Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice

https://jamanetwork.com/journals/jama/fullarticle/2790791

On the same day in March 2020 that President Donald Trump declared the COVID-19 pandemic a national emergency, researchers at the Larry A. Green Center in Virginia launched an ongoing survey of COVID-19’s effects on primary care practices. Over the past 2 years, more than 36 000 survey responses from clinicians across the country have painted an alarming picture of a workforce that’s increasingly burned out, traumatized, anxious, and depressed. As Green Center codirector Rebecca S. Etz, PhD, summed up her survey’s findings in a recent interview with JAMA, “It’s been bad for primary care over the pandemic and it’s getting worse.”

iStock.com/Armand Burger

Another national health care worker survey, the Coping With COVID study, found that burnout approached 50% in 2020 among 9266 physicians across medical disciplines. Last year’s survey results, which haven’t been published yet, are more dire still, according to study coauthor Mark Linzer, MD, a professor of medicine at the University of Minnesota whose research focuses on burnout. His takeaway: burnout has increased considerably as the pandemic has dragged on.

“It has been a very, very trying 2 years for the clinician workforce, and the health care workforce in general,” Linzer said in an interview. “Particularly over the last 6 months, I think people have really just needed to process what they’ve been through and have time to recuperate. But there really has not been time, given all the pent-up demand for care and the continuing pandemic and the Omicron surge.”

Meanwhile, Lotte Dyrbye, MD, MHPE, chief well-being officer for the University of Colorado School of Medicine, said that some physicians have had the opposite experience during the pandemic—too little work. “An important thing to realize is that how the pandemic has affected physicians is incredibly heterogeneous,” she said in an interview.

Many medical specialties saw the workload decrease in the pandemic’s first year and even during subsequent surges, when demand for non–COVID-19–related visits and elective procedures evaporated. Some practices watched their business and finances dry up.

Experts warn that the COVID-19 pandemic, now entering its third year, has pushed an already fragile workforce to the brink. For many clinicians the workplace challenges—ranging from high stress and burnout to understaffing and reduced income, often in combination—have become insurmountable.

Worsening staffing issues are now the biggest stressor for clinicians. Health care worker shortages, especially in rural and otherwise underserved areas of the country, have reached critical and unsustainable levels, according to the National Institute for Occupational Safety and Health (NIOSH).

“The evidence shows that health workers have been leaving the workforce at an alarming rate over the past 2 years,” Thomas R. Cunningham, PhD, a senior behavioral scientist at NIOSH, wrote in a statement emailed to JAMA.

In the absence of national data, Etz says the Green Center data point to a meaningful reduction in the primary care workforce during the pandemic. In the February 2022 survey, 62% of 847 clinicians had personal knowledge of other primary care clinicians who retired early or quit during the pandemic and 29% knew of practices that had closed up shop. That’s on top of a preexisting shortage of general and family medicine physicians. “I think we have a platform that is collapsed, and we haven’t recognized it yet,” Etz said.

In fact, surveys indicate that a “great clinician resignation” lies ahead. A quarter of clinicians said they planned to leave primary care within 3 years in Etz’s February survey. The Coping With COVID study predicts a more widespread clinician exodus: in the pandemic’s first year, 23.8% of the more than 9000 physicians from various disciplines in the study and 40% of 2301 nurses planned to exit their practice in the next 2 years. (The Coping With COVID study was funded by the American Medical Association, the publisher of JAMA.)

A lesson that’s been underscored during the pandemic is that physician wellness has a lot to do with other health workers’ satisfaction. “The ‘great resignation’ is affecting a lot of our staff, who don’t feel necessarily cared for by their organizations,” Linzer said. “The staff are leaving, which leaves the physicians to do more nonphysician work. So really, in order to solve this, we need to pay attention to all of our health care workers.”

Nurses who said they intended to leave their positions within 6 months cited 3 main drivers in an American Nurses Foundation survey: work negatively affecting their health and well-being, insufficient staffing, and a lack of employer support during the pandemic.

“Health care is a team sport,” L. Casey Chosewood, MD, MPH, director of the NIOSH Office for Total Worker Health, wrote in the agency’s emailed statement. “When nurses and other support personnel are under tremendous strain or not able to perform at optimal levels, or when staffing is inadequate, the impact flows both upstream to physicians who then face a heavier workload and loss of efficiency, and downstream impacting patient care and treatment outcomes.”

