MSV Statement

While hundreds of health care providers are on the frontlines of COVID-19 in Virginia, hundreds of other Virginia’s physicians, PAs, and nurses have been ordered to stay home or only provide limited health care to their patients. Rather than help and work with Virginia’s physicians and PAs, Governor Northam’s new executive order (EO 57) encourages the use of out of state providers and needlessly waives the statutory requirement for many nurse practitioners (other than CRNAs) to have a practice agreement with their patient care team physician during the scope of the disaster. The Medical Society of Virginia has learned that with the fast pace of dealing with the COVID pandemic, consulting with the Medical Society was inadvertently overlooked during drafting of the order.  We have shared our concern and we have been assured that heightened engagement with the Medical Society will resume.

EO57 Letter to Governor From Health Care Stakeholders

Executive Order 57

Importance of the Issue

The COVID-19 disease, caused by a virus that spreads easily from person to person that may result in serious illness or death and has been classified by the World Health Organization as a worldwide pandemic, has spread throughout the Commonwealth. The number of cases of COVID-19 continues to increase within the Commonwealth and in neighboring states. It is anticipated that COVID-19 will result in increased demands on the Commonwealth’s health professional workforce that will require additional personnel. Authorizing out-of-state licensed professionals, as well as residents, interns, and certain senior students to practice in the Commonwealth will assist in meeting that demand. In addition, permitting experienced nurse practitioners to practice without a practice agreement will increase the availability of primary care and hospital providers. Finally, expanding the use of telehealth will assist in the provision of needed health care services to the citizens of the Commonwealth.

Directive

Therefore, by virtue of the authority vested in me by the Constitution of Virginia and §44-146.17 of the Code of Virginia, during the state of emergency declared in Executive Order 51, I hereby order the following:

1. During the state of emergency declared by Executive Order 51, a license in good standing issued to a health care practitioner by another state shall be deemed to be an active license issued by the Commonwealth to provide health care or professional services as a health care practitioner of the same type for which such license is issued in another state, provided such health care practitioner is engaged by a hospital or an affiliate of such hospital where both share the same corporate parent, licensed nursing facility, dialysis facility, physicians’ office, or other health care facility in the Commonwealth for the purpose of assisting that office or facility with public health and medical disaster response operations. Hospitals, licensed nursing facilities, dialysis facilities, physicians’ offices, and other health care facilities must submit to the applicable licensing board each out-of-state health care practitioner’s name, license type, state of license, and license identification number within a reasonable time of such healthcare practitioner providing services for the health care facility or office in the Commonwealth. A health care facility includes assisted living facilities, congregate care settings, and any alternate care facility established in response to the COVID-19 emergency.
2. A clinical psychologist, professional counselor, marriage and family therapist, and clinical social worker with an active license issued by another state may be issued a temporary license by endorsement as a health care practitioner of the same type for which such license is issued in another state upon submission of an application and information requested by the applicable licensing board and the board’s verification that the applicant’s license issued by another state is active in good standing and there are no current reports in the United States Department of Health and Human Services National Practitioner Data Bank. Such temporary license shall expire ninety (90) days after the state of emergency ends. During such time the practitioner may seek a full Virginia license or transition patients to Virginia-licensed practitioners.
3. Health care practitioners with an active license issued by another state may provide continuity of care to their current patients who are Virginia residents through telehealth services. Establishment of a relationship with a new patient requires a Virginia license unless pursuant to paragraphs 1 or 2 above.
4. A healthcare practitioner may use any non-public facing audio or remote communication product that is available to communicate with patients. This exercise of discretion applies to telehealth provided for any reason regardless of whether the telehealth service is related to the diagnosis and treatment of COVID-19.
5. Nurse practitioners licensed in the Commonwealth of Virginia, except those licensed in the category of certified registered nurse anesthetists, with two or more years of clinical experience may practice in the practice category in which they are certified and licensed and prescribe without a written or electronic practice agreement.
6. Interns, residents, and fellows with active temporary training licenses to practice medicine issued by the Virginia Board of Medicine may practice in a hospital, including a clinic or alternate care facility operated by a hospital. without the supervision of a licensed physician or fully licensed member of the applicable faculty program at all times. The level of supervision required for each intern, resident, and fellow shall be established by the training program in coordination with the hospital where practice is occurring.
7. Senior fourth year medical students may practice in a hospital, including a clinic or alternate care facility operated by a hospital. without the direct tutorial supervision by a licensed physician member of the hospital staff. The level of supervision required for each student shall be established by the institution in coordination with the hospital where practice is occurring.
8. Individuals who have completed an accredited respiratory care program may practice respiratory therapy and for ninety (90) days thereafter or until the individual has passed the National Board on Respiratory Care licensure examination and been issued a license or has failed the examination, whichever occurs first.

