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Join us for a thought-provoking podcast episode as we dive into the critical topic of mental health and suicide among health care providers. Our guests, Jessica Singh, an experienced emergency physician, and Lorenzo Norris, a psychiatrist, provide invaluable insights into the challenges faced by health care professionals and the pressing need for systemic reform. Together, we explore the tragic story of Dr. Lorna Breen, whose death brought attention to the stigma surrounding mental health in the health care system. Discover the barriers that health care providers encounter when seeking mental health services and the alarming prevalence of suicide among nurses and physicians. We also discuss the impact of the COVID-19 pandemic on burnout and mental health challenges, as well as the recent legislation, such as the Dr. Lorna Breen Health Care Provider Protection Act. Tune in for a compelling conversation that aims to raise awareness and foster change to support the well-being of those who dedicate their lives to caring for others.
Jessica Singh is an emergency physician. Lorenzo Norris is a psychiatrist.
They share their stories and discuss the KevinMD article, “Doctors and nurses are dying by suicide, as America’s health care workers call for change.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Jessica Singh and Lorenzo Norris. Jessica is an emergency physician, Lorenzo is a psychiatrist, and together they co-wrote the KevinMD article “Doctors and nurses are dying by suicide, as America’s health care workers call for change.” Jessica, Lorenzo, welcome to the show.
Jessica Singh: Thank you, Kevin.
Kevin Pho: So, guys, I’d like each of you to just briefly share your stories and journeys to where you are today. Jessica, why don’t you go first?
Jessica Singh: So I trained and practiced as an emergency medicine physician. I had the opportunity to practice in the community after residency and then to do the first physician wellness fellowship out at Stanford. That was the first time I really got to understand the systems drivers of burnout and how much really needs to go into making the health care environment more conducive for both provider well-being and patient safety. And so after fellowship, I transitioned careers to be able to pursue that more through consulting.
Kevin Pho: Fantastic. Jessica, I’ve never actually heard of a physician wellness fellowship, so tell us more about that.
Jessica Singh: It was amazing. It was the first one. Dr. Rebecca Smith-Coggins and Dr. Corey Poffenberger out at Stanford created a one-year physician wellness fellowship where you worked half time as an attending in the emergency room, and the other half of the time was devoted to the fellowship. In the fellowship, there were journal clubs, book clubs, didactic activities, process improvement, which was so important, because how much of well-being doesn’t involve our workflow and our processes, and research. It was a really wonderful opportunity.
Kevin Pho: And how many of you were taking this fellowship?
Jessica Singh: One.
Kevin Pho: Yeah, fantastic. So the fact that we need a physician wellness fellowship, what does that say about our current health care system?
Jessica Singh: That they’re changing, that this fellowship is possible, and hopefully more will have it.
Kevin Pho: Excellent. All right, Lorenzo, tell us your story and journey to where you are today.
Lorenzo Norris: OK, I’m glad to be here, Kevin. First and foremost, I was born and bred in Cleveland, Ohio. I am a psychiatrist by training, a consultation-liaison psychiatrist, and I’ve filled a lot of different roles. I’ve been a medical director of psychiatric behavioral services. Currently I am the chief wellness officer for the GW Medical Enterprise, and I’m also an associate dean of student affairs and administration.
And maybe to one of your earlier points, Kevin, I did not initially start out in any way, shape, or form seeking to become a chief wellness officer. But what occurred was that our dean, Dean Bass at the GW School of Medicine, in the midst of the COVID pandemic, when we were looking at the well-being of our residents, it was not good, as it is for many health care professionals. So that’s when we dusted off an old plan and said, “All right, let’s see what we can do with it.” So it’s interesting: I had no ambition to become a chief wellness officer, but given the state of our health care professionals’ well-being and our system, whether it’s fellowships or new initiatives or things of that nature, it is needed.
Kevin Pho: So, Lorenzo, you said that during the pandemic, the well-being of your residents wasn’t good. What were you seeing?
Lorenzo Norris: What I was seeing, if you will, was, one, the same drivers that we see: overwork and administrative bureaucracy. But in addition to that, Kevin, with COVID we had isolation. We had loneliness. We had a whole generation of health care professionals, particularly at different stages of their training, whether it’s UME. And when I say health care professionals, I mean all my colleagues: nursing, PA, PT, OT, everybody, anyone associated with health care, residents, as well as, I would include, for lack of a better word, junior staff and faculty members. They were affected by this.
But if everyone goes back to COVID, it was a very lonely place. So we think a lot about the loneliness and the strain. And I still remember all of this “You’re heroes, you’re this, you’re that.” We’d see this, and my kids would be like, “Dad, they’re applauding for you.” And I was like, “That’s great, but I’d actually rather have PPE.” It’s that double-edged sword. And actually, there’s been a lot of pushback, as I’m sure people who listen to your podcast or your blog probably realize, that people just want to do their job and have purpose in it and not be considered heroes. So heroes, loneliness, incredible amounts of stress, training that has possibly been changed, as well as everything else that has happened with COVID, made an already impossibly challenging situation even more challenging and difficult, and outright worse.
