This loss of trust is harmful not only to patient care, but to the long-term health and compliance of patients overall. It makes addressing the epidemic of ED violence crucial to all stakeholders, healthcare providers and patients alike.”

Experienced clinicians have a sense of what triggers patients to an act of violence, although that understanding may not help in a fast-moving crisis, Dr. Skog said. In addition to the lack of trust between patients and clinicians, frustrations over delays in treatment, obvious agitation, intoxication, and drug-seeking behavior may be warning signs. “I can see patients’ past violent behavior red-flagged in their chart, but they are still assaulting us.”

What else could help? More use of metal detectors and the 24-hour presence of security personnel able to rapidly respond to escalating situations can be great tools in specific situations, he said. But EDs vary widely in size and setting. Another tool is an emergency device that can alert the entire department in a crisis.

But for Dr. Skog, one of the most important responses is to actually hold patients accountable for their acts of violence – to report them to the police and the criminal justice system. According to the new poll, hospital security departments pressed charges for such incidents a mere 2% of the time.

In Oregon, it now is merely a misdemeanor to assault a hospital worker, he said. A bill proposing to change that just died in the state legislature.

ACEP engaged Marketing General Incorporated to replicate a brief polling survey originally conducted in 2018. Dr. Skog and Dr. Glatter disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It is no secret that medical school is expensive. Depending on where in the world you live, the cost of a medical degree varies. In the United States, it is well known that medical students end up with an average of $241,600 in debt after at least 8 years of education; attending a public, private, Ivy League or non–Ivy League school may cause this to differ among students.

In the United Kingdom, however, the true cost of medical training isn’t as obvious. All students pay the same amount of tuition, which is usually paid for by a government loan for the entirety of their course. For those who need it, a maintenance loan is also available for living expenses. Naturally, those from lower income households receive higher maintenance loans and therefore, have a higher debt burden by the end of their studies – debt you don’t think about until your first real paycheck post medical school. (It is also important to note that these loans are completely optional – throughout my time in medical school, I’ve encountered students who didn’t need all or any of their student loans to pay for their medical school tuition or living expenses.)

The real cost, however, the one we have to live with everyday as students, comes from expenses that we were not warned about when embarking on our journey through medical school – for example, the cost of a stethoscope, revision resources, transport, and housing. In addition, as the commitment of a medical degree intensifies, there is less and less time for students to work-part time outside of their studies, meaning less income coming in while expenses increase and student loans accumulate interest.

Furthermore, it is common knowledge that a higher proportion of students from affluent backgrounds are accepted into medical school and that socioeconomic status and one’s finances create a huge disparity in achievement and general well-being during medical school. Indeed, studies show that higher levels of debt are negatively correlated with mental well-being and academic performance; students from lower socioeconomic backgrounds have higher debts and as a result, worry more about money.

Four years into my medical education, I have experienced and now understand the financial strain of a medical degree. The path to becoming a doctor truly is one of life-long sacrifice, so why doesn’t our society look after those who make it their life’s work to look after them? It is incredibly unfortunate that there is a lack of financial support and assistance for medical trainees, especially those from lower socioeconomic backgrounds. In fact, according to a BMJ study, about 5% of students were considering dropping out of medical school because of financial hardship alone and have cut back on simple living essentials such as heating and food.

Unfortunately, these are the students that are more representative of the patient population; the average patient that we see is not one had that a private school education or had affluent parents. Although more people from diverse backgrounds are enrolling in medical school, finances act as yet another barrier preventing them from completing this degree; such factors are why we see such limited diversity in medicine.

Talking about finances appears to be a taboo in the medical field, but doing so is important, for it not only raises awareness and creates a voice for those 5% of students who are struggling financially but also helps premed students have a realistic understanding of the financial sacrifice of pursuing medicine, allowing them to make more informed choices about their future careers. In the meantime, as we create this new culture, it will be important for institutions to consider supporting students financially through bursaries and scholarships (and reducing tuition prices) throughout their time at university. In this way, we can create a more equitable and encouraging environments for all medical trainees.

Ms. Ntorinkansah is a medical student at the University of Nottingham (England). She reported no conflicts of interest.

A version of this article first appeared on Medscape.com.

It is no secret that medical school is expensive. Depending on where in the world you live, the cost of a medical degree varies. In the United States, it is well known that medical students end up with an average of $241,600 in debt after at least 8 years of education; attending a public, private, Ivy League or non–Ivy League school may cause this to differ among students.

In the United Kingdom, however, the true cost of medical training isn’t as obvious. All students pay the same amount of tuition, which is usually paid for by a government loan for the entirety of their course. For those who need it, a maintenance loan is also available for living expenses. Naturally, those from lower income households receive higher maintenance loans and therefore, have a higher debt burden by the end of their studies – debt you don’t think about until your first real paycheck post medical school. (It is also important to note that these loans are completely optional – throughout my time in medical school, I’ve encountered students who didn’t need all or any of their student loans to pay for their medical school tuition or living expenses.)

The real cost, however, the one we have to live with everyday as students, comes from expenses that we were not warned about when embarking on our journey through medical school – for example, the cost of a stethoscope, revision resources, transport, and housing. In addition, as the commitment of a medical degree intensifies, there is less and less time for students to work-part time outside of their studies, meaning less income coming in while expenses increase and student loans accumulate interest.

Furthermore, it is common knowledge that a higher proportion of students from affluent backgrounds are accepted into medical school and that socioeconomic status and one’s finances create a huge disparity in achievement and general well-being during medical school. Indeed, studies show that higher levels of debt are negatively correlated with mental well-being and academic performance; students from lower socioeconomic backgrounds have higher debts and as a result, worry more about money.

Four years into my medical education, I have experienced and now understand the financial strain of a medical degree. The path to becoming a doctor truly is one of life-long sacrifice, so why doesn’t our society look after those who make it their life’s work to look after them? It is incredibly unfortunate that there is a lack of financial support and assistance for medical trainees, especially those from lower socioeconomic backgrounds. In fact, according to a BMJ study, about 5% of students were considering dropping out of medical school because of financial hardship alone and have cut back on simple living essentials such as heating and food.

Unfortunately, these are the students that are more representative of the patient population; the average patient that we see is not one had that a private school education or had affluent parents. Although more people from diverse backgrounds are enrolling in medical school, finances act as yet another barrier preventing them from completing this degree; such factors are why we see such limited diversity in medicine.

Talking about finances appears to be a taboo in the medical field, but doing so is important, for it not only raises awareness and creates a voice for those 5% of students who are struggling financially but also helps premed students have a realistic understanding of the financial sacrifice of pursuing medicine, allowing them to make more informed choices about their future careers. In the meantime, as we create this new culture, it will be important for institutions to consider supporting students financially through bursaries and scholarships (and reducing tuition prices) throughout their time at university. In this way, we can create a more equitable and encouraging environments for all medical trainees.

Ms. Ntorinkansah is a medical student at the University of Nottingham (England). She reported no conflicts of interest.

A version of this article first appeared on Medscape.com.

It is no secret that medical school is expensive. Depending on where in the world you live, the cost of a medical degree varies. In the United States, it is well known that medical students end up with an average of $241,600 in debt after at least 8 years of education; attending a public, private, Ivy League or non–Ivy League school may cause this to differ among students.

In the United Kingdom, however, the true cost of medical training isn’t as obvious. All students pay the same amount of tuition, which is usually paid for by a government loan for the entirety of their course. For those who need it, a maintenance loan is also available for living expenses. Naturally, those from lower income households receive higher maintenance loans and therefore, have a higher debt burden by the end of their studies – debt you don’t think about until your first real paycheck post medical school. (It is also important to note that these loans are completely optional – throughout my time in medical school, I’ve encountered students who didn’t need all or any of their student loans to pay for their medical school tuition or living expenses.)

The real cost, however, the one we have to live with everyday as students, comes from expenses that we were not warned about when embarking on our journey through medical school – for example, the cost of a stethoscope, revision resources, transport, and housing. In addition, as the commitment of a medical degree intensifies, there is less and less time for students to work-part time outside of their studies, meaning less income coming in while expenses increase and student loans accumulate interest.

Furthermore, it is common knowledge that a higher proportion of students from affluent backgrounds are accepted into medical school and that socioeconomic status and one’s finances create a huge disparity in achievement and general well-being during medical school. Indeed, studies show that higher levels of debt are negatively correlated with mental well-being and academic performance; students from lower socioeconomic backgrounds have higher debts and as a result, worry more about money.

Four years into my medical education, I have experienced and now understand the financial strain of a medical degree. The path to becoming a doctor truly is one of life-long sacrifice, so why doesn’t our society look after those who make it their life’s work to look after them? It is incredibly unfortunate that there is a lack of financial support and assistance for medical trainees, especially those from lower socioeconomic backgrounds. In fact, according to a BMJ study, about 5% of students were considering dropping out of medical school because of financial hardship alone and have cut back on simple living essentials such as heating and food.

Unfortunately, these are the students that are more representative of the patient population; the average patient that we see is not one had that a private school education or had affluent parents. Although more people from diverse backgrounds are enrolling in medical school, finances act as yet another barrier preventing them from completing this degree; such factors are why we see such limited diversity in medicine.

Talking about finances appears to be a taboo in the medical field, but doing so is important, for it not only raises awareness and creates a voice for those 5% of students who are struggling financially but also helps premed students have a realistic understanding of the financial sacrifice of pursuing medicine, allowing them to make more informed choices about their future careers. In the meantime, as we create this new culture, it will be important for institutions to consider supporting students financially through bursaries and scholarships (and reducing tuition prices) throughout their time at university. In this way, we can create a more equitable and encouraging environments for all medical trainees.

Ms. Ntorinkansah is a medical student at the University of Nottingham (England). She reported no conflicts of interest.

A version of this article first appeared on Medscape.com.

Unlike for many other professions, there is no age limit for practicing medicine. According to international standards, airplane pilots, for example, who are responsible for the safety of many human lives, must retire by the age of 60 if they work alone, or 65 if they have a copilot. In Brazil, however, this age limit does not exist for pilots or physicians.

The only restriction on professional practice within the medical context is the mandatory retirement imposed on medical professors who teach at public (state and federal) universities, starting at the age of 75. Nevertheless, these professionals can continue practicing administrative and research-related activities. After “expulsion,” as this mandatory retirement is often called, professors who stood out or contributed to the institution and science may receive the title of professor emeritus.

In the private sector, age limits are not formally set, but the hiring of middle-aged professionals is limited.

At the Heart Institute of the University of São Paulo (Brazil) School of Medicine Clinical Hospital (InCor/HCFMUSP), one of the world’s largest teaching and research centers for cardiovascular and pulmonary diseases, several octogenarian specialists lead studies and teams. One of these is Noedir Stolf, MD, an 82-year-old cardiovascular surgeon who operates almost every day and coordinates studies on transplants, mechanical circulatory support, and aortic surgery. There is also Protásio Lemos da Luz, MD, an 82-year-old clinical cardiologist who guides research on subjects including atherosclerosis, the endothelium, microbiota, and diabetes. The protective effect of wine on atherosclerosis is one of his best-known studies.