Nothing in this order designates the healthcare practitioners above as agents of the Commonwealth.

These actions are in concert with, and further the provisions of Executive Order 51 in marshalling all resources and appropriate preparedness, response, and recovery measures to respond to the emergency.

Effective Date of this Executive Order

This Executive Order shall be effective April 17, 2020, and shall remain in full force and in effect until June 10, 2020 unless sooner amended or rescinded by further executive order. Given under my hand and under the Seal of the Commonwealth of Virginia, this 17th day of April, 2020.

Download A Copy of Executive Order 57

To all physicians and health care providers across the Commonwealth:

These are exceptional times. COVID-19 is a risk to the lives and well-being of nearly every American. Even if individuals and their loved ones avoid this virus, the ripple effects across our nation and our Commonwealth will be immeasurable. The Medical Society of Virginia (MSV) understands the immensity of the challenge before Virginia and all heath care professionals. Any successful effort to stop COVID-19 will require coordinated sacrifice and a deep community response.

The MSV serves as the voice of Virginia’s physicians, residents, medical students, physician assistants and physician assistant students, representing all medical specialties in all regions of the Commonwealth. Our membership is at the frontlines of responding to the COVID-19 crisis.

In order to lead the response to COVID-19, protect patients, and make best use of health providers’ training and expertise, the MSV recommends all physicians and providers follow the American College of Surgeons guidelines, CMS guidelines, and specialty society recommendations postponing elective procedures. Given the risk of COVID-19, there are several reasons elective procedures should be postponed:

1. As stated by AMA President Patrice A. Harris, M.D., M.A., “there is nowhere near enough PPE in the fight against COVID-19–a shortage that endangers patients and jeopardizes the entire response to this virus.” Elective procedures that use PPE and other resources potentially jeopardize our national response to COVID-19.
2. COVID-19 is spread through aerosolized droplets that are expelled during coughing, sneezing, or breathing. Performing elective procedures puts patients and providers in a position for infection by bringing them into the hospital and exposing them to multiple potential transfers. This violates the edict of social distancing. We need as many physicians, nurses and other health care workers as possible responding to this crisis—not endangering themselves for nonessential work.
3. Accountability does not lessen during a crisis, it only heightens. Physicians live under a staff privileging regulatory framework that already accounts for unethical behavior and incorporates the individual needs of each region.
4. Cancelling elective procedures is an ethical responsibility. This not an administrative decision, but a medical decision. The entire national health care community is asking people to stay home, miss work, and do what they can to mitigate the spread of COVID-19. Physicians owe it to our communities to make similar decisions. Under the current threat, performance of inappropriate procedures is unethical.

It is up to each physician to make the best recommendation for their patient given the risks, benefits, and alternatives. The MSV will update its recommendation as new information develops. The MSV is committed to providing our members and the broader health community with the most up to date COVID-19 information. Please visit MSV.org/COVID19 to get the latest information.

Sincerely,
Clifford L. Deal III, MD, FACS
President

Find a PDF copy of the letter here.

By Robert D. Morton, CPHRM, CPPS, Assistant Vice President, Department of Patient Safety and Risk Management, The Doctors Company

The term “burnout” has been questioned as a labeling error—and rightfully so. Burnout implies victim shaming. What many healthcare professionals on the frontlines are experiencing is a normal response (symptoms) to an abnormal situation (cause), like sick fish in a tank of toxic water. A diagnosis of burnout suggests that the solution is to medicate the fish. A more holistic view is to say, “There’s really nothing wrong with you; let’s clean the tank.”