Kevin Pho: Now, both of you talk more about this issue in your KevinMD article titled “Doctors and nurses are dying by suicide, as America’s health care workers call for change.” Now, Jessica, how did this article come together?
Jessica Singh: Honestly, it came together organically. I had the pleasure of actually meeting Lorenzo through LinkedIn. That’s how this collaboration started, which was unbelievable. And I had heard Corey Feist speak at the Virginia Patient Safety Summit, back I think it was in 2021. The year that COVID came, that was the year of my fellowship as well. And I just remember going through training and then practice environments, and being in environments where physicians had died by suicide, and it was just one of those “What is being done?” moments. And then to learn about the Dr. Lorna Breen Heroes’ Foundation, and to figure out that now this is actually going to the federal government and they’re taking action to make change. Yes, it’s way overdue, and yes, way more is needed.
As we talk about in the article, there needs to be more expansion of these efforts. And one of the big things is not just to focus on mental health, but to focus on operations and systems changes to make it a more conducive environment to practice medicine, and, like Lorenzo said, to have that meaning and have that fulfillment. And so we had the pleasure of speaking with Corey Feist and having his insight on the impact of this article, and it really just felt like such a tribute. It was such an honor just to collaborate to increase advocacy and raise awareness of these issues.
Kevin Pho: And Jessica, I’ve had Corey on this podcast before, so I know his story and Dr. Lorna Breen’s story. For those who aren’t familiar, tell us who Dr. Lorna Breen was, and tell us a little bit more about the Dr. Lorna Breen Heroes’ Foundation.
Jessica Singh: I will try to do them justice. Dr. Lorna Breen was a physician who practiced as the medical director of the emergency department. She was at NewYork-Presbyterian Allen Hospital. Unfortunately, she had contracted COVID while caring for patients, and unexpectedly she died by suicide. She didn’t have any mental health issues that anybody knew about. And really her sister and her brother-in-law, they heard the cry of people reaching out to them, and they formed the Dr. Lorna Breen Heroes’ Foundation. Through this, there were health initiatives to raise advocacy, and they had a lot of support in order to create this initiative, and ultimately had a lot of federal support, and that led to the initiative of having the Dr. Lorna Breen Health Care Provider Protection Act.
Kevin Pho: Tell us a little more about this act, Jessica, in terms of what kind of changes this act made.
Jessica Singh: Sure. So it’s amazing, because it called for $103 million of funding over three years in order to support the mental health of health care providers, and this was done through grants. One of the biggest things that was really helpful to hear from Corey was how much more needs to happen. They were only able to fund 45 hospitals out of almost 6,000 in this country, and that’s less than 1 percent of those that needed funding. And so while it’s amazing, grants take time. They will show change, and this is exactly what’s needed: that evidence-based change, to have these interventions known, so that more hospitals can learn from each other as to how to make the environment better.
Kevin Pho: So, Lorenzo, whenever hospitals and medical institutions address burnout, a lot of it focuses on improving clinician and health care worker resiliency. And you know, these resiliency training classes are sometimes supplemented by some yoga classes and relaxation techniques. Are they enough?
Lorenzo Norris: No. Absolutely, positively not. They are not enough, not even close. And one of the things is that it starts at the organizational level. That’s really where the conversation has to start, and we want to honor our colleagues by acknowledging that another, if you will, mindfulness-based intervention, another resiliency class, and by the way, I’m all for those things, is not enough. We have to implement things at an organizational as well as, I would dare say, a national level, which was touched upon in the article. I agree with that completely, Kevin. So the short and correct answer is absolutely not enough.
Kevin Pho: So, Lorenzo, when you say that changes need to be implemented on a systemic level and an organizational level, tell us a story. Give us an example. What does that mean?
Lorenzo Norris: What that means is, if we look at the COVID pandemic, depending on what organization you’re in, your attrition rates for health care professionals might have escalated to, like, two to three times what you’re normally used to. This is further going to exacerbate issues in regard to, if you will, administrative EMR burden. If you have less staff or resources, that is going to make things worse. If you did not have a solid foundational, if you will, health infrastructure for supporting well-being, in terms of people’s health care, self-care, and things of that nature, that will further exacerbate things.
And then, going to the Lorna Breen Foundation, part of what they look at is if people want to reach out and just, even on that individual level, get support, there are many things in terms of licensure and different credentialing practices that serve as barriers. So until we actually have a coherent system, the easiest way to say it, Kevin, is that you actually have to have clinician and health care provider well-being at the start of any new system or infrastructure. And hence, that’s what the national plan is trying to get at. In the article, we had mentioned, or I should say Corey mentioned, that the plan is there; it’s just the steps in implementing it. But unless you have that wraparound system approach, any of us, in terms of our own individual resilience or what have you, it is going to be limited, beyond limited.
Kevin Pho: So, Lorenzo, you mentioned that you are the chief wellness officer at your medical institution. What’s one way that you’ve moved the needle when it comes to clinician burnout?