No longer working is also not in the cards for Angelita Habr-Gama, MD, who, at 89 years old, is one of the oldest physicians in current practice. With a career spanning more than 7 decades, she is a world reference in coloproctology. She was the first woman to become a surgical resident at the HCFMUSP, where she later founded the coloproctology specialty and created the first residency program for the specialty. In April 2022, Dr. Habr-Gama joined the ranks of the 100 most influential scientists in the world, nominated by researchers at Stanford (Calif.) University, and published in PLOS Biology.

In 2020, she was sedated, intubated, and hospitalized in the intensive care unit of the Oswaldo Cruz German Hospital for 54 days because of a SARS-CoV-2 infection. After her discharge, she went back to work in less than 10 days – and added chess classes to her routine. “To get up and go to work makes me very happy. Work is my greatest hobby. No one has ever heard me complain about my life,” Dr. Habr-Gama told this news organization after having rescheduled the interview twice because of emergency surgeries.

“Doctors have a professional longevity that does not exist for other professions in which the person retires and stops practicing their profession or goes on to do something else for entertainment. Doctors can retire from one place of employment or public practice and continue practicing medicine in the office as an administrator or consultant,” Ângelo Vattimo, first secretary of the state of São Paulo Regional Board of Medicine (CREMESP), stated. The board regularly organizes a ceremony to honor professionals who have been practicing for 50 years, awarding them a certificate and engraved medal. “Many of them are around 80 years old, working and teaching. This always makes us very happy. What profession has such exceptional compliance for so long?” said Mr. Vattimo.

In the medical field, the older the age range, the smaller the number of women. According to the 2020 Medical Demographics in Brazil survey, only 2 out of 10 practicing professionals older than 70 are women.

Not everyone over 80 has Dr. Habr-Gama’s vitality, because the impact of aging is not equal. “If you look at a group of 80-year-olds, there will be much more variability than within a group of 40-year-olds,” stated Mark Katlic, MD, chief of surgery at LifeBridge Health System in the United States, who has dedicated his life to studying the subject. Dr. Katlic spoke on the subject in an interview that was published in the article “How Old Is Too Old to Work as a Doctor?” published by this news organization in April of 2022. The article discusses the evaluations of elderly physicians’ skills and competences that U.S. companies conduct. The subject has been leading to profound debate.

Dr. Katlic defends screening programs for elderly physicians, which already are in effect at the company for which he works, LifeBridge Health, and various others in the United States. “We do [screen elderly physicians at LifeBridge Health], and so do a few dozen other [U.S. institutions], but there are hundreds [of health care institutions] that do not conduct this screening,” he pointed out.

Age-related assessment faces great resistance in the United States. One physician who is against the initiative is Frank Stockdale, MD, PhD, an 86-year-old practicing oncologist affiliated with Stanford (Calif.) University Health. “It’s age discrimination ... Physicians [in the United States] receive assessments throughout their careers as part of the accreditation process – there’s no need to change that as physicians reach a certain age,” Dr. Stockdale told this news organization.

The U.S. initiative of instituting physician assessment programs for those of a certain age has even been tested in court. According to an article published in Medscape, “in New Haven, Connecticut, for instance, the U.S. Equal Employment Opportunity Commission (EEOC) filed a suit in 2020 on behalf of the Yale New Haven Hospital staff, alleging a discriminatory late career practitioner policy.”

Also, according to the article, a similar case in Minnesota reached a settlement in 2021, providing monetary relief to staff impacted by out-of-pocket costs for the assessment, in addition to requiring that the hospital in question report to the EEOC any complaints related to age discrimination.

The fact is that increased life expectancy and, subsequently, the number of middle-aged physicians in practice, has raised several questions regarding the impact of aging on professional practice. In Brazil, the subject is of interest to more than 34,571 physicians between 65 and 69 years of age and 34,237 physicians older than 70. In all, this population represents approximately 14.3% of the country’s active workforce, according to the 2020 Medical Demographics in Brazil survey.

The significant participation of health care professionals over age 50 in a survey conducted by this news organization to learn what physicians think about the age limit for practicing their professions is evidence that the subject is a present concern. Of a total of 1,641 participants, 57% were age 60 or older, 17% were between 50 and 59 years, and 12% were between 40 and 49 years. Among all participants, 51% were against these limitations, 17% approved of the idea for all specialties, and 32% believed the restriction was appropriate only for some specialties. Regarding the possibility of older physicians undergoing regular assessments, the opinions were divided: Thirty-one percent thought they should be assessed in all specialties. Furthermore, 31% believed that cognitive abilities should be regularly tested in all specialties, 31% thought this should take place for some specialties, and 38% were against this approach.

Professionals want to know, for example, how (and whether) advanced age can interfere with performance, what are the competences required to practice their activities, and if the criteria vary by specialty. “A psychiatrist doesn’t have to have perfect visual acuity, as required from a dermatologist, but it is important that they have good hearing, for example,” argued Clóvis Constantino, MD, former president of the São Paulo Regional Medical Board (CRM-SP) and former vice president of the Brazilian Federal Medical Board (CFM). “However, a surgeon has to stand for several hours in positions that may be uncomfortable. It’s not easy,” he told this news organization.

In the opinion of 82-year-old Henrique Klajner, MD, the oldest pediatrician in practice at the Albert Einstein Israeli Hospital in São Paulo, the physician cannot be subjected to the types of evaluations that have been applied in the United States. “Physicians should conduct constant self-evaluations to see if they have the competences and skills needed to practice their profession ... Moreover, this is not a matter of age. It is a matter of ethics,” said Dr. Klajner.

The ability to adapt to change and implement innovation is critical to professional longevity, he said. “Nowadays, when I admit patients, I no longer do hospital rounds, which requires a mobility equal to physical abuse for me. Therefore, I work with physicians who take care of my hospitalized patients.”

Dr. Klajner also feels there is a distinction between innovations learned through studies and what can be offered safely to patients. “If I have to care for a hospitalized patient with severe pneumonia, for example, since I am not up to date in this specialty, I am going to call upon a pulmonologist I trust and forgo my honorarium for this admission. But I will remain on the team, monitoring the patient’s progression,” he said.

During the COVID-19 pandemic, Dr. Klajner stopped seeing patients in person under the recommendation of his son, Sidney Klajner, MD, also a physician. The elder Dr. Klajner began exploring telemedicine, which opened a whole new world of possibilities. “I have conducted several online visits to provide educational instruction to mothers returning home post delivery, for example,” he told this news organization. The time to stop is not something that concerns Dr. Klajner. “I’m only going to stop when I have a really important reason to do so. For example, if I can no longer write or study, reading and rereading an article without being able to understand what is being said. At this time, none of that is happening.”

In the United States, as well as in Brazil, physicians rarely provide information to human resources departments on colleagues showing signs of cognitive or motor decline affecting their professional performance. “The expectation is that health care professionals will report colleagues with cognitive impairments, but that often does not happen,” Dr. Katlic said.

It is also not common for professionals to report their own deficits to their institutions. In large part, this is caused by a lack of well-defined policies for dealing with this issue. This news organization sought out several public and private hospitals in Brazil to see if there is any guidance on professional longevity: Most said that there is not. Only the A. C. Camargo Cancer Center reported, through its public relations team, that a committee is discussing the subject but that it is still in the early stages.

Brazilian specialist associations do not offer guidelines or instructions on the various aspects of professional longevity. Dr. Constantino tried to put the subject on the agenda during the years in which he was an administrator with the CFM. “We tried to open up discussions regarding truly elderly physicians, but the subject was not well received. I believe that it is precisely because there is a tradition of physicians working until they are no longer able that this is more difficult in Brazil ... No one exactly knows what to do in this respect.” Dr. Constantino is against the use of age as a criterion for quitting practice.

“Of course, this is a point that has to be considered, but I always defended the need for regular assessment of physicians, regardless of age range. And, although assessments are always welcome, in any profession, I also believe this would not be well received in Brazil.” He endorses an assessment of one’s knowledge and not of physical abilities, which are generally assessed through investigation when needed.

The absence of guidelines increases individual responsibility, as well as vulnerability. “Consciously, physicians will not put patients at risk if they do not have the competence to care for them or to perform a surgical procedure,” said Clystenes Odyr Soares Silva, MD, PhD, adjunct professor of pulmonology of the Federal University of São Paulo (Brazil) School of Medicine (UNIFESP). “Your peers will tell you if you are no longer able,” he added. The problem is that physicians rarely admit to or talk about their colleagues’ deficits, especially if they are in the spotlight because of advanced age. In this situation, the observation and opinion of family members regarding the health care professional’s competences and skills will hold more weight.

In case of health-related physical impairment, such as partial loss of hand movement, for example, “it is expected that this will set off an ethical warning in the person,” said Dr. Constantino. When this warning does not occur naturally, patients or colleagues can report the professional, and this may lead to the opening of an administrative investigation. If the report is found to be true, this investigation is used to suspend physicians who do not have the physical or mental ability to continue practicing medicine.

“If it’s something very serious, the physician’s license can be temporarily suspended while [the physician] is treated by a psychiatrist, with follow-up by the professional board. When discharged, the physician will get his or her [professional] license back and can go back to work,” Dr. Constantino explained. If an expert evaluation is needed, the physician will then be assessed by a forensic psychiatrist. One of the most in-demand forensic psychiatrists in Brazil is Guido Arturo Palomba, MD, 73 years old. “I have assessed some physicians for actions reported to see if they were normal people or not, but never for circumstances related to age,” Dr. Palomba said.

In practice, Brazilian medical entities do not have policies or programs to guide physicians who wish to grow old while they work or those who have started to notice they are not performing as they used to. “We have never lived as long; therefore, the quality of life in old age, as well as the concept of aging, are some of the most relevant questions of our time. These are subjects requiring additional discussion, broadening understanding and awareness in this regard,” observed Mr. Vattimo.

Dr. Constantino and Dr. Silva, who are completely against age-based assessments, believe that recertification of the specialist license every 5 years is the best path to confirming whether the physician is still able to practice. “A knowledge-based test every 5 years to recertify the specialist license has often been a topic of conversation. I think it’s an excellent idea. The person would provide a dossier of all they have done in terms of courses, conferences, and other activities, present it, and receive a score,” said Dr. Silva.

In practice, recertification of the specialist license is a topic of discussion that has been raised for years, and it is an idea that the Brazilian Medical Association (AMB) defends. In conjunction with the CFM, the association is studying a way to best implement this assessment. “It’s important to emphasize that this measure would not be retroactive at first. Instead, it would only be in effect for professionals licensed after the recertification requirement is established,” the AMB pointed out in a note sent to this news organization. Even so, the measure has faced significant resistance from a faction of the profession, and its enactment does not seem to be imminent.