The pandemic began to take its toll on primary care clinicians early on, says Etz, who is a professor in the department of family medicine and population health at Virginia Commonwealth University. Although primary care offices typically handle the vast majority of respiratory infections in the community, they weren’t prioritized for personal protective equipment (PPE) and other crucial supplies when COVID-19 struck. “Our survey showed, going as far as 6 months into the pandemic, half the [clinicians] still didn’t have PPE,” Etz said. “People were wearing coffee filters and garbage bags to take care of their patients.”

The Green Center survey showed that primary care clinicians’ stress levels improved last summer as vaccines became widely available in the US, but the Delta variant surge reversed this. Since then, physician mental and physical exhaustion has returned to prevaccine levels.

As of this February, only about a fifth of Green Center survey respondents were fully staffed, and 44% had open clinician positions they could not fill. Still, 40% of respondents said they had taken on an influx of new patients whose previous practices closed. The pandemic also required primary care practices to provide new or expanded services—telehealth, home monitoring of patients with COVID-19, and more mental health care, to name a few.

They’ve done all this with limited resources. Throughout the public health crisis, primary care physician practices have struggled with low reimbursement for telehealth and long-overdue payments from insurers, Etz says. Applying for aid, such as Paycheck Protection Program (PPP) or Small Business Association (SBA) loans, was onerous and itself often costly. “The primary care practices that I know that were able to get money from PPP and the SBA loans that were available had to hire accountants to help them figure out how to do it,” Etz said. Unpublished data from various states and task forces suggest that less than 5% of health care sector financial assistance may have gone to primary care, she noted.Trying to do more for patients while dealing with shrinking staff and resources—all during an unprecedented infectious disease crisis—has left some clinicians traumatized. “In our qualitative comments,” Etz said of the Green Survey, “we still get people sharing suicidal ideation. Talking about panic attacks in their sleep and pulling over on their way to work to puke because they’re under so much stress.” Recent survey responses reflect the ongoing distress:

“I cannot continue to work at this pace and retire at 65. I am 50. I am chronically exhausted. There is no relief in sight.”

“I’m burned out. The patients have so much anxiety and it has affected me. I see 21 patients daily for relatively low pay. I’m on my way out of this position—I can’t remain healthy and stay here.”

“I am emotionally traumatized and experiencing severe burnout. I would quit if I was able.”

“I had planned to work for at least 10 more years, now I’m thinking about ways to retire as soon as possible.”

“I have been in practice for over 30 years and have never felt so emotionally and physically drained as I have this year. I have given up trying to correct COVID misinformation and this is so very discouraging.”

“I’ve exited practice. Pray I don’t ever need to go back. It’s miserable with no positive indicators for improvement.”

Etz, who trained as a cultural anthropologist, sees a troubling pattern in the responses: lack of hope. Hopelessness was also apparent in a mid-2021 survey by the nonprofit Physicians Foundation. About 20% of 2504 physicians said they knew a physician who had either considered, attempted, or died by suicide during the COVID-19 pandemic.

Today, frontline clinicians are experiencing high rates of depression, anxiety, sleep disturbance, and posttraumatic stress disorder, according to Dyrbye, who is a member of the National Academies of Medicine’s Clinician Well-being Collaborative. “Many of them are running on the very last steam,” she said. She noted that compassion fatigue, a result of high levels of work stress, has also set in for some: “They’re getting tired of taking care of patients who are incredibly sick and aren’t vaccinated.”

“There’s clearly still widespread burnout, fatigue, and frustration not only related to the earlier phases of the pandemic, but also the aftermath related to shortage of staffing,” Lou Baptista, MD, MPH, executive vice chair of the department of psychiatry at Columbia University Medical Center (CUMC), said in an interview.

As a result, some physicians are cutting their clinical hours for the first time or jumping ship to different institutions where they feel they’ll be better cared for. Baptista says that many mental health professionals at CUMC are leaving for private practice, where they can work fewer days, make more money, and practice telemedicine from the comfort of their own home.

An important mitigator of health care burnout and intention to leave, it turns out, is feeling valued by one’s organization, which Linzer says requires more from employers than simply expressing the sentiment. Dyrbye says health care organizations must undertake systemic steps to improve the work environment. That means finding ways to reduce workload, improve work efficiency, maximize teamwork, and promote a culture of wellness.

