In her tenure as American Medical Association President, Dr Patrice Harris has faced a unique confluence of challenges – physician burnout, the COVID-19 pandemic, and racial inequality. Dr. Harris was the 274th President of the AMA, but was the organization’s first African-American woman to hold that position. Her specialty? Psychiatry. Her experience? County public health director.
I think it would be an understatement to say that Dr. Harris has the right experience, skills and perspective that has been needed this past year. I recently had the opportunity to sit down with Dr. Harris via conference call and I asked her about these three challenges she has faced. Below is a summarized version of our conversation.
This pandemic has really put a financial squeeze on primary care physicians. Many are predicting that physicians will be closing their practices and become hospitalists. What are you hearing?
The AMA has really made sure that we had our ears and eyes to the ground during the pandemic. Of course, we do that all the time, but we really put additional focus on it during the pandemic. We wanted to make sure that we were hearing from physicians and doing what we could to act and advocate for physicians and their practices.
The AMA supports physicians practicing in the manner that best suits their needs. But clearly, and for obvious reasons, the smaller independent practices were worried. Fortunately, there was no dissent or disagreement about the need to shut down practices early on because we certainly wanted to limit the spread of COVID-19. We, like everyone else, were learning as we go, but originally we knew so little about what was appropriate. Physicians were worried and that’s why the AMA advocated for the paycheck protection program (PPP) and direct support to physicians – because many of these independent practices are in underserved areas. It’s so important to maintain the viability of those practices, and that’s why we did all the work that we did. But that work is not enough and it will continue to be a focus for us.
Some have said openly that rescuing physician practices is not a prudent use of funds. That perhaps we should just allow these practices to close and let other care models rise – like retail clinics or urgent care centers. Is the decline of primary care just part of the evolution of healthcare?
I would vehemently disagree that it’s “okay” to watch primary care decline. Certainly, I would agree that there is not one right way, but primary care is so critical to successful outcomes. We absolutely need primary care to be the center of our work and a vital part of the healthcare ecosystem.
Even as new models rise and become established and accepted, primary care physicians and primary care offices still provide such an important part of the care delivery network. And it’s so fragile right now. You can’t really take a piece away and expect care to continue to move smoothly. We need to ensure seamless continuity of care. That absolutely includes primary care and specialty care. But it needs to work together, and that’s where primary care plays a critical role.
Primary care is central to health coordination and gives us a look into other issues we need to address like structural and social determinants of health. There are so many people who want to take a piece of that care journey and working in silos is not the way to go. While I’m always happy to learn, I haven’t seen any fragmented model that really works. You can’t work in silos when health outcomes are at stake. We have got to be in the business of silo-busting.
Can you speak about the problem of physician burnout and how you are thinking about it now versus before the pandemic?
Physician burnout is definitely a key area of focus for me in general, but specifically at the AMA. When we first began the conversation around physician burnout, we heard a lot of “Physician – heal thyself. Get more sleep and exercise, and just eat right and burnout will improve.”
We at the AMA did a lot of work in partnership with the Mayo Clinic and Stanford around the issues of physician burnout. While all of us should certainly get appropriate sleep, eat right, and exercise, we learned that burnout is about a lot more. There are several systemic issues that contribute to it. For example, regulations, rules, and requirements cause administrative burdens. We have also learned that for every hour a physician spends with patients, they spend two hours on administrative work.
I can tell you that as a psychiatrist this isn’t ideal. Physicians experience such joy working with patients, but when you add the administrative work on top, it takes that joy away. You can’t layer it on top of the things we do in our own lives – like me visiting my dad and taking care of all my own needs – then expect me to come home and work at night.
In the vein of physician burnout, we have seen a disturbing increase in the number of physician suicides. Physicians are experiencing major depression and anxiety, and those are medical disorders. But somehow, we don’t treat physician burnout as a medical disorder.
Lastly, we’re watching physicians working on the front lines during the COVID-19 pandemic without the support they need like sufficient PPE. Hospital systems developed different ways to deal with that. Some offered wellness rounds to check in after each shift to try to provide resources for physicians. In that way, COVID-19 has amplified the importance of physician health.
Physician burnout and suicide is something we need to continue to focus on.
Mental health has become more in-focus during COVID-19. There are now many ways for patients to access mental health support. Can we take any learnings from that and apply it to delivering services to clinicians?
I think we probably won’t know what was or is the best way until we continue to try things and get feedback. Right now, we’re in the midst of it all, but my hypothesis is that anything we can do to standardize and make routine, this type of support, will be beneficial.
