Why we need a new “GI Bill” for clinicians
Originally published in Zocalo Public Square on April 10, 2020.
By Judith Garber, Shannon Brownlee, and Vikas Saini
In late March, a mutual friend of ours called with a grim picture of the situation on the ground at the Queens hospital where he works. New York City had not yet experienced the peak of the outbreak, but the hospital already had 140 COVID-positive patients, 35 of them on ventilators. And there were only five ventilators left.
Our friend, a physician, had just witnessed the death of a 27-year-old man with no chronic conditions. In his hospital, doctors were already making decisions about who to put on ventilators. “It’s a mess and there’s no help,” he told us. The young residents—doctors in training—were completely disillusioned; one of them told him, “When this is over, I don’t want to do this anymore, if this is what our health care system has come to.”
If this pandemic can be compared to a war, we have sent our soldiers—our medical professionals—to the front lines without the protection they need to survive.
We should all be afraid about that reaction to COVID-19. If this pandemic can be compared to a war, we have sent our soldiers—our medical professionals—to the front lines without the protection and protocols they need to survive. Physicians, nurses, and other hospital workers are overwhelmed by endless streams of patients, the extra-long hours, and the deaths they see all around them. Scared and confused, they fight on. We should expect that when their duty is done, some of our best and brightest will decide never to return to the battlefield again.
In this respect, this pandemic is an extension of the ordinary. The United States routinely neglects the needs of one of its most vital workforces. If COVID-19 has any silver linings, the most important one will be its exposure of the fault lines in American healthcare, including the fact that even before the epidemic hit, healthcare professionals were suffering from toxic levels of burnout that hampers their ability to care about their patients.
More broadly, this epidemic shows that many aspects of the way we speak and think about healthcare, and the way we provide it, need to be reconceived and redesigned. To do that, we need to listen to doctors, nurses, and other healthcare professionals.
Despite the health risks of treating COVID-19 patients and the lack of masks and basic protection in many hospitals, healthcare professionals are not running from the challenge. Instead, they are building their own masks out of office supplies, coming out of retirement to offer aid, and isolating themselves in garages and trailers to protect their families.
Such commitment is particularly impressive when you consider that even before COVID-19, a significant proportion of them were unhappy in their jobs. According to research from the National Academy of Medicine, between 35 percent and 54 percent of U.S. nurses and physicians feel substantial symptoms of burnout, including exhaustion, depression, and emotional numbness. For medical students and residents, the prevalence of burnout ranges from 45 to 60 percent.
Even before COVID-19 hit, healthcare professionals were suffering from toxic levels of burnout that hampers their ability to care for their patients.
Our caregivers are not just tired or stressed—they are experiencing “moral injury.” The term moral injury was coined in 2009 to describe how soldiers’ mental health suffered from having to act against their own moral compass in times of war. Dr. Simon G. Talbot and Dr. Wendy Dean applied this term to the healthcare setting to describe the “suffering, anguish, and loss” clinicians feel when they cannot deliver the care patients need in our profit-based healthcare system.
In our profit-based healthcare industry, billing is king, and clinicians bear the brunt of the busy work that’s required. According to an annual survey conducted by Medscape, an online medical news outlet, the most common contributor to moral injury is the absurd number of bureaucratic tasks healthcare workers now do. For example, a 2016 study found that physicians in four specialties spend about half of their work day filling out electronic medical records and paperwork. Family physicians spend another 1 to 2 hours at home after work doing coding and billing in the electronic medical record.
Another casualty of profit-driven healthcare is the time doctors get to spend with patients. More patients per day means more billing opportunities, and many clinicians are pressured to fit as many patients in their schedule as possible. The “15-minute visit” in primary care has become routine. Many physicians barely have time to listen to patients’ concerns before sending them for one test or another. This diminished time with patients gives doctors and nurses the feeling that they are mere cogs in a computerized system that cares little about people and their health problems.