The debate regarding professional longevity is taking place in various countries. In 2021, the American Medical Association Council on Medical Education released a report with a set of guidelines for the screening and assessment of physicians. The document is the product of a committee created in 2015 to study the subject. The AMA recommends that the assessment of elderly physicians be based on evidence and ethical, relevant, fair, equitable, transparent, verifiable, nonexhaustive principles, contemplating support and protecting against legal proceedings. In April of this year, a new AMA document highlighted the same principles.

Also in the United States, one of oldest initiatives created to support physicians in the process of recycling, the University of California San Diego Physician Assessment and Clinical Education Program (PACE), has a section focusing on the extended practice of medicine (Practicing Medicine Longer). For those wanting to learn more about discussions on this subject, there are online presentations on experiences in Quebec and Ontario with assessing aging physicians, neuropsychological perspectives on the aging medical population, and what to expect of healthy aging, among other subjects.

Created in 1996, PACE mostly provides services to physicians who need to address requirements of the state medical boards. Few physicians enroll on their own.

The first part of the program assesses knowledge and skills over approximately 2 days. In the second phase, the physician participates in a series of activities in a corresponding residency program. Depending on the results, the physician may have to go through a remedial program with varying activities to deal with performance deficiencies to clinical experiences at the residency level.

A version of this article first appeared on Medscape.com.

Unlike for many other professions, there is no age limit for practicing medicine. According to international standards, airplane pilots, for example, who are responsible for the safety of many human lives, must retire by the age of 60 if they work alone, or 65 if they have a copilot. In Brazil, however, this age limit does not exist for pilots or physicians.

The only restriction on professional practice within the medical context is the mandatory retirement imposed on medical professors who teach at public (state and federal) universities, starting at the age of 75. Nevertheless, these professionals can continue practicing administrative and research-related activities. After “expulsion,” as this mandatory retirement is often called, professors who stood out or contributed to the institution and science may receive the title of professor emeritus.

In the private sector, age limits are not formally set, but the hiring of middle-aged professionals is limited.

At the Heart Institute of the University of São Paulo (Brazil) School of Medicine Clinical Hospital (InCor/HCFMUSP), one of the world’s largest teaching and research centers for cardiovascular and pulmonary diseases, several octogenarian specialists lead studies and teams. One of these is Noedir Stolf, MD, an 82-year-old cardiovascular surgeon who operates almost every day and coordinates studies on transplants, mechanical circulatory support, and aortic surgery. There is also Protásio Lemos da Luz, MD, an 82-year-old clinical cardiologist who guides research on subjects including atherosclerosis, the endothelium, microbiota, and diabetes. The protective effect of wine on atherosclerosis is one of his best-known studies.

No longer working is also not in the cards for Angelita Habr-Gama, MD, who, at 89 years old, is one of the oldest physicians in current practice. With a career spanning more than 7 decades, she is a world reference in coloproctology. She was the first woman to become a surgical resident at the HCFMUSP, where she later founded the coloproctology specialty and created the first residency program for the specialty. In April 2022, Dr. Habr-Gama joined the ranks of the 100 most influential scientists in the world, nominated by researchers at Stanford (Calif.) University, and published in PLOS Biology.

In 2020, she was sedated, intubated, and hospitalized in the intensive care unit of the Oswaldo Cruz German Hospital for 54 days because of a SARS-CoV-2 infection. After her discharge, she went back to work in less than 10 days – and added chess classes to her routine. “To get up and go to work makes me very happy. Work is my greatest hobby. No one has ever heard me complain about my life,” Dr. Habr-Gama told this news organization after having rescheduled the interview twice because of emergency surgeries.

“Doctors have a professional longevity that does not exist for other professions in which the person retires and stops practicing their profession or goes on to do something else for entertainment. Doctors can retire from one place of employment or public practice and continue practicing medicine in the office as an administrator or consultant,” Ângelo Vattimo, first secretary of the state of São Paulo Regional Board of Medicine (CREMESP), stated. The board regularly organizes a ceremony to honor professionals who have been practicing for 50 years, awarding them a certificate and engraved medal. “Many of them are around 80 years old, working and teaching. This always makes us very happy. What profession has such exceptional compliance for so long?” said Mr. Vattimo.

In the medical field, the older the age range, the smaller the number of women. According to the 2020 Medical Demographics in Brazil survey, only 2 out of 10 practicing professionals older than 70 are women.

Not everyone over 80 has Dr. Habr-Gama’s vitality, because the impact of aging is not equal. “If you look at a group of 80-year-olds, there will be much more variability than within a group of 40-year-olds,” stated Mark Katlic, MD, chief of surgery at LifeBridge Health System in the United States, who has dedicated his life to studying the subject. Dr. Katlic spoke on the subject in an interview that was published in the article “How Old Is Too Old to Work as a Doctor?” published by this news organization in April of 2022. The article discusses the evaluations of elderly physicians’ skills and competences that U.S. companies conduct. The subject has been leading to profound debate.

Dr. Katlic defends screening programs for elderly physicians, which already are in effect at the company for which he works, LifeBridge Health, and various others in the United States. “We do [screen elderly physicians at LifeBridge Health], and so do a few dozen other [U.S. institutions], but there are hundreds [of health care institutions] that do not conduct this screening,” he pointed out.

Age-related assessment faces great resistance in the United States. One physician who is against the initiative is Frank Stockdale, MD, PhD, an 86-year-old practicing oncologist affiliated with Stanford (Calif.) University Health. “It’s age discrimination ... Physicians [in the United States] receive assessments throughout their careers as part of the accreditation process – there’s no need to change that as physicians reach a certain age,” Dr. Stockdale told this news organization.

The U.S. initiative of instituting physician assessment programs for those of a certain age has even been tested in court. According to an article published in Medscape, “in New Haven, Connecticut, for instance, the U.S. Equal Employment Opportunity Commission (EEOC) filed a suit in 2020 on behalf of the Yale New Haven Hospital staff, alleging a discriminatory late career practitioner policy.”

Also, according to the article, a similar case in Minnesota reached a settlement in 2021, providing monetary relief to staff impacted by out-of-pocket costs for the assessment, in addition to requiring that the hospital in question report to the EEOC any complaints related to age discrimination.

The fact is that increased life expectancy and, subsequently, the number of middle-aged physicians in practice, has raised several questions regarding the impact of aging on professional practice. In Brazil, the subject is of interest to more than 34,571 physicians between 65 and 69 years of age and 34,237 physicians older than 70. In all, this population represents approximately 14.3% of the country’s active workforce, according to the 2020 Medical Demographics in Brazil survey.

The significant participation of health care professionals over age 50 in a survey conducted by this news organization to learn what physicians think about the age limit for practicing their professions is evidence that the subject is a present concern. Of a total of 1,641 participants, 57% were age 60 or older, 17% were between 50 and 59 years, and 12% were between 40 and 49 years. Among all participants, 51% were against these limitations, 17% approved of the idea for all specialties, and 32% believed the restriction was appropriate only for some specialties. Regarding the possibility of older physicians undergoing regular assessments, the opinions were divided: Thirty-one percent thought they should be assessed in all specialties. Furthermore, 31% believed that cognitive abilities should be regularly tested in all specialties, 31% thought this should take place for some specialties, and 38% were against this approach.

Professionals want to know, for example, how (and whether) advanced age can interfere with performance, what are the competences required to practice their activities, and if the criteria vary by specialty. “A psychiatrist doesn’t have to have perfect visual acuity, as required from a dermatologist, but it is important that they have good hearing, for example,” argued Clóvis Constantino, MD, former president of the São Paulo Regional Medical Board (CRM-SP) and former vice president of the Brazilian Federal Medical Board (CFM). “However, a surgeon has to stand for several hours in positions that may be uncomfortable. It’s not easy,” he told this news organization.

In the opinion of 82-year-old Henrique Klajner, MD, the oldest pediatrician in practice at the Albert Einstein Israeli Hospital in São Paulo, the physician cannot be subjected to the types of evaluations that have been applied in the United States. “Physicians should conduct constant self-evaluations to see if they have the competences and skills needed to practice their profession ... Moreover, this is not a matter of age. It is a matter of ethics,” said Dr. Klajner.

The ability to adapt to change and implement innovation is critical to professional longevity, he said. “Nowadays, when I admit patients, I no longer do hospital rounds, which requires a mobility equal to physical abuse for me. Therefore, I work with physicians who take care of my hospitalized patients.”

Dr. Klajner also feels there is a distinction between innovations learned through studies and what can be offered safely to patients. “If I have to care for a hospitalized patient with severe pneumonia, for example, since I am not up to date in this specialty, I am going to call upon a pulmonologist I trust and forgo my honorarium for this admission. But I will remain on the team, monitoring the patient’s progression,” he said.

During the COVID-19 pandemic, Dr. Klajner stopped seeing patients in person under the recommendation of his son, Sidney Klajner, MD, also a physician. The elder Dr. Klajner began exploring telemedicine, which opened a whole new world of possibilities. “I have conducted several online visits to provide educational instruction to mothers returning home post delivery, for example,” he told this news organization. The time to stop is not something that concerns Dr. Klajner. “I’m only going to stop when I have a really important reason to do so. For example, if I can no longer write or study, reading and rereading an article without being able to understand what is being said. At this time, none of that is happening.”

In the United States, as well as in Brazil, physicians rarely provide information to human resources departments on colleagues showing signs of cognitive or motor decline affecting their professional performance. “The expectation is that health care professionals will report colleagues with cognitive impairments, but that often does not happen,” Dr. Katlic said.

It is also not common for professionals to report their own deficits to their institutions. In large part, this is caused by a lack of well-defined policies for dealing with this issue. This news organization sought out several public and private hospitals in Brazil to see if there is any guidance on professional longevity: Most said that there is not. Only the A. C. Camargo Cancer Center reported, through its public relations team, that a committee is discussing the subject but that it is still in the early stages.

Brazilian specialist associations do not offer guidelines or instructions on the various aspects of professional longevity. Dr. Constantino tried to put the subject on the agenda during the years in which he was an administrator with the CFM. “We tried to open up discussions regarding truly elderly physicians, but the subject was not well received. I believe that it is precisely because there is a tradition of physicians working until they are no longer able that this is more difficult in Brazil ... No one exactly knows what to do in this respect.” Dr. Constantino is against the use of age as a criterion for quitting practice.

“Of course, this is a point that has to be considered, but I always defended the need for regular assessment of physicians, regardless of age range. And, although assessments are always welcome, in any profession, I also believe this would not be well received in Brazil.” He endorses an assessment of one’s knowledge and not of physical abilities, which are generally assessed through investigation when needed.

The absence of guidelines increases individual responsibility, as well as vulnerability. “Consciously, physicians will not put patients at risk if they do not have the competence to care for them or to perform a surgical procedure,” said Clystenes Odyr Soares Silva, MD, PhD, adjunct professor of pulmonology of the Federal University of São Paulo (Brazil) School of Medicine (UNIFESP). “Your peers will tell you if you are no longer able,” he added. The problem is that physicians rarely admit to or talk about their colleagues’ deficits, especially if they are in the spotlight because of advanced age. In this situation, the observation and opinion of family members regarding the health care professional’s competences and skills will hold more weight.