Different systems have put different things into place and we’ll need to look back on all of that to see what was most effective for physicians. Whether it’s checking in every hour, using telehealth, weekly check-ins, or alternatives – we need to evaluate those things to determine what’s working best.
There’s rarely a “one size fits all” approach that works, and that’s what equity is all about. There’s a cartoon that differentiates between equality and equity. We don’t need to give everyone the same size box. The best thing to do is to evaluate after the pandemic as to what best met everyone’s needs.
Inequity and diversity are a hot topic at the moment. There’s inequity in delivery and access to care, and there’s also inequity within healthcare itself. What do you hope to see from healthcare moving forward in terms of dealing with inequity?
The AMA has been working to address inequality for many years. In about 2003 or 2004, we established the Commission to End Health Disparities along with the National Medical Association and the National Hispanic Medical Association. About a year and a half ago, the AMA established the Center for Health Equity and hired our first Chief Health Equity Officer, Dr. Aletha Maybank. More recently, we have partnered with a group here in Chicago to pilot a model that makes investments in our community and works with them on their particular needs.
People may not know that the AMA did not allow African Americans to join the Association for many years. Sometimes the first step in progress is publicly admitting any past wrongdoing. Obviously, that’s not the only step needed, but the AMA did publicly apologize for that. We want to move forward and increase diversity in the physician workforce.
One of our areas of focus is how to change medical education to change these issues and raise awareness around implicit bias and how physicians can look inward to see if they have their own implicit biases. For example, unfortunately, there have been some studies that have concluded that some physicians think African Americans feel pain differently or less or other people. Those biases and the lingering issues around Tuskegee revolve around trust. The AMA is cognizant of that and we are dedicated to talking, listening, and amplifying the importance of gaining trust as an overall part of dismantling health inequities.
Is there anything you personally recommend for individuals to do? I think a lot of people are wondering, “What can I do as an individual to have a positive impact on diversity and inequity?”
There’s a test out of Harvard – the Harvard Implicit Bias Assessment. Taking that is a great start. Beyond that, individuals can look inward, and they can listen. I also recommend a book called White Fragility. Listen, learn, and be allies. And when thinking about what to say or not say, rather than being afraid to say the wrong thing and therefore not say anything, find someone you trust and ask them to help you say the right thing. We’re in the midst of a paradigm shift in how people think of what the right thing to say or do is.
Lastly, I would also recommend breathing and counting to ten when you hear something that causes a knee-jerk or reflexive reaction. I do this frequently when something offends me. It really does help to breathe and count to ten and think about the reason for your reaction. Ask yourself, “What is this about? Is this a reflexive action? Can I look at this a different way?”
What technologies are you excited about?
I’m excited about a lot of technology, but I’m always a “promise in peril” person. I like to look down the road and be proactive about intended consequences. I used telehealth in my practice pre-COVID, and I want us to be thoughtful about which ones should continue. But we shouldn’t decide that whatever worked during COVID is the final answer. We need to make sure we make it routine to have a regular evaluation period to make the right choices. As telehealth is adopted, we need to fine tune it.
Even with telehealth, we have to be mindful of broadband availability. When parents were trying to educate their children at home, not everyone had data plans. Not everyone has computers or laptops. I recall seeing a community that fitted school buses with wifi and took the buses out into the neighborhood to help. we need to make sure there’s equitable opportunity for people to participate in technology. We need to be sensitive to individuals’ unique needs.
People are talking about AI and apps, and those things are exciting, but we should be mindful that we don’t allow these technologies exacerbate inequalities that already exist.
When you look back ten years from now on your time as AMA President, what will you remember the most?
I think I’ll most remember the unique opportunity I had at this moment. I’ve had the opportunity to be my authentic self and speak truth to power. I’ve brought my set of skills to bear that were critical at this particular moment. I love that and then certainly I hope that we don’t have another year like this, but the confluence of factors I’ve presided over has just been completely unique in history so that I think will make my time as President very unique and memorable.
In my inaugural address last year, I said I wanted to use my platform to further Advance the AMA’s strategic priorities overall. I wanted to amplify the importance of mental health and overall health. I wanted to amplify the importance of diversity and equity. Those three issues are critical at the moment.
What’s next for you?
As immediate past President, I’m still engaged and involved with the AMA. People still want to talk about racism and health equity and mental health. As I said on Twitter on my last day, although my tenure ends my work will continue.
This article is part of the #HealthIT100in100