Linzer, who directs the Hennepin Healthcare Institute for Professional Worklife, offered a workload solution: if resources allow, float physicians can be hired for periodic coverage, or locum tenens clinicians could be brought in to cover shifts during critical times. “I’m hoping that our health system has learned that as we go through these crises, not unlike in the military, one needs to plan how many times you deploy someone, how long you deploy them for, when you give them a rest to put somebody else in place,” he said.

Early in the pandemic, when time off wasn’t a reality for New York City’s frontline health workers, Baptista helped organize a group of CUMC psychologists and psychiatrists who began volunteering their services to other clinicians in the health system. The program, called CopeColumbia, offered 30-minute peer-to-peer telehealth support sessions, small group sessions customized for different clinical departments, and larger webinars and town halls devoted to topics like stress, trauma, and grief.

“Our thinking was, can we create these brief spaces of just half an hour to give them support,” said Baptista, who last year was named chief well-being officer at ColumbiaDoctors. About a third of the early peer-to-peer sessions led to referrals for clinical care. Over the past 24 months, CopeColumbia has expanded to become the main platform that provides well-being resources and peer support to all medical center employees, not just clinicians.

Last year, NIOSH launched a campaign to address health worker stress, burnout, depression, anxiety, substance use disorders, and suicidal behavior—long-standing problems exacerbated by the pandemic. A goal of the Health Worker Mental Health Initiative is system-wide, organizational-level improvements. The program’s research, funded by the American Rescue Plan Act, could help inform fundamental changes to health care worker shifts, workloads, benefits, time off, and more.

NIOSH’s Chosewood acknowledged the challenge ahead: “The design of work in healthcare needs an overhaul,” he wrote. “Ideally, health worker jobs are so well-designed that doctors, nurses and technicians go home at the end of a fulfilling work day even healthier than when they arrived. I don’t think that’s a pipe dream.”

Linzer agrees that changes are overdue to reduce burnout. “I think there’s a lot of ways that things could be done differently—a lot of work that could be done by others, that would give a chance for physicians to grieve, debrief, heal, and then continue again,” he said. “But the idea of just rushing to start again is, I think, not going to work.”

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Sugar substitutes may interfere with liver’s ability to detoxify, researchers say

https://www.foxnews.com/health/sugar-substitutes-interfere-liver-ability-detoxify

‘With an estimated 40% of Americans regularly consuming non-nutritive sweeteners, it’s important to understand how they affect the body’

Two sugar substitutes, also known as non-nutritive sweeteners, may disrupt the function of a protein that plays an important role in detoxifying the liver and the metabolizing certain drugs, including blood pressure medications and antidepressants, a new study suggested. 

These sweeteners are commonly used in foods and even some medications to give a sweet taste while providing an alternative to table sugar with few or no calories, according to nutrition experts. 

“With an estimated 40% of Americans regularly consuming non-nutritive sweeteners, it’s important to understand how they affect the body,” Laura Danner, a doctoral student at the Medical College of Wisconsin said in the release.

Danner, who presented the new research at the American Society for Biochemistry and Molecular Biology annual meeting this week in Philadelphia, also said in the release, “In fact, many people don’t realize that these sweeteners are found in light or zero-sugar versions of yogurts and snack foods and even in non-food products like liquid medicines and certain cosmetics.” 

Non-nutritive sweeteners, acesulfame potassium and sucralose, were analyzed while using liver cells and cell-free assays, which allow the study of cellular processes such as transport, the authors explained in the release. 

The investigators found that acesulfame potassium and sucralose inhibited the activity of a protein in the body called P-glycoprotein (PGP). PGP pumps many foreign substances out of cells, according to health experts, and is part of a group of transporters that help cleanse the body of drugs, toxins, and drug metabolites. 

“We observed that sweeteners impacted PGP activity in liver cells at concentrations expected through consumption of common foods and beverages, far below the recommended FDA maximum limits,” Stephanie Olivier Van Stichelen, PhD, who lead the research team, said in the release. “To our knowledge, we are the first group to decipher the molecular mechanism by which non-nutritive sweeteners impact detoxification in the liver.” 

According to the team’s work, the study also showed that the sweeteners stimulate transport activity and likely bind to PGP. This causes a competition with and inhibits the transport of other substrates such as xenobiotics, drugs and their metabolites, short-chain lipids and bile acids, the release stated. According to a presentation by Danner, this potentially leaves other PGP substrates such as certain medications left trapped in cells, possibly leading to liver toxicity.