The World Health Organization (WHO) announced plans to include what it labels “burn-out” as an occupational phenomenon in the International Classification of Diseases (ICD-11). The syndrome, which results from chronic workplace stress, is characterized by feelings of exhaustion, increased mental distancing from one’s work or cynicism about work, and reduced professional efficacy.[i]

The WHO’s actions seem to further legitimize what many are experiencing: an ever more exhausting, distancing, and chronically stressful healthcare system that makes connecting with patients and providing quality care more challenging and contributes to burnout, healthcare professional distress, or to what some have even labeled moral injury or human rights violations.[ii][iii][iv]

Physician Burnout Thought Leaders Weigh In

Drs. Simon Talbot and Wendy Dean, who co-founded the nonprofit organization MoralInjury.healthcare, borrowed the expression “moral injury” from Jonathan Shay, MD, PhD, a clinical psychiatrist who coined the phrase. Briefly, it is (1) a betrayal of what’s right, (2) by someone who holds authority, (3) in a high-stakes situation.[v] Discussions of moral injury include the view that repeated daily betrayals by authorities within the system are manifest in healthcare every day in the form of mandates from leaders to see more patients with less time to care for them, forced use of dysfunctional electronic health record (EHR) systems, overburdens by payers, competing financial considerations, fear of litigation, and more. These types of betrayals run counter to patients’ best interests—which pains doctors, whose unifying creed is that patients come first.

While other physician thought leaders like Dr. Dike Drummond (thehappymd.com), Dr. Paul DeChant (author, Preventing Physician Burnout), Dr. Zubin Damania (aka ZDoggMD), and Dr. Pamela Wible (idealmedicalcare.org) may differ on the terminology, each makes a similar call for leadership and action equal to the severity and scope of the dilemma. They all call for partnering with enlightened leaders to change the systemic and institutional patterns that inflict betrayals on the practice of good medicine.

Dr. Wible calls these issues human rights violations that begin in medical education and training due to labor law abuses, sleep/food/water deprivation, discrimination, violence, understaffing, and more—driving up depression and suicide rates.[vi] Because of the profound impact on individuals, there is broad consensus about the immediate need to expand access to confidential, nonpunitive mental healthcare for doctors and nurses.

In response to systemic conditions, some doctors are quitting because having less time with patients has driven morale to rock bottom, and those who remain are warning of a mass exodus if things don’t improve.[vii] According to Paul DeChant, MD, MBA, a failure to step up and meet this challenge is a failure of leadership and constitutes management malpractice, with some administrators asserting that they are suffering from management burnout.[viii]

Dr. Howard Marcus, an internist in Austin, Texas, responded, “Most of us do not see our administrators as oppressors but, rather, as stuck along with the rest of us in a system that has piled on time-consuming burdens—which saps us of the time and energy required to do the best we can for our patients in the time available.”

An Annals of Internal Medicine cost-consequence analysis reported that physician burnout is costing $4.6 billion per year related to physician turnover and reduced clinical hours. The authors offer a prescription that burnout “can effectively be reduced with moderate levels of investment,” suggesting there is “substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.”[ix]

The National Academy of Medicine issued a report that offers a bold vision for systemic change—because “the system,” the amorphous healthcare-industrial complex, is designed, unwittingly or not, to produce the results it is producing. When you take what is at its core a moral and scientific enterprise, that is the practice of medicine, and relentlessly mess with it in an unscientific manner driven by economics and regulation, physician burnout is the expected outcome. The scope and breadth of the problem requires unprecedented leadership, shared “collective and coordinated action across all levels of the health care system—front line care delivery, the health care organization, and the external environment.”[x]

Leadership matters. The Mayo Clinic reported that a one-point increase in the leadership score of a physician’s immediate supervisor was associated with a 3.3 percent decrease in the likelihood of burnout.[xi] This and other reports support the often-quoted conclusion that your supervisor is more important to your health than your primary care doctor. If leadership will not make this issue a priority, lead as though no help is coming.

Executive leaders in some healthcare systems are beginning to require all executive staff to frequently round with or shadow physicians and to ask questions like “What isn’t working?” To be of value, executive leaders must be armed with the courage to lead and an organizational commitment to change. Some systems have appointed chief wellness officers and formed clinician wellness teams, giving them authority to create opportunities to support well-being and resiliency.

Steven Beeson, MD, founder of the Clinician Experience Project, urges “to advance care for patients and take on the healthcare imperatives in front of us, we have to care for those caring for others first. To care for the care team we must listen to clinicians, respond to the things they need, invest in burden reduction, support and develop them to be their best, empower them to lead the way, allow them to be the clinician they envisioned, and appreciate the impact they make when we do these things.” (Stephen Beeson, MD, email communication, July 17, 2019.)