In case of health-related physical impairment, such as partial loss of hand movement, for example, “it is expected that this will set off an ethical warning in the person,” said Dr. Constantino. When this warning does not occur naturally, patients or colleagues can report the professional, and this may lead to the opening of an administrative investigation. If the report is found to be true, this investigation is used to suspend physicians who do not have the physical or mental ability to continue practicing medicine.

“If it’s something very serious, the physician’s license can be temporarily suspended while [the physician] is treated by a psychiatrist, with follow-up by the professional board. When discharged, the physician will get his or her [professional] license back and can go back to work,” Dr. Constantino explained. If an expert evaluation is needed, the physician will then be assessed by a forensic psychiatrist. One of the most in-demand forensic psychiatrists in Brazil is Guido Arturo Palomba, MD, 73 years old. “I have assessed some physicians for actions reported to see if they were normal people or not, but never for circumstances related to age,” Dr. Palomba said.

In practice, Brazilian medical entities do not have policies or programs to guide physicians who wish to grow old while they work or those who have started to notice they are not performing as they used to. “We have never lived as long; therefore, the quality of life in old age, as well as the concept of aging, are some of the most relevant questions of our time. These are subjects requiring additional discussion, broadening understanding and awareness in this regard,” observed Mr. Vattimo.

Dr. Constantino and Dr. Silva, who are completely against age-based assessments, believe that recertification of the specialist license every 5 years is the best path to confirming whether the physician is still able to practice. “A knowledge-based test every 5 years to recertify the specialist license has often been a topic of conversation. I think it’s an excellent idea. The person would provide a dossier of all they have done in terms of courses, conferences, and other activities, present it, and receive a score,” said Dr. Silva.

In practice, recertification of the specialist license is a topic of discussion that has been raised for years, and it is an idea that the Brazilian Medical Association (AMB) defends. In conjunction with the CFM, the association is studying a way to best implement this assessment. “It’s important to emphasize that this measure would not be retroactive at first. Instead, it would only be in effect for professionals licensed after the recertification requirement is established,” the AMB pointed out in a note sent to this news organization. Even so, the measure has faced significant resistance from a faction of the profession, and its enactment does not seem to be imminent.

The debate regarding professional longevity is taking place in various countries. In 2021, the American Medical Association Council on Medical Education released a report with a set of guidelines for the screening and assessment of physicians. The document is the product of a committee created in 2015 to study the subject. The AMA recommends that the assessment of elderly physicians be based on evidence and ethical, relevant, fair, equitable, transparent, verifiable, nonexhaustive principles, contemplating support and protecting against legal proceedings. In April of this year, a new AMA document highlighted the same principles.

Also in the United States, one of oldest initiatives created to support physicians in the process of recycling, the University of California San Diego Physician Assessment and Clinical Education Program (PACE), has a section focusing on the extended practice of medicine (Practicing Medicine Longer). For those wanting to learn more about discussions on this subject, there are online presentations on experiences in Quebec and Ontario with assessing aging physicians, neuropsychological perspectives on the aging medical population, and what to expect of healthy aging, among other subjects.

Created in 1996, PACE mostly provides services to physicians who need to address requirements of the state medical boards. Few physicians enroll on their own.

The first part of the program assesses knowledge and skills over approximately 2 days. In the second phase, the physician participates in a series of activities in a corresponding residency program. Depending on the results, the physician may have to go through a remedial program with varying activities to deal with performance deficiencies to clinical experiences at the residency level.

A version of this article first appeared on Medscape.com.

Unlike for many other professions, there is no age limit for practicing medicine. According to international standards, airplane pilots, for example, who are responsible for the safety of many human lives, must retire by the age of 60 if they work alone, or 65 if they have a copilot. In Brazil, however, this age limit does not exist for pilots or physicians.

The only restriction on professional practice within the medical context is the mandatory retirement imposed on medical professors who teach at public (state and federal) universities, starting at the age of 75. Nevertheless, these professionals can continue practicing administrative and research-related activities. After “expulsion,” as this mandatory retirement is often called, professors who stood out or contributed to the institution and science may receive the title of professor emeritus.

In the private sector, age limits are not formally set, but the hiring of middle-aged professionals is limited.

At the Heart Institute of the University of São Paulo (Brazil) School of Medicine Clinical Hospital (InCor/HCFMUSP), one of the world’s largest teaching and research centers for cardiovascular and pulmonary diseases, several octogenarian specialists lead studies and teams. One of these is Noedir Stolf, MD, an 82-year-old cardiovascular surgeon who operates almost every day and coordinates studies on transplants, mechanical circulatory support, and aortic surgery. There is also Protásio Lemos da Luz, MD, an 82-year-old clinical cardiologist who guides research on subjects including atherosclerosis, the endothelium, microbiota, and diabetes. The protective effect of wine on atherosclerosis is one of his best-known studies.

No longer working is also not in the cards for Angelita Habr-Gama, MD, who, at 89 years old, is one of the oldest physicians in current practice. With a career spanning more than 7 decades, she is a world reference in coloproctology. She was the first woman to become a surgical resident at the HCFMUSP, where she later founded the coloproctology specialty and created the first residency program for the specialty. In April 2022, Dr. Habr-Gama joined the ranks of the 100 most influential scientists in the world, nominated by researchers at Stanford (Calif.) University, and published in PLOS Biology.

In 2020, she was sedated, intubated, and hospitalized in the intensive care unit of the Oswaldo Cruz German Hospital for 54 days because of a SARS-CoV-2 infection. After her discharge, she went back to work in less than 10 days – and added chess classes to her routine. “To get up and go to work makes me very happy. Work is my greatest hobby. No one has ever heard me complain about my life,” Dr. Habr-Gama told this news organization after having rescheduled the interview twice because of emergency surgeries.

“Doctors have a professional longevity that does not exist for other professions in which the person retires and stops practicing their profession or goes on to do something else for entertainment. Doctors can retire from one place of employment or public practice and continue practicing medicine in the office as an administrator or consultant,” Ângelo Vattimo, first secretary of the state of São Paulo Regional Board of Medicine (CREMESP), stated. The board regularly organizes a ceremony to honor professionals who have been practicing for 50 years, awarding them a certificate and engraved medal. “Many of them are around 80 years old, working and teaching. This always makes us very happy. What profession has such exceptional compliance for so long?” said Mr. Vattimo.

In the medical field, the older the age range, the smaller the number of women. According to the 2020 Medical Demographics in Brazil survey, only 2 out of 10 practicing professionals older than 70 are women.

Not everyone over 80 has Dr. Habr-Gama’s vitality, because the impact of aging is not equal. “If you look at a group of 80-year-olds, there will be much more variability than within a group of 40-year-olds,” stated Mark Katlic, MD, chief of surgery at LifeBridge Health System in the United States, who has dedicated his life to studying the subject. Dr. Katlic spoke on the subject in an interview that was published in the article “How Old Is Too Old to Work as a Doctor?” published by this news organization in April of 2022. The article discusses the evaluations of elderly physicians’ skills and competences that U.S. companies conduct. The subject has been leading to profound debate.

Dr. Katlic defends screening programs for elderly physicians, which already are in effect at the company for which he works, LifeBridge Health, and various others in the United States. “We do [screen elderly physicians at LifeBridge Health], and so do a few dozen other [U.S. institutions], but there are hundreds [of health care institutions] that do not conduct this screening,” he pointed out.

Age-related assessment faces great resistance in the United States. One physician who is against the initiative is Frank Stockdale, MD, PhD, an 86-year-old practicing oncologist affiliated with Stanford (Calif.) University Health. “It’s age discrimination ... Physicians [in the United States] receive assessments throughout their careers as part of the accreditation process – there’s no need to change that as physicians reach a certain age,” Dr. Stockdale told this news organization.

The U.S. initiative of instituting physician assessment programs for those of a certain age has even been tested in court. According to an article published in Medscape, “in New Haven, Connecticut, for instance, the U.S. Equal Employment Opportunity Commission (EEOC) filed a suit in 2020 on behalf of the Yale New Haven Hospital staff, alleging a discriminatory late career practitioner policy.”

Also, according to the article, a similar case in Minnesota reached a settlement in 2021, providing monetary relief to staff impacted by out-of-pocket costs for the assessment, in addition to requiring that the hospital in question report to the EEOC any complaints related to age discrimination.

The fact is that increased life expectancy and, subsequently, the number of middle-aged physicians in practice, has raised several questions regarding the impact of aging on professional practice. In Brazil, the subject is of interest to more than 34,571 physicians between 65 and 69 years of age and 34,237 physicians older than 70. In all, this population represents approximately 14.3% of the country’s active workforce, according to the 2020 Medical Demographics in Brazil survey.

The significant participation of health care professionals over age 50 in a survey conducted by this news organization to learn what physicians think about the age limit for practicing their professions is evidence that the subject is a present concern. Of a total of 1,641 participants, 57% were age 60 or older, 17% were between 50 and 59 years, and 12% were between 40 and 49 years. Among all participants, 51% were against these limitations, 17% approved of the idea for all specialties, and 32% believed the restriction was appropriate only for some specialties. Regarding the possibility of older physicians undergoing regular assessments, the opinions were divided: Thirty-one percent thought they should be assessed in all specialties. Furthermore, 31% believed that cognitive abilities should be regularly tested in all specialties, 31% thought this should take place for some specialties, and 38% were against this approach.

Professionals want to know, for example, how (and whether) advanced age can interfere with performance, what are the competences required to practice their activities, and if the criteria vary by specialty. “A psychiatrist doesn’t have to have perfect visual acuity, as required from a dermatologist, but it is important that they have good hearing, for example,” argued Clóvis Constantino, MD, former president of the São Paulo Regional Medical Board (CRM-SP) and former vice president of the Brazilian Federal Medical Board (CFM). “However, a surgeon has to stand for several hours in positions that may be uncomfortable. It’s not easy,” he told this news organization.

In the opinion of 82-year-old Henrique Klajner, MD, the oldest pediatrician in practice at the Albert Einstein Israeli Hospital in São Paulo, the physician cannot be subjected to the types of evaluations that have been applied in the United States. “Physicians should conduct constant self-evaluations to see if they have the competences and skills needed to practice their profession ... Moreover, this is not a matter of age. It is a matter of ethics,” said Dr. Klajner.

The ability to adapt to change and implement innovation is critical to professional longevity, he said. “Nowadays, when I admit patients, I no longer do hospital rounds, which requires a mobility equal to physical abuse for me. Therefore, I work with physicians who take care of my hospitalized patients.”