In a case where an individual takes blood pressure medications, antidepressants and antibiotics, which are medications that rely on PGP as a primary detoxification transporter, this could be problematic, the researchers said in the release. 

The researchers did recommend that the findings be further confirmed through preclinical and clinical studies, since their study is preliminary. 

“If future studies confirm that non-nutritive sweeteners impair the body’s detoxification process, it would be essential to study the potential interactions and determine safe levels of consumption for at-risk groups,” Danner said in the release and added, “It might also be important to include specific amounts non-nutritive sweeteners included on food labels so that people can better track their intake.” The researchers noted in the release that PGP also plays a role with maintaining the blood-brain barrier and therefore it is important to explore how inhibition of this protein may interfere with the function of cells in other organs besides the liver. 

The researchers plan on conducting further research on the two sweeteners using more complex models of drug transport and also plan on studying mixes of these sweeteners, since that is typically how they are found in food products.

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Dear Pain Warriors , our feature documentary film on the epidemic of Chronic Pain is going strong on Amazon Prime and Tubi, for FREE . We have 8 stars on IMDB , the international data base of movies.

Our goal is to get it seen by doctors ,nurses , healthcare providers and decision makers . Please SHARE and help us spread the word.

We were just awarded 3 prizes at film festivals around the world for our efforts. People are getting the message that Chronic Pain is a serious issue that MUST be recognized by society. Please help our stories be told. Thanks 

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Perhaps you can help with this relatively new practice of pharmacists in FL.  It just started occurring over the last month or so, where a patient who has been going to the same pharmacy for years, suddenly out of nowhere and without reason, the pharmacist is stating, “l am not comfortable filling this prescription”. Another arbitrary statement is ,”…it’s my clinical opinion you are on too much medication” ( or something to that effect).

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Evidence for Pharmacogenetic Testing in Patients With Treatment-Resistant Depression

https://www.uspharmacist.com/article/evidence-for-pharmacogenetic-testing-in-patients-with-treatmentresistant-depression

Toronto—Pharmacogenetic testing is increasingly a game-changer when it comes to selecting medications for a range of conditions.

In fact, a new Canadian study suggests that it was associated with an 89% increase in remission rates compared with treatment-as-usual (TAU) in patients with treatment-resistant depression (TRD).

The 52-week double-blind study, comparing pharmacogenetic testing-guided treatment to TAU, from the Centre for Addiction and Mental Health (CAMH) in Toronto was published recently in the journal Translational Psychiatry. It is touted as the first-of-its-kind in Canada.

The participants were 276 patients who had been previously diagnosed with TRD; this meant they did not improve after trying at least two antidepressant medications.

“Remission, or full recovery from symptoms, is one of the most challenging endpoints to achieve when treating major depressive disorder,” stated senior author James Kennedy, MD, PhD, head of the Tanenbaum Centre for Pharmacogenetics at the Campbell Family Mental Health Research Institute at CAMH. “The findings from this study contribute the first randomized, controlled data in Canada to the growing body of evidence of the clinical value of combined multi-gene pharmacogenetic testing.”

Pharmacogenetics uses customized genetic testing, usually with a cheek swab, to help clinicians select appropriate drugs and dosages based on their unique genetic makeup.

Background information in the study pointed out that the pharmacological treatment of depression “consists of stages of trial and error, with less than 40% of patients achieving remission during first medication trial.”

The authors noted, however, that in a large, randomized-controlled trial (RCT) in the U.S. called Genomics Used to Improve Depression Decisions (GUIDED), significant improvements in response and remission rates were observed in patients who received treatment guided by combinatorial pharmacogenomic testing.

The Canadian “GAPP-MDD” RCT was a year-long, three-arm, multicenter, participant- and rater–blinded trial that evaluated clinical outcomes among patients with depression whose treatment was guided by combinatorial pharmacogenomic testing compared with TAU. Defined as the outcome was symptom improvement (change in 17-item Hamilton Depression Rating Scale [HAM-D17]) at Week 8. Secondary outcomes included response (>50% decrease in HAM-D17) and remission (HAM-D17 <7) during the same time period.

The researchers found that patients in the guided-care arm had greater symptom improvement (27.6% vs. 22.7%), response (30.3% vs. 22.7%), and remission rates (15.7% vs. 8.3%) compared with TAU, although the differences were not statistically significant. Still, the authors observed that relative improvements in response and remission rates were consistent between the GAPP-MDD (33.0% response, 89.0% remission) and GUIDED (31.0% response, 51.0% remission) trials.