This is not what most practitioners signed up for, and the mismatch between the ideals of medicine and the reality takes a high toll. Physicians in the U.S. have the highest suicide rate of any profession. That statistic may reflect the fact that physicians are stigmatized and sometimes punished for seeking mental healthcare.
Of course, the COVID-19 pandemic has reinforced the sense of purpose driving many medical professionals. But as they’re putting themselves in danger, and their mental health is suffering as they watch patients and even colleagues die. For many, including our friend in Queens and his colleagues, the crisis has already inflicted a devastating emotional impact.
In order to retain health professionals after this epidemic, we must answer their long-held concerns–and involve them in charting the path to a new health system.
In order to retain health professionals after this epidemic, we must do more than recognize their sacrifices, or address their current anger. We must answer their long-held concerns—and involve them in charting new policies and ways of keeping them healthy enough to tend the sick. Call it the GI Bill for Healthcare Professionals, if you will.
Some of these new policies should be financial. Nursing and medical students often leave school with thousands of dollars in debt, and the mental stress that accompanies it. Educational debt also adds pressure for doctors to choose a high-paying specialty rather than primary care and geriatrics, where the need for a larger workforce is most urgent. Steps can be taken to address that: Erase all health professionals’ school debt to help those already in the field. In addition, medical, nursing, and physician’s assistant training should be free for all low-income students, to encourage more people from disadvantaged neighborhoods and regions to pursue these necessary careers.
We also need to ease some of the burdens of daily work life. Electronic health records, as currently configured, are primarily tools for maximizing billing. Beyond the time required to fill them out, they create all kinds of headaches for doctors and nurses, who find them incredibly frustrating to use. These record systems need to be redesigned into one single, easy-to-use platform, with the primary purpose of improving care. A committee of healthcare workers should be the principal advisors in this endeavor.
We also need to adjust regulations to make it easier to deliver care to patients. In this state of emergency, the federal government has eased regulatory requirements to allow increased flexibility in where and how patients are treated. For example, Medicare is now paying clinicians for a wide range of telehealth services. We have heard from frontline clinicians that the reprieve from many regulatory and administrative burdens has reminded them of how much better it feels to devote time to caring for patients, rather than navigating paperwork and rules.
One primary care doctor told us that before COVID, she would have to see patients in person to determine that they did not need to see her for in-person visits. Now, she is encouraged to care for patients virtually whenever possible, without an unnecessary in-person visit beforehand. Common-sense policy changes like these should be made permanent if possible, with recommendations from healthcare workers helping to drive decisions.
Unfortunately, it isn’t enough to make health jobs easier and more patient-focused. After this pandemic, doctors, nurses, and other healthcare workers will need to recover from what they’ve recently experienced. Hospitals should expand access to counselors and other mental health services we need, and teaching hospitals must do the same for trainees. Health professional schools should follow the example of Weill Cornell Medicine in offering free mental health counseling for all students. Mental health services should be accompanied by safe and confidential screening services for depression, PTSD, and other mental health issues, to reduce barriers to access.
World War II veterans got the GI Bill. Clinicians today deserve the same assurances.
Finally, in the wake of COVID-19, the U.S. public health response to pandemics will have to be re-evaluated and overhauled. One priority must be to make sure healthcare workers are never forced to beg for masks and other basic protections again. To that end, we should establish a Clinician’s Affairs agency within the Department of Health and Human Services with representation from nurses and doctors. By putting clinician representation at HHS, and also at the Department of Homeland Security, it would position healthcare professionals to give direct input on national health and security policies.
For years, Americans have stood by as the healthcare system pushes our doctors and nurses to the breaking point. Now, our need for them is as great as it’s ever been, and we are pushing them further. World War II veterans got the GI Bill. Clinicians today deserve the same assurances. We need a Healthcare Professionals Bill that eases their educational debt and also includes them in redesigning multiple aspects of our broken system.