Dr. Klajner also feels there is a distinction between innovations learned through studies and what can be offered safely to patients. “If I have to care for a hospitalized patient with severe pneumonia, for example, since I am not up to date in this specialty, I am going to call upon a pulmonologist I trust and forgo my honorarium for this admission. But I will remain on the team, monitoring the patient’s progression,” he said.

During the COVID-19 pandemic, Dr. Klajner stopped seeing patients in person under the recommendation of his son, Sidney Klajner, MD, also a physician. The elder Dr. Klajner began exploring telemedicine, which opened a whole new world of possibilities. “I have conducted several online visits to provide educational instruction to mothers returning home post delivery, for example,” he told this news organization. The time to stop is not something that concerns Dr. Klajner. “I’m only going to stop when I have a really important reason to do so. For example, if I can no longer write or study, reading and rereading an article without being able to understand what is being said. At this time, none of that is happening.”

In the United States, as well as in Brazil, physicians rarely provide information to human resources departments on colleagues showing signs of cognitive or motor decline affecting their professional performance. “The expectation is that health care professionals will report colleagues with cognitive impairments, but that often does not happen,” Dr. Katlic said.

It is also not common for professionals to report their own deficits to their institutions. In large part, this is caused by a lack of well-defined policies for dealing with this issue. This news organization sought out several public and private hospitals in Brazil to see if there is any guidance on professional longevity: Most said that there is not. Only the A. C. Camargo Cancer Center reported, through its public relations team, that a committee is discussing the subject but that it is still in the early stages.

Brazilian specialist associations do not offer guidelines or instructions on the various aspects of professional longevity. Dr. Constantino tried to put the subject on the agenda during the years in which he was an administrator with the CFM. “We tried to open up discussions regarding truly elderly physicians, but the subject was not well received. I believe that it is precisely because there is a tradition of physicians working until they are no longer able that this is more difficult in Brazil ... No one exactly knows what to do in this respect.” Dr. Constantino is against the use of age as a criterion for quitting practice.

“Of course, this is a point that has to be considered, but I always defended the need for regular assessment of physicians, regardless of age range. And, although assessments are always welcome, in any profession, I also believe this would not be well received in Brazil.” He endorses an assessment of one’s knowledge and not of physical abilities, which are generally assessed through investigation when needed.

The absence of guidelines increases individual responsibility, as well as vulnerability. “Consciously, physicians will not put patients at risk if they do not have the competence to care for them or to perform a surgical procedure,” said Clystenes Odyr Soares Silva, MD, PhD, adjunct professor of pulmonology of the Federal University of São Paulo (Brazil) School of Medicine (UNIFESP). “Your peers will tell you if you are no longer able,” he added. The problem is that physicians rarely admit to or talk about their colleagues’ deficits, especially if they are in the spotlight because of advanced age. In this situation, the observation and opinion of family members regarding the health care professional’s competences and skills will hold more weight.

In case of health-related physical impairment, such as partial loss of hand movement, for example, “it is expected that this will set off an ethical warning in the person,” said Dr. Constantino. When this warning does not occur naturally, patients or colleagues can report the professional, and this may lead to the opening of an administrative investigation. If the report is found to be true, this investigation is used to suspend physicians who do not have the physical or mental ability to continue practicing medicine.

“If it’s something very serious, the physician’s license can be temporarily suspended while [the physician] is treated by a psychiatrist, with follow-up by the professional board. When discharged, the physician will get his or her [professional] license back and can go back to work,” Dr. Constantino explained. If an expert evaluation is needed, the physician will then be assessed by a forensic psychiatrist. One of the most in-demand forensic psychiatrists in Brazil is Guido Arturo Palomba, MD, 73 years old. “I have assessed some physicians for actions reported to see if they were normal people or not, but never for circumstances related to age,” Dr. Palomba said.

In practice, Brazilian medical entities do not have policies or programs to guide physicians who wish to grow old while they work or those who have started to notice they are not performing as they used to. “We have never lived as long; therefore, the quality of life in old age, as well as the concept of aging, are some of the most relevant questions of our time. These are subjects requiring additional discussion, broadening understanding and awareness in this regard,” observed Mr. Vattimo.

Dr. Constantino and Dr. Silva, who are completely against age-based assessments, believe that recertification of the specialist license every 5 years is the best path to confirming whether the physician is still able to practice. “A knowledge-based test every 5 years to recertify the specialist license has often been a topic of conversation. I think it’s an excellent idea. The person would provide a dossier of all they have done in terms of courses, conferences, and other activities, present it, and receive a score,” said Dr. Silva.

In practice, recertification of the specialist license is a topic of discussion that has been raised for years, and it is an idea that the Brazilian Medical Association (AMB) defends. In conjunction with the CFM, the association is studying a way to best implement this assessment. “It’s important to emphasize that this measure would not be retroactive at first. Instead, it would only be in effect for professionals licensed after the recertification requirement is established,” the AMB pointed out in a note sent to this news organization. Even so, the measure has faced significant resistance from a faction of the profession, and its enactment does not seem to be imminent.

The debate regarding professional longevity is taking place in various countries. In 2021, the American Medical Association Council on Medical Education released a report with a set of guidelines for the screening and assessment of physicians. The document is the product of a committee created in 2015 to study the subject. The AMA recommends that the assessment of elderly physicians be based on evidence and ethical, relevant, fair, equitable, transparent, verifiable, nonexhaustive principles, contemplating support and protecting against legal proceedings. In April of this year, a new AMA document highlighted the same principles.

Also in the United States, one of oldest initiatives created to support physicians in the process of recycling, the University of California San Diego Physician Assessment and Clinical Education Program (PACE), has a section focusing on the extended practice of medicine (Practicing Medicine Longer). For those wanting to learn more about discussions on this subject, there are online presentations on experiences in Quebec and Ontario with assessing aging physicians, neuropsychological perspectives on the aging medical population, and what to expect of healthy aging, among other subjects.

Created in 1996, PACE mostly provides services to physicians who need to address requirements of the state medical boards. Few physicians enroll on their own.

The first part of the program assesses knowledge and skills over approximately 2 days. In the second phase, the physician participates in a series of activities in a corresponding residency program. Depending on the results, the physician may have to go through a remedial program with varying activities to deal with performance deficiencies to clinical experiences at the residency level.

A version of this article first appeared on Medscape.com.

To be cost effective, compared with metformin, for initial therapy for type 2 diabetes, prices for a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) agonist would have to fall by at least 70% and at least 90%, respectively, according to estimates.

Thinkstock Photos

The study, modeled on U.S. patients, by Jin G. Choi, MD, and colleagues, was published online Oct. 3 in the Annals of Internal Medicine.

The researchers simulated the lifetime incidence, prevalence, mortality, and costs associated with three different first-line treatment strategies – metformin, an SGLT2 inhibitor, or a GLP-1 agonist – in U.S. patients with untreated type 2 diabetes.

Compared with patients who received initial treatment with metformin, those who received one of the newer drugs had 4.4% to 5.2% lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke.

However, to be cost-effective at under $150,000 per quality-adjusted life-years (QALY), SGLT2 inhibitors would need to cost less than $5 a day ($1,800 a year), and GLP-1 agonists would have to cost less than $6 a day ($2,100 a year), a lot less than now.

Knowing how expensive these drugs are, “I am not surprised” that the model predicts that the price would have to drop so much to make them cost-effective, compared with first-line treatment with metformin, senior author Neda Laiteerapong, MD, said in an interview.

“But I am disappointed,” she said, because these drugs are very effective, and if the prices were lower, more people could benefit.

“In the interest of improving access to high-quality care in the United States, our study results indicate the need to reduce SGLT2 inhibitor and GLP-1 receptor agonist medication costs substantially for patients with type 2 [diabetes] to improve health outcomes and prevent exacerbating diabetes health disparities,” the researchers conclude.

One way that the newer drugs might be more widely affordable is if the government became involved, possibly by passing a law similar to the Affordable Insulin Now Act, speculated Dr. Laiteerapong, who is associate director at the Center for Chronic Disease Research and Policy, University of Chicago.
 

‘Current prices too high to encourage first-line adoption’

Guidelines recommend the use of SGLT2 inhibitors and GLP-1 agonists as second-line therapies for patients with type 2 diabetes, but it has not been clear if clinical benefits would outweigh costs for use as first-line therapies.

“Although clinical trials have demonstrated the clinical effectiveness of these newer drugs, they are hundreds of times more expensive than other ... diabetes drugs,” the researchers note.

On the other hand, costs may fall in the coming years when these new drugs come off-patent.

The current study was designed to help inform future clinical guidelines.

The researchers created a population simulation model based on the United Kingdom Prospective Diabetes Study, Outcomes Model version 2 (UKPDS OM2) for diabetes-related complications and mortality, with added information about hypoglycemic events, quality of life, and U.S. costs. 

The researchers also identified a nationally representative sample of people who would be eligible to start first-line diabetes therapy when their A1c reached 7% for the model. 

Using National Health and Nutrition Examination Survey (NHANES) data (2013-2016), the researchers identified about 7.3 million U.S. adults aged 18 and older with self-reported diabetes or an A1c greater than 6.5% with no reported use of diabetes medications.

Patients were an average age of 55, and 55% were women. They had had diabetes for an average of 4.2 years, and 36% had a history of diabetes complications.

The model projected that patients would have an improved life expectancy of 3.0 and 3.4 months from first-line SGLT2 inhibitors and GLP-1 agonists, respectively, compared with initial therapy with metformin due to reduced rates of macrovascular disease.  

“However, the current drug costs would be too high to encourage their adoption as first-line for usual clinical practice,” the researchers report.
 

‘Disparities could remain for decades’

Generic SGLT2 inhibitors could enter the marketplace shortly, because one of two dapagliflozin patents expired in October 2020 and approval for generic alternatives has been sought from the U.S. Food and Drug Administration, Dr. Choi and colleagues note.

However, it could still take decades for medication prices to drop low enough to become affordable, the group cautions. For example, a generic GLP-1 agonist became available in 2017, but costs remain high.

“Without external incentives,” the group writes, “limited access to these drug classes will likely persist (for example, due to higher copays or requirements for prior authorizations), as will further diabetes disparities – for decades into the future – because of differential access to care due to insurance (for example, private vs. public), which often tracks race and ethnicity.”

The study was supported by the American Diabetes Association. Dr. Choi was supported by a National Institutes of Health, National Institute on Aging grant. Dr. Laiteerapong and other co-authors are members of the National Institute of Diabetes and Digestive and Kidney Diseases Chicago Center for Diabetes Translation Research at the University of Chicago. Dr. Choi and Dr. Laiteerapong have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

To be cost effective, compared with metformin, for initial therapy for type 2 diabetes, prices for a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) agonist would have to fall by at least 70% and at least 90%, respectively, according to estimates.

Thinkstock Photos

The study, modeled on U.S. patients, by Jin G. Choi, MD, and colleagues, was published online Oct. 3 in the Annals of Internal Medicine.