“Together with GUIDED, the results from the GAPP-MDD trial indicate that combinatorial pharmacogenomic testing can be an effective tool to help guide depression treatment in the context of the Canadian healthcare setting,” they wrote.

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I got a message from two of my regular readers a few minutes ago with this messaage:

Hi Steve. Just wanted to let you know that 8 of your posts that I’ve shared, (previously removed by fb) have been returned w/an apology…?! Interesting….

I just made a new post with a hyperlink to my blog and it DID NOT GET REJECTED !!!

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FDA advisory panel votes against recommending COVID-19 booster shots for most Americans

https://nypost.com/2021/09/17/fda-advisory-panel-refuses-to-green-light-booster-shots-for-people-16-and-over/

A Food and Drug Administration advisory panel voted against green-lighting COVID-19 booster shots Friday for most people — throwing up a major hurdle for President Biden’s plan to dole out a third dose to most Americans.

But the independent panel, which reviewed a 23-page FDA briefing document highlighting recent studies,  recommended emergency use of a third dose for Americans over age 65 and those at high risk of severe infection.

The panel said more data is needed before it can okay boosters for people ages 16 and older, and that the two-dose Pfizer regimen is still highly protective against the spread of the super-contagious Delta variant for most people.

“In particular, there is a lack of data on effectiveness and duration,” Dr. Michael Carome, director of Public Citizen’s Health Research Group, said at the meeting Friday.

“Current evidence does not appear to show a need for boosting.”

The FDA is not bound to follow the advice of the independent advisory panel but has followed its guidance so far on COVID-19 vaccinations.

Overall, the panel voted 16-2 not to recommend a third dose for people 16 years and up while unanimously green-lighting it for people 65 years and older.

In coming to its decision, the advisory panel scrutinized several studies to determine whether a booster shot was effective and necessary at least six months after a second dose.

The panel noted research published in the New England Journal of Medicine in July showing that people who have received both doses of Pfizer’s COVID-19 vaccine are still 88 percent protected against getting sick from the Delta variant.

The much-anticipated vote comes after a key member of the panel, Dr. Paul A. Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, last week called third doses “premature.” 

“There is no compelling reason to get a third dose now,” he told the New York Times.

The independent group of experts on Friday also reviewed a Pfizer study of 306 people showing that virus-fighting antibodies jumped threefold after a booster shot was given around six to eight months after the second dose.

But Meg Seymour, of the National Center for Health Research, argued there wasn’t enough data for older adults.

“The total safety sample is very small,” she said. “Twelve people over 65 is much too small to draw conclusions about safety.”

Another study out of Israel, which was also highlighted by the vaccine maker, tracked about 1 million people age 60 and older and found that a third jab was “roughly 95 percent” effective at protecting against the Delta variant.

The efficacy is comparable to the protection seen shortly after the vaccine’s rollout earlier in the year.

Still, the panel was ultimately not convinced by those studies and others.

The FDA’s reviewers had suggested ahead of the vote that they preferred to focus on research involving Americans, insisting that domestic studies “most accurately represent vaccine effectiveness in the US population.”

Meanwhile, President Biden and the country’s top health advisers insisted last month that booster shots would be needed — and likely available the week of Sept. 20.

Dr. Anthony Fauci, the nation’s top infectious diseases expert, said he was “certain” that Americans would need a booster shot eight months after their second shot.

But not everyone in the scientific community agrees. The World Health Organization recently argued against boosters, saying that rich nations shouldn’t dole out a third dose when poor countries don’t have enough vaccines for their first.

“It is unfortunate the While House announced the need for booster shots prior to the FDA’s assessment of the data,” Seymour admitted at the panel meeting Friday.

Dr. Peter Marks, director of the Center for Biologics Evaluation and Research within the FDA, acknowledged the divisive viewpoints during opening remarks to the advisory panel.

“We know there may be differing opinions in interpreting the data,” he said. “We strongly encourage all the different viewpoints to be voiced and discussed regarding the data, which is complex and evolving.”

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This is a question & answer zoom call that I had with RSDSA – whose mission statement is: Reflex Sympathetic Dystrophy Syndrome Association (RSDSA) mission is to provide support, education, and hope to all affected by the pain and disability of CRPS/RSD, while we drive research to develop better treatments and a cure.

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