Efforts to Improve EHR Usability

EHR rescue and optimization work is becoming more common to regain lost relationships with patients. Executive leaders who are desperate for help often contact firms like Medical Advantage Group (MAG), a subsidiary of The Doctors Company. MAG conducts system database audits, followed by workflow analysis, previsit planning, and redesign of work screens to make the EHR function better as a convenient, accessible clinical source of truth. Ironically, this improvement in EHR accessibility and usability makes the EHR function more like old paper charts when everything was at hand. Other benefits of this work include increases in quality-based payments, improved EHR user efficiency and experience, reduced time spent searching, and reduced or eliminated “pajama time” (charting at home).

On a smaller scale, Dr. Gabe Charbonneau (fightburnout.org), a family physician and EHR problem-solver who is on a mission to disrupt burnout, finds his greatest fulfillment in helping doctors one-on-one. Another example related to EHR usability is at Atrius Health, where a collaboration with its IT department reduced inefficiencies by cutting 1,500 clicks per day per physician.[xii] This sustained, resourced commitment to improvements resulted in less time spent in the EHR and improved professional satisfaction.

Like any meaningful change, improvements require leadership with a growth mindset that demonstrates a deep respect for people and for the nature of their work. This means exhibiting leadership behaviors such as deference to expertise and sensitivity to clinical operations—two characteristics of the continuous improvement mindset on the journey toward high reliability. Effective leaders meet physicians where they live—on the frontlines of care—and seek to understand what is getting in the way of connecting with patients and providing quality care. The best leaders then work tirelessly to remove the barriers.

Additional Resource

American Hospital Association and AHA Physician Alliance. Well-being playbook: a guide for hospital and health system leaders. https://www.aha.org/system/files/media/file/2019/05/plf-well-being-playbook.pdf. Published May 2019.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Reprinted with permission. ©2019 The Doctors Company (www.thedoctors.com).

[i] Burn-out an “occupational phenomenon”: International Classification of Diseases. World Health Organization. https://www.who.int/mental_health/evidence/burn-out/en/. May 28, 2019. Accessed June 12, 2019.

[ii] Swenson S. Esprit de corps: turning vicious cycle virtuous. Talk presented at: NEJM Catalyst event Essentials of High-Performing Organizations; July 25, 2018; Institute for Healthcare Policy and Innovation, University of Michigan. https://catalyst.nejm.org/videos/esprit-de-corps-vicious-virtuous-cycle/. Accessed March 4, 2019.

[iii] Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat website. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Published July 26, 2018. Accessed April 30, 2019.

[iv] Wible P. Not “burnout,” not moral injury—human rights violations. https://www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rights-violations/. Posted March 18, 2019. Accessed May 10, 2019.

[v] Shay J. Moral injury. Psychoanal Psychol. 2014;31(2):182–191. https://www.law.upenn.edu/live/files/4602-moralinjuryshayexcerptpdf.

[vi] Wible P. Not “burnout,” not moral injury—human rights violations. https://www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rights-violations/. Posted March 18, 2019. Accessed May 10, 2019.

[vii] Eichacker C. Doctors quit EMMC as changes leave less time with patients, push morale to ‘all-time low.’ Bangor Daily News. May 13, 2019. https://bangordailynews.com/2019/05/13/news/bangor/doctors-quit-emmc-as-changes-leave-less-time-with-patients-push-morale-to-all-time-low/. Accessed May 14, 2019.

[viii] DeChant P. Management burnout. www.pauldechantmd.com/management-burnout/. Posted April 26, 2019. Accessed April 29, 2019.

[ix] Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. [Epub ahead of print 28 May 2019] 170:784–790. https://annals.org/aim/article-abstract/2734784/estimating-attributable-cost-physician-burnout-united-states. Accessed June 12, 2019.

[x] Taking action against clinician burnout: A systems approach to professional well-being. Slide 19. National Academy of Medicine. https://nam.edu/wp-content/uploads/2019/10/Public-release-PPT-10-23-19.pdf. Published October 23, 2019. Accessed October 25, 2019.

[xi] Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. https://www.mayoclinicproceedings.org/article/S0025-6196%2816%2930625-5/pdf.

[xii] Berg S. How collaboration with IT cut 1,500 clicks a day per physician. American Medical Association. https://www.ama-assn.org/practice-management/digital/how-collaboration-it-cut-1500-clicks-day-physician. Published March 7, 2019. Accessed May 1, 2019.