The researchers simulated the lifetime incidence, prevalence, mortality, and costs associated with three different first-line treatment strategies – metformin, an SGLT2 inhibitor, or a GLP-1 agonist – in U.S. patients with untreated type 2 diabetes.

Compared with patients who received initial treatment with metformin, those who received one of the newer drugs had 4.4% to 5.2% lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke.

However, to be cost-effective at under $150,000 per quality-adjusted life-years (QALY), SGLT2 inhibitors would need to cost less than $5 a day ($1,800 a year), and GLP-1 agonists would have to cost less than $6 a day ($2,100 a year), a lot less than now.

Knowing how expensive these drugs are, “I am not surprised” that the model predicts that the price would have to drop so much to make them cost-effective, compared with first-line treatment with metformin, senior author Neda Laiteerapong, MD, said in an interview.

“But I am disappointed,” she said, because these drugs are very effective, and if the prices were lower, more people could benefit.

“In the interest of improving access to high-quality care in the United States, our study results indicate the need to reduce SGLT2 inhibitor and GLP-1 receptor agonist medication costs substantially for patients with type 2 [diabetes] to improve health outcomes and prevent exacerbating diabetes health disparities,” the researchers conclude.

One way that the newer drugs might be more widely affordable is if the government became involved, possibly by passing a law similar to the Affordable Insulin Now Act, speculated Dr. Laiteerapong, who is associate director at the Center for Chronic Disease Research and Policy, University of Chicago.
 

‘Current prices too high to encourage first-line adoption’

Guidelines recommend the use of SGLT2 inhibitors and GLP-1 agonists as second-line therapies for patients with type 2 diabetes, but it has not been clear if clinical benefits would outweigh costs for use as first-line therapies.

“Although clinical trials have demonstrated the clinical effectiveness of these newer drugs, they are hundreds of times more expensive than other ... diabetes drugs,” the researchers note.

On the other hand, costs may fall in the coming years when these new drugs come off-patent.

The current study was designed to help inform future clinical guidelines.

The researchers created a population simulation model based on the United Kingdom Prospective Diabetes Study, Outcomes Model version 2 (UKPDS OM2) for diabetes-related complications and mortality, with added information about hypoglycemic events, quality of life, and U.S. costs. 

The researchers also identified a nationally representative sample of people who would be eligible to start first-line diabetes therapy when their A1c reached 7% for the model. 

Using National Health and Nutrition Examination Survey (NHANES) data (2013-2016), the researchers identified about 7.3 million U.S. adults aged 18 and older with self-reported diabetes or an A1c greater than 6.5% with no reported use of diabetes medications.

Patients were an average age of 55, and 55% were women. They had had diabetes for an average of 4.2 years, and 36% had a history of diabetes complications.

The model projected that patients would have an improved life expectancy of 3.0 and 3.4 months from first-line SGLT2 inhibitors and GLP-1 agonists, respectively, compared with initial therapy with metformin due to reduced rates of macrovascular disease.  

“However, the current drug costs would be too high to encourage their adoption as first-line for usual clinical practice,” the researchers report.
 

‘Disparities could remain for decades’

Generic SGLT2 inhibitors could enter the marketplace shortly, because one of two dapagliflozin patents expired in October 2020 and approval for generic alternatives has been sought from the U.S. Food and Drug Administration, Dr. Choi and colleagues note.

However, it could still take decades for medication prices to drop low enough to become affordable, the group cautions. For example, a generic GLP-1 agonist became available in 2017, but costs remain high.

“Without external incentives,” the group writes, “limited access to these drug classes will likely persist (for example, due to higher copays or requirements for prior authorizations), as will further diabetes disparities – for decades into the future – because of differential access to care due to insurance (for example, private vs. public), which often tracks race and ethnicity.”

The study was supported by the American Diabetes Association. Dr. Choi was supported by a National Institutes of Health, National Institute on Aging grant. Dr. Laiteerapong and other co-authors are members of the National Institute of Diabetes and Digestive and Kidney Diseases Chicago Center for Diabetes Translation Research at the University of Chicago. Dr. Choi and Dr. Laiteerapong have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

To be cost effective, compared with metformin, for initial therapy for type 2 diabetes, prices for a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) agonist would have to fall by at least 70% and at least 90%, respectively, according to estimates.

Thinkstock Photos

The study, modeled on U.S. patients, by Jin G. Choi, MD, and colleagues, was published online Oct. 3 in the Annals of Internal Medicine.

The researchers simulated the lifetime incidence, prevalence, mortality, and costs associated with three different first-line treatment strategies – metformin, an SGLT2 inhibitor, or a GLP-1 agonist – in U.S. patients with untreated type 2 diabetes.

Compared with patients who received initial treatment with metformin, those who received one of the newer drugs had 4.4% to 5.2% lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke.

However, to be cost-effective at under $150,000 per quality-adjusted life-years (QALY), SGLT2 inhibitors would need to cost less than $5 a day ($1,800 a year), and GLP-1 agonists would have to cost less than $6 a day ($2,100 a year), a lot less than now.

Knowing how expensive these drugs are, “I am not surprised” that the model predicts that the price would have to drop so much to make them cost-effective, compared with first-line treatment with metformin, senior author Neda Laiteerapong, MD, said in an interview.

“But I am disappointed,” she said, because these drugs are very effective, and if the prices were lower, more people could benefit.

“In the interest of improving access to high-quality care in the United States, our study results indicate the need to reduce SGLT2 inhibitor and GLP-1 receptor agonist medication costs substantially for patients with type 2 [diabetes] to improve health outcomes and prevent exacerbating diabetes health disparities,” the researchers conclude.

One way that the newer drugs might be more widely affordable is if the government became involved, possibly by passing a law similar to the Affordable Insulin Now Act, speculated Dr. Laiteerapong, who is associate director at the Center for Chronic Disease Research and Policy, University of Chicago.
 

‘Current prices too high to encourage first-line adoption’

Guidelines recommend the use of SGLT2 inhibitors and GLP-1 agonists as second-line therapies for patients with type 2 diabetes, but it has not been clear if clinical benefits would outweigh costs for use as first-line therapies.

“Although clinical trials have demonstrated the clinical effectiveness of these newer drugs, they are hundreds of times more expensive than other ... diabetes drugs,” the researchers note.

On the other hand, costs may fall in the coming years when these new drugs come off-patent.

The current study was designed to help inform future clinical guidelines.

The researchers created a population simulation model based on the United Kingdom Prospective Diabetes Study, Outcomes Model version 2 (UKPDS OM2) for diabetes-related complications and mortality, with added information about hypoglycemic events, quality of life, and U.S. costs. 

The researchers also identified a nationally representative sample of people who would be eligible to start first-line diabetes therapy when their A1c reached 7% for the model. 

Using National Health and Nutrition Examination Survey (NHANES) data (2013-2016), the researchers identified about 7.3 million U.S. adults aged 18 and older with self-reported diabetes or an A1c greater than 6.5% with no reported use of diabetes medications.

Patients were an average age of 55, and 55% were women. They had had diabetes for an average of 4.2 years, and 36% had a history of diabetes complications.

The model projected that patients would have an improved life expectancy of 3.0 and 3.4 months from first-line SGLT2 inhibitors and GLP-1 agonists, respectively, compared with initial therapy with metformin due to reduced rates of macrovascular disease.  

“However, the current drug costs would be too high to encourage their adoption as first-line for usual clinical practice,” the researchers report.
 

‘Disparities could remain for decades’

Generic SGLT2 inhibitors could enter the marketplace shortly, because one of two dapagliflozin patents expired in October 2020 and approval for generic alternatives has been sought from the U.S. Food and Drug Administration, Dr. Choi and colleagues note.

However, it could still take decades for medication prices to drop low enough to become affordable, the group cautions. For example, a generic GLP-1 agonist became available in 2017, but costs remain high.

“Without external incentives,” the group writes, “limited access to these drug classes will likely persist (for example, due to higher copays or requirements for prior authorizations), as will further diabetes disparities – for decades into the future – because of differential access to care due to insurance (for example, private vs. public), which often tracks race and ethnicity.”

The study was supported by the American Diabetes Association. Dr. Choi was supported by a National Institutes of Health, National Institute on Aging grant. Dr. Laiteerapong and other co-authors are members of the National Institute of Diabetes and Digestive and Kidney Diseases Chicago Center for Diabetes Translation Research at the University of Chicago. Dr. Choi and Dr. Laiteerapong have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A higher percentage of family physicians quit during the early months of the pandemic than the average yearly percentage that did in the prior decade, according to data from Canada.

The researchers conducted two analyses of billing claims data for family physicians practicing in Ontario. They examined data for a period from 2010 to 2019 – before the onset of the pandemic – and from 2019 through 2020. The findings were published in Annals of Family Medicine.

Overall, the proportion of family physicians who stopped working rose from an average of 1.6% each year for the period between 2010 and 2019 to 3% in the period from 2019 to 2020. The pandemic data set included 12,247 physicians in Ontario. Of these, 385 (3.1%) reported no billings in the first 6 months of the pandemic.

Compared with family physicians billing for work during the pandemic, those reporting no billings were significantly more likely to be 75 years or older (13.0% vs. 3.4%), to have patient panels of less than 500 patients (40.0% vs. 25.8%), and to be eligible for fee-for-service reimbursement (37.7% vs. 24.9%; P less than .001 for all). The family physicians who reported no billing early in the pandemic also had fewer billing days in the previous year (mean of 73 days vs. 101 days, P less than .001).

In a regression analysis, the absolute increase in the percentage of family physicians who stopped working was 0.3% per year from 2010 to 2019, but rose to 1.2% between 2019 and 2020.

Challenges to family physicians in Ontario in the early months of the COVID-19 pandemic included reduced revenue, inability to keep offices fully staffed, and problems obtaining enough personal protective equipment. Such challenges may have prompted some family physicians to stop working prematurely, but more research is needed in other settings, wrote study author Tara Kiran, MD, of the University of Toronto, and colleagues.

“There were a lot of stories and suggestions that more family physicians were choosing to retire due to COVID,” Michael Green, MD, a coauthor of the paper, said in an interview. “Given the preexisting shortages we thought it would be important to see if this was true, and how big of an issue it was,” he said.

Although the absolute number of primary care physicians who stopped working is small, the implications are large given the ongoing shortage of family physicians in Canada, the researchers wrote.

The characteristics of physicians stopping work, such as older age and smaller practice size, were consistent with that of physicians preparing for retirement, the researchers noted. In addition, 56% of the family physicians who stopped working during the pandemic practiced in a patient enrollment model, in which patients are enrolled and between 15% and 70% of payment is based on age and sex. In this study, approximately 80% of physicians worked in this model. The remaining 20% operated in independent, fee-for-service practices.

“Although we cannot directly attribute causation, we hypothesize that some family physicians accelerated their retirement plans because of the pandemic,” the researchers noted. They proposed that possible reasons include health concerns, increased costs of infection prevention and control, reduced revenue from office visits, and burnout. The current study did not examine these issues.

