Social determinants of health, burnout and self-care

If you attended or watched last week’s Grand Rounds given by Dr. Robert Wallace from the College of Public Health, you would have learned that we had been losing ground in the United States when it comes to life expectancy even before COVID-19 appeared. The reason for this comes back again and again to social determinants of health (SDOH). His lecture underscored the imperative that as providers of health care, our responsibility extends beyond our focus on the acute symptoms, presentation, or manifestations of our patients’ chronic disease and into recognizing and accounting for many factors outside of the clinical presentation. There are factors such as medication costs—consider for example the ability of a patient with diabetes to afford their insulin—that many of us already take into consideration when we make therapeutic recommendations. But how about stable housing, food insecurity, reduced availability of childcare, opioid dependency, and other challenges that clearly impact access to and efficacy of proven therapies? I mentioned this in my post just before Juneteenth, but I remain hopeful in the strategy that Dr. Martha Carvour and her colleagues will employ in their P3-funded research project. Their holistic approach to public health will be instructive in turning us away from medicine that is exclusively reactive and episodic, toward an approach that recognizes and invests in prevention and health equity. A renewed focus on building systems that focus on SDOH will likely prove to be not only cost-effective, but will address fundamental aspects of human dignity, and perhaps may start to bend the life expectancy curves back in the right direction. As we embrace a culture in which familiarizing ourselves with mitigating circumstances in each person’s experience—such as living situation, work life, and economic challenges—in our quest to provide truly compassionate care, I recognize that as providers we also have to navigate challenging encounters. Not everyone who comes into our clinics or in-patient wards is going to treat us with the same respect that we are committed to providing. But I know that the majority of our physicians, our advanced practice providers, our residents, fellows, and students work diligently to maintain professionalism and empathy in these challenging circumstances. That said, many of these are skills that can be learned and are aligned with our commitment to health equity. As such, I want to bring to your attention a recently launched educational initiative designed by the Graduate Medical Education office to address identity-based discrimination and harassment by patients in the clinical learning environment.
The two one-hour sessions focusing on “What to Say: Responding to Patient-Initiated Harassment” is a GME-sponsored workshop that can provide you a framework for handling these difficult situations. We are currently exploring whether it can be scaled for a larger venue, such as a Grand Rounds, but for now if you would like to register you can use this link, or contact our own faculty members Dr. Poorani Sekar and Dr. Nicole Nisly, who are trained facilitators, or Dr. Kanya Ferguson in the DEI Office if you have any questions. I also want to bring to your attention the work of one of our recently graduated Ophthalmology residents (also an outstanding Internal Medicine prelim!) Dr. Lauren Hock, who developed and recently published a toolkit for responding to harassment that was also presented at Internal Medicine Grand Rounds last year. Finally, I want to reflect on the importance of taking care of ourselves, which directly impacts our ability to provide cutting-edge, effective, and relevant care to our patients. This issue recently came into sharper focus for me when I came across a survey result revealing the significant time-burden that providers devote to documentation. I have heard from many faculty for a while about the time outside of the clinic spent in documentation and its contribution to burnout. But seeing it quantified in this way brought the issue home. I included these data in my recent budget presentation to senior leadership and will use this to advocate for systems-level changes to address this concern. Our faculty and providers are an irreplaceable part of our care delivery team and your health and well-being must be maintained. Before the pandemic, the National Academy of Medicine (NAM) published the results of an extensive perspective on the issue of burnout and well-being. I hope that as we move beyond the pandemic, which contributed an extra layer to the drivers of provider burnout, that we redouble our focus on reducing physician burden to increase safety and health. For now, I hope that you will take the time to review the NAM’s assessment and let me know your thoughts about what we should focus on to address our unique challenges. More than 78% of the Department of Internal Medicine have already made their thoughts known when they completed the Working in Iowa survey recently. Thank you to everyone who took the time. We have been reviewing the data and will release relevant data sets to division directors and anyone in supervisory roles that received more than 5 responses from direct reports. In addition, a department-wide town hall is being planned during which we will discuss some of the larger trends, our strengths and areas for growth, and how we intend to meet them. I was pleased to see that we received highly positive scores on some of the foundational questions like whether you believe your work makes a difference, whether you believe we provide high-quality service, and whether your supervisor treats you with respect. The challenges identified, such as suboptimal work-life balance and the need for adequate staffing of our service areas, will need to be addressed. With our strong alignment and commitment to our missions, I believe that the foundation and will is there for us to forge solutions for these areas of concerns, and I look forward to receiving feedback as we begin to meet together to review these issues. Give me a team full of members who believe in their work and the work others do around them and we can achieve anything.

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