Additional studies are needed to understand the impact on population health, the researchers concluded, but they estimated that the number of family physicians who stopped work during the pandemic would have provided care for approximately 170,000 patients.

The study findings reflect a genuine turnover by family physicians, vs. a departure from family practice to a fellowship and practice in another specialty, Dr. Green said. “We looked at physician billings to determine who stopped practicing, so we report only on those who stopped billing the Ontario Health Insurance Program altogether,” he explained.

The ongoing pandemic accelerated the issue of an upcoming wave of physician retirements and added to an already large number of people without a family physician, Dr. Green noted.

“We know there will be significant shortages of family physicians if we don’t modernize our ways of delivering primary care,” said Dr. Green. More research is needed on how to support family doctors with teams and administrative supports to allow them to provide high quality care to more patients, he said. Better models to estimate health workforce needs in primary care are needed as well, he added.

In the United States, a physician shortage has been growing since before the pandemic, according to a report published in 2021 by the Association of American Medical Colleges. In this report, “The Complexities of Physician Supply and Demand: Projections from 2019 to 2034,” the authors specifically projected a primary care physician shortage of 17,800 to 48,000 by 2034. This projection is in part based on an increase in the percentage of the U.S. population aged 65 years and older, which will increase the demand for care, according to the authors. The report also confirmed that many U.S. physicians are approaching retirement age and that more than two of five active physicians will be 65 years or older within the next 10 years.

However, the authors of this U.S. report acknowledged that the impact of the pandemic on existing primary care shortages remains unclear.

“There are still many unknowns about the direct short-term and long-term impacts of COVID-19 on the physician workforce, and it may be several years before those impacts are clearly understood,” they said in the executive summary of their report.

Alison N. Huffstetler, MD, a coauthor of a recent report that tried to identify the active primary care workforce in Virginia, said, “We know from other research that there are not enough primary care doctors, right now, to do the work that needs to be done – some citations have noted it would take a primary care doc over 20 hours a day just to provide preventive care.

“As our population continues to age, live longer, and need more complex care management, we must ensure we have an accountable, accessible, and knowledgeable primary care network to care for our communities,” she said.
 

Current state of primary care in Virginia

The study by Dr. Huffstetler, of Virginia Commonwealth University, Richmond, and colleagues was published in Annals of Family Medicine. It used a novel strategy involving the analysis of state all-payer claims data to determine how many physicians were practicing primary care in Virginia.

The researchers used the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD) and identified all Virginia physicians and their specialties through the NPPES between 2015 and 2019. Active physicians were defined as those with at least one claim in the VA-APCD during the study period. They identified 20,976 active physicians in Virginia, 28.1% of whom were classified as primary care. Of these, 52% were family medicine physicians, 18.5% were internal medicine physicians, 16.8% were pediatricians, 11.8% were ob.gyns., and 0.5% were other specialists.

Clinician specialties were identified via specialty codes from the NPPES. Physicians were identified as primary care providers in two ways. The first way was by identifying those who had a National Uniform Claim Committee (NUCC) taxonomy of family medicine. The NUCC identifies a provider’s specialty using several levels of classification based on board certification and subspecialty certification data. The second identifier was having been a physician who had billed for at least 10 wellness visit codes from Jan. 1, 2019, through Dec. 31, 2019.

Over the 5-year study period (2015-2019), the counts and percentages of primary care physicians in the workforce remained stable, and the overall number of physicians in the state increased by 3.5%, the researchers noted. A total of 60.45% of all physicians and 60.87% of primary care physicians remained active, and 11.66% of all physicians had a claim in only 1 of the 5 years.
 

How distribution and access impact patients

In an interview, Dr. Huffstetler said the study she and colleagues authored “offers a transparent and reproducible process for identifying primary care physicians in a state, where they practice, and what changes in staffing occur over time.”

“In Virginia, this is particularly important, as we recently expanded Medicaid, making primary care more affordable for over 500,000 people,” she said. “We also saw the importance of distribution and accessibility to primary care over the past 3 years of COVID. In order to adequately prepare for community needs in the coming years, we must know who is providing primary care, and where they are.”

However, the model used in this study has its limitations, Dr. Huffstetler said, including the lack of a definitive definition of primary care using claims data.

“We used a data-informed wellness visit threshold, but it is likely that primary care is delivered in some locations without claims that are reflected by a wellness visit, and we hope to look at scope in the future to help refine these results,” she said.
 

Canadian study shows pandemic’s impact on patient care

“The pandemic’s impact on primary care remains palpable, and Dr. Kiran’s team has done an excellent analysis on the practice trends during the past several years,” Dr. Huffstetler said.

“The Canadian analysis uses claims in a similar manner to our study; however, it appears that they already knew who the FPs were in Ontario,” Dr. Huffstetler noted. “Their claims threshold of 50 for active practice was higher than ours, at only 1. Should those FPs have moved to a different specialty, the physicians would still have claims for the patients seen in other subspecialties. As such, I don’t suspect that their analysis miscalculated those that transitioned, rather than stopped practice,” she explained.

The Ontario study was supported by the Initial Credential Evaluation Service, which is funded by the Ontario Ministry of Health and the Ministry of Long-Term Care, as well as by the Canadian Institutes of Health Research. Additional support came from the INSPIRE Primary Health Care Research Program, which is also funded by the Ontario Ministry of Health and Long-Term Care. The researchers had no financial conflicts to disclose.

The Virginia study was supported by the Department of Medical Assistance Services and the National Center for Advancing Translational Sciences. The researchers had no financial conflicts to disclose.

The supply and demand report was conducted for the AAMC by IHS Markit, a global information company.

A higher percentage of family physicians quit during the early months of the pandemic than the average yearly percentage that did in the prior decade, according to data from Canada.

The researchers conducted two analyses of billing claims data for family physicians practicing in Ontario. They examined data for a period from 2010 to 2019 – before the onset of the pandemic – and from 2019 through 2020. The findings were published in Annals of Family Medicine.

Overall, the proportion of family physicians who stopped working rose from an average of 1.6% each year for the period between 2010 and 2019 to 3% in the period from 2019 to 2020. The pandemic data set included 12,247 physicians in Ontario. Of these, 385 (3.1%) reported no billings in the first 6 months of the pandemic.

Compared with family physicians billing for work during the pandemic, those reporting no billings were significantly more likely to be 75 years or older (13.0% vs. 3.4%), to have patient panels of less than 500 patients (40.0% vs. 25.8%), and to be eligible for fee-for-service reimbursement (37.7% vs. 24.9%; P less than .001 for all). The family physicians who reported no billing early in the pandemic also had fewer billing days in the previous year (mean of 73 days vs. 101 days, P less than .001).

In a regression analysis, the absolute increase in the percentage of family physicians who stopped working was 0.3% per year from 2010 to 2019, but rose to 1.2% between 2019 and 2020.

Challenges to family physicians in Ontario in the early months of the COVID-19 pandemic included reduced revenue, inability to keep offices fully staffed, and problems obtaining enough personal protective equipment. Such challenges may have prompted some family physicians to stop working prematurely, but more research is needed in other settings, wrote study author Tara Kiran, MD, of the University of Toronto, and colleagues.

“There were a lot of stories and suggestions that more family physicians were choosing to retire due to COVID,” Michael Green, MD, a coauthor of the paper, said in an interview. “Given the preexisting shortages we thought it would be important to see if this was true, and how big of an issue it was,” he said.

Although the absolute number of primary care physicians who stopped working is small, the implications are large given the ongoing shortage of family physicians in Canada, the researchers wrote.

The characteristics of physicians stopping work, such as older age and smaller practice size, were consistent with that of physicians preparing for retirement, the researchers noted. In addition, 56% of the family physicians who stopped working during the pandemic practiced in a patient enrollment model, in which patients are enrolled and between 15% and 70% of payment is based on age and sex. In this study, approximately 80% of physicians worked in this model. The remaining 20% operated in independent, fee-for-service practices.

“Although we cannot directly attribute causation, we hypothesize that some family physicians accelerated their retirement plans because of the pandemic,” the researchers noted. They proposed that possible reasons include health concerns, increased costs of infection prevention and control, reduced revenue from office visits, and burnout. The current study did not examine these issues.

Additional studies are needed to understand the impact on population health, the researchers concluded, but they estimated that the number of family physicians who stopped work during the pandemic would have provided care for approximately 170,000 patients.

The study findings reflect a genuine turnover by family physicians, vs. a departure from family practice to a fellowship and practice in another specialty, Dr. Green said. “We looked at physician billings to determine who stopped practicing, so we report only on those who stopped billing the Ontario Health Insurance Program altogether,” he explained.

The ongoing pandemic accelerated the issue of an upcoming wave of physician retirements and added to an already large number of people without a family physician, Dr. Green noted.

“We know there will be significant shortages of family physicians if we don’t modernize our ways of delivering primary care,” said Dr. Green. More research is needed on how to support family doctors with teams and administrative supports to allow them to provide high quality care to more patients, he said. Better models to estimate health workforce needs in primary care are needed as well, he added.

In the United States, a physician shortage has been growing since before the pandemic, according to a report published in 2021 by the Association of American Medical Colleges. In this report, “The Complexities of Physician Supply and Demand: Projections from 2019 to 2034,” the authors specifically projected a primary care physician shortage of 17,800 to 48,000 by 2034. This projection is in part based on an increase in the percentage of the U.S. population aged 65 years and older, which will increase the demand for care, according to the authors. The report also confirmed that many U.S. physicians are approaching retirement age and that more than two of five active physicians will be 65 years or older within the next 10 years.

However, the authors of this U.S. report acknowledged that the impact of the pandemic on existing primary care shortages remains unclear.

“There are still many unknowns about the direct short-term and long-term impacts of COVID-19 on the physician workforce, and it may be several years before those impacts are clearly understood,” they said in the executive summary of their report.

Alison N. Huffstetler, MD, a coauthor of a recent report that tried to identify the active primary care workforce in Virginia, said, “We know from other research that there are not enough primary care doctors, right now, to do the work that needs to be done – some citations have noted it would take a primary care doc over 20 hours a day just to provide preventive care.

“As our population continues to age, live longer, and need more complex care management, we must ensure we have an accountable, accessible, and knowledgeable primary care network to care for our communities,” she said.
 

Current state of primary care in Virginia

The study by Dr. Huffstetler, of Virginia Commonwealth University, Richmond, and colleagues was published in Annals of Family Medicine. It used a novel strategy involving the analysis of state all-payer claims data to determine how many physicians were practicing primary care in Virginia.

The researchers used the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD) and identified all Virginia physicians and their specialties through the NPPES between 2015 and 2019. Active physicians were defined as those with at least one claim in the VA-APCD during the study period. They identified 20,976 active physicians in Virginia, 28.1% of whom were classified as primary care. Of these, 52% were family medicine physicians, 18.5% were internal medicine physicians, 16.8% were pediatricians, 11.8% were ob.gyns., and 0.5% were other specialists.

Clinician specialties were identified via specialty codes from the NPPES. Physicians were identified as primary care providers in two ways. The first way was by identifying those who had a National Uniform Claim Committee (NUCC) taxonomy of family medicine. The NUCC identifies a provider’s specialty using several levels of classification based on board certification and subspecialty certification data. The second identifier was having been a physician who had billed for at least 10 wellness visit codes from Jan. 1, 2019, through Dec. 31, 2019.

Over the 5-year study period (2015-2019), the counts and percentages of primary care physicians in the workforce remained stable, and the overall number of physicians in the state increased by 3.5%, the researchers noted. A total of 60.45% of all physicians and 60.87% of primary care physicians remained active, and 11.66% of all physicians had a claim in only 1 of the 5 years.
 

How distribution and access impact patients

In an interview, Dr. Huffstetler said the study she and colleagues authored “offers a transparent and reproducible process for identifying primary care physicians in a state, where they practice, and what changes in staffing occur over time.”

“In Virginia, this is particularly important, as we recently expanded Medicaid, making primary care more affordable for over 500,000 people,” she said. “We also saw the importance of distribution and accessibility to primary care over the past 3 years of COVID. In order to adequately prepare for community needs in the coming years, we must know who is providing primary care, and where they are.”

However, the model used in this study has its limitations, Dr. Huffstetler said, including the lack of a definitive definition of primary care using claims data.

“We used a data-informed wellness visit threshold, but it is likely that primary care is delivered in some locations without claims that are reflected by a wellness visit, and we hope to look at scope in the future to help refine these results,” she said.
 

Canadian study shows pandemic’s impact on patient care

“The pandemic’s impact on primary care remains palpable, and Dr. Kiran’s team has done an excellent analysis on the practice trends during the past several years,” Dr. Huffstetler said.

“The Canadian analysis uses claims in a similar manner to our study; however, it appears that they already knew who the FPs were in Ontario,” Dr. Huffstetler noted. “Their claims threshold of 50 for active practice was higher than ours, at only 1. Should those FPs have moved to a different specialty, the physicians would still have claims for the patients seen in other subspecialties. As such, I don’t suspect that their analysis miscalculated those that transitioned, rather than stopped practice,” she explained.

The Ontario study was supported by the Initial Credential Evaluation Service, which is funded by the Ontario Ministry of Health and the Ministry of Long-Term Care, as well as by the Canadian Institutes of Health Research. Additional support came from the INSPIRE Primary Health Care Research Program, which is also funded by the Ontario Ministry of Health and Long-Term Care. The researchers had no financial conflicts to disclose.

The Virginia study was supported by the Department of Medical Assistance Services and the National Center for Advancing Translational Sciences. The researchers had no financial conflicts to disclose.

The supply and demand report was conducted for the AAMC by IHS Markit, a global information company.

A higher percentage of family physicians quit during the early months of the pandemic than the average yearly percentage that did in the prior decade, according to data from Canada.

The researchers conducted two analyses of billing claims data for family physicians practicing in Ontario. They examined data for a period from 2010 to 2019 – before the onset of the pandemic – and from 2019 through 2020. The findings were published in Annals of Family Medicine.

Overall, the proportion of family physicians who stopped working rose from an average of 1.6% each year for the period between 2010 and 2019 to 3% in the period from 2019 to 2020. The pandemic data set included 12,247 physicians in Ontario. Of these, 385 (3.1%) reported no billings in the first 6 months of the pandemic.

Compared with family physicians billing for work during the pandemic, those reporting no billings were significantly more likely to be 75 years or older (13.0% vs. 3.4%), to have patient panels of less than 500 patients (40.0% vs. 25.8%), and to be eligible for fee-for-service reimbursement (37.7% vs. 24.9%; P less than .001 for all). The family physicians who reported no billing early in the pandemic also had fewer billing days in the previous year (mean of 73 days vs. 101 days, P less than .001).

In a regression analysis, the absolute increase in the percentage of family physicians who stopped working was 0.3% per year from 2010 to 2019, but rose to 1.2% between 2019 and 2020.

Challenges to family physicians in Ontario in the early months of the COVID-19 pandemic included reduced revenue, inability to keep offices fully staffed, and problems obtaining enough personal protective equipment. Such challenges may have prompted some family physicians to stop working prematurely, but more research is needed in other settings, wrote study author Tara Kiran, MD, of the University of Toronto, and colleagues.

“There were a lot of stories and suggestions that more family physicians were choosing to retire due to COVID,” Michael Green, MD, a coauthor of the paper, said in an interview. “Given the preexisting shortages we thought it would be important to see if this was true, and how big of an issue it was,” he said.

Although the absolute number of primary care physicians who stopped working is small, the implications are large given the ongoing shortage of family physicians in Canada, the researchers wrote.

The characteristics of physicians stopping work, such as older age and smaller practice size, were consistent with that of physicians preparing for retirement, the researchers noted. In addition, 56% of the family physicians who stopped working during the pandemic practiced in a patient enrollment model, in which patients are enrolled and between 15% and 70% of payment is based on age and sex. In this study, approximately 80% of physicians worked in this model. The remaining 20% operated in independent, fee-for-service practices.

“Although we cannot directly attribute causation, we hypothesize that some family physicians accelerated their retirement plans because of the pandemic,” the researchers noted. They proposed that possible reasons include health concerns, increased costs of infection prevention and control, reduced revenue from office visits, and burnout. The current study did not examine these issues.

Additional studies are needed to understand the impact on population health, the researchers concluded, but they estimated that the number of family physicians who stopped work during the pandemic would have provided care for approximately 170,000 patients.

The study findings reflect a genuine turnover by family physicians, vs. a departure from family practice to a fellowship and practice in another specialty, Dr. Green said. “We looked at physician billings to determine who stopped practicing, so we report only on those who stopped billing the Ontario Health Insurance Program altogether,” he explained.

The ongoing pandemic accelerated the issue of an upcoming wave of physician retirements and added to an already large number of people without a family physician, Dr. Green noted.

“We know there will be significant shortages of family physicians if we don’t modernize our ways of delivering primary care,” said Dr. Green. More research is needed on how to support family doctors with teams and administrative supports to allow them to provide high quality care to more patients, he said. Better models to estimate health workforce needs in primary care are needed as well, he added.

In the United States, a physician shortage has been growing since before the pandemic, according to a report published in 2021 by the Association of American Medical Colleges. In this report, “The Complexities of Physician Supply and Demand: Projections from 2019 to 2034,” the authors specifically projected a primary care physician shortage of 17,800 to 48,000 by 2034. This projection is in part based on an increase in the percentage of the U.S. population aged 65 years and older, which will increase the demand for care, according to the authors. The report also confirmed that many U.S. physicians are approaching retirement age and that more than two of five active physicians will be 65 years or older within the next 10 years.

However, the authors of this U.S. report acknowledged that the impact of the pandemic on existing primary care shortages remains unclear.

“There are still many unknowns about the direct short-term and long-term impacts of COVID-19 on the physician workforce, and it may be several years before those impacts are clearly understood,” they said in the executive summary of their report.

Alison N. Huffstetler, MD, a coauthor of a recent report that tried to identify the active primary care workforce in Virginia, said, “We know from other research that there are not enough primary care doctors, right now, to do the work that needs to be done – some citations have noted it would take a primary care doc over 20 hours a day just to provide preventive care.

“As our population continues to age, live longer, and need more complex care management, we must ensure we have an accountable, accessible, and knowledgeable primary care network to care for our communities,” she said.
 

Current state of primary care in Virginia

The study by Dr. Huffstetler, of Virginia Commonwealth University, Richmond, and colleagues was published in Annals of Family Medicine. It used a novel strategy involving the analysis of state all-payer claims data to determine how many physicians were practicing primary care in Virginia.

The researchers used the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD) and identified all Virginia physicians and their specialties through the NPPES between 2015 and 2019. Active physicians were defined as those with at least one claim in the VA-APCD during the study period. They identified 20,976 active physicians in Virginia, 28.1% of whom were classified as primary care. Of these, 52% were family medicine physicians, 18.5% were internal medicine physicians, 16.8% were pediatricians, 11.8% were ob.gyns., and 0.5% were other specialists.

Clinician specialties were identified via specialty codes from the NPPES. Physicians were identified as primary care providers in two ways. The first way was by identifying those who had a National Uniform Claim Committee (NUCC) taxonomy of family medicine. The NUCC identifies a provider’s specialty using several levels of classification based on board certification and subspecialty certification data. The second identifier was having been a physician who had billed for at least 10 wellness visit codes from Jan. 1, 2019, through Dec. 31, 2019.

Over the 5-year study period (2015-2019), the counts and percentages of primary care physicians in the workforce remained stable, and the overall number of physicians in the state increased by 3.5%, the researchers noted. A total of 60.45% of all physicians and 60.87% of primary care physicians remained active, and 11.66% of all physicians had a claim in only 1 of the 5 years.
 

How distribution and access impact patients

In an interview, Dr. Huffstetler said the study she and colleagues authored “offers a transparent and reproducible process for identifying primary care physicians in a state, where they practice, and what changes in staffing occur over time.”

“In Virginia, this is particularly important, as we recently expanded Medicaid, making primary care more affordable for over 500,000 people,” she said. “We also saw the importance of distribution and accessibility to primary care over the past 3 years of COVID. In order to adequately prepare for community needs in the coming years, we must know who is providing primary care, and where they are.”

However, the model used in this study has its limitations, Dr. Huffstetler said, including the lack of a definitive definition of primary care using claims data.

“We used a data-informed wellness visit threshold, but it is likely that primary care is delivered in some locations without claims that are reflected by a wellness visit, and we hope to look at scope in the future to help refine these results,” she said.
 

Canadian study shows pandemic’s impact on patient care

“The pandemic’s impact on primary care remains palpable, and Dr. Kiran’s team has done an excellent analysis on the practice trends during the past several years,” Dr. Huffstetler said.

“The Canadian analysis uses claims in a similar manner to our study; however, it appears that they already knew who the FPs were in Ontario,” Dr. Huffstetler noted. “Their claims threshold of 50 for active practice was higher than ours, at only 1. Should those FPs have moved to a different specialty, the physicians would still have claims for the patients seen in other subspecialties. As such, I don’t suspect that their analysis miscalculated those that transitioned, rather than stopped practice,” she explained.

The Ontario study was supported by the Initial Credential Evaluation Service, which is funded by the Ontario Ministry of Health and the Ministry of Long-Term Care, as well as by the Canadian Institutes of Health Research. Additional support came from the INSPIRE Primary Health Care Research Program, which is also funded by the Ontario Ministry of Health and Long-Term Care. The researchers had no financial conflicts to disclose.

The Virginia study was supported by the Department of Medical Assistance Services and the National Center for Advancing Translational Sciences. The researchers had no financial conflicts to disclose.

The supply and demand report was conducted for the AAMC by IHS Markit, a global information company.