Lorenzo Norris: Probably the biggest thing, in my opinion, is actually having surveys and metrics that we follow, and that we’re committed to actually implementing and doing something about. I want to give a big shout-out to Dr. Ripp at Mount Sinai Hospital, a couple of other people, and also the folks at Mayo Clinic, even though I think I’ve met them once or twice, and all the work that they have done. I reference their articles quite a bit. But in order to do something, you have to actually measure it, and then you have to have buy-in from your organizational leaders on multiple levels who want you to do something about it. I would say at GW, we are now using a Mayo model; we’re at a nascent stage, and other folks are much more advanced in it.
But I personally also think we have to go beyond that. It has to be at a national level, because all of us interact or work together, so it’s not good enough for one hospital or one organization or one group to do it. We need it at a high, national, organizational level. And also, I dare say, just to toss it back to Jessica, we need different voices. We need the voices of different generations. And that’s why she mentioned that we met on LinkedIn. But it was something about Jessica, because normally, I mean, you get a lot of links and stuff, and you’re kind of like, “OK.” But she had a certain passion to her, and I was like, “Wait a minute, hold it. This young clinician has something that I would love to support in terms of her getting it out there.” So I just want to acknowledge that, Jessica. You know, I’ve just been so pleased watching you do this from my vantage point. I’m kind of a bit of an old head now, so I love to see your generation, and I think that’s where a lot of these answers are going to come from.
But yes, Kevin, at an organizational level, at the bare minimum, if you’re not measuring it and committed to acting upon it, there’s not going to be any change. That’s probably one of the biggest things that I’ve been able to do. Along with our superb team here at the Resiliency and Well-Being Center, with my associate director, Leigh Frame, we’ve been able to get some stuff done.
Kevin Pho: So, Jessica, tell me about your ideal world in terms of the things that you would like to see done in order to combat burnout, suicide, and mental health issues among health care professionals. And I’m going to ask the second part to that question: Once you articulate what your ideal world is, what are some of the obstacles that prevent us from getting there?
Jessica Singh: Those are great, and I’m also going to build off of what Lorenzo had said. So the first step is just education, awareness, and acknowledgment. I wish I had known about this stuff in medical education or in premedical education. There’s so much about the great health care provider exodus. You spend your whole life doing something; I never expected to change careers. And it really comes down to fulfillment and what you are doing every day. Does it have meaning to you?
And so on the other point, in terms of an ideal world and measuring: With burnout, the Mayo Clinic did the Well-Being Index, and thanks to Dr. Tait Shanafelt and all of his work, they talk about professional fulfillment. There you have the Stanford WellMD model, where it’s culture of wellness, efficiency of practice, and personal resilience, which is just one-third of those domains. And how often are you in a health care environment where they’re correlating burnout with provider quality and safety, and really correlating it with their own provider turnover, to really see? You know, if someone’s unhappy with the schedule, or there are so many other barriers to flow, what is the incentive for changing? How do you get leadership to change it, and how do you bridge that gap?
And so in the ideal world you’re asking about, there would be that bridge between what’s coming from administration and what’s actually going on at the front line. You were asking earlier, you know, what does the fact that there is a physician wellness fellowship say about the health care system? It’s about the fact that you need physician leaders, people who know what’s going on. And there are more and more leaders coming up. More and more physicians are pursuing MBAs, and more and more physicians are assuming C-suite positions, because you keep that intricate knowledge of the health care system to actually bridge the gaps.
Kevin Pho: Jessica, what do you see as the biggest obstacles that are preventing us from getting to where you want to go?
Jessica Singh: You’re in a system. You’re expected to perform a certain way in medical school, and in medical education the curriculum is already so jammed with everything that you have to learn. There’s really very little buffer, and it’s not even buffer. Where is the room for the important stuff? You go through medicine without learning how health care operates or about the business of medicine. So how can you learn about a system without understanding how it operates? So there are so many barriers in terms of logistics and structure, and just the whole way our system is set up. But at least, just to end on not a daunting note, things are changing.
Kevin Pho: So, Lorenzo, if we don’t address this, tell us what’s going to happen, and frame it in terms of how that is going to affect patients if we don’t address this issue appropriately.
Lorenzo Norris: Well, we’re going to have more health care providers, unfortunately, with loss of life, first and foremost. Second, we’re going to have a massive, and I feel comfortable saying this, a massive exodus of people who were invested in health care for a purpose, and they’re going to leave the field. That’s going to affect who comes in and the quality of care that is given, and this is ultimately going to have an effect on patients in any number of realms, because, if you will, the shortfall of health care providers has been well documented. This will only increase, in addition to the increasing burden, or I wouldn’t say burden, but challenges, involving health care with an aging population. We already know, if you will, that child and adolescent suicide rates have increased, just to give a couple of different types of effects.
So what you’re going to have is, you’re going to be hit from both ends. You’re going to have people who leave the health care environment, or they’re going to do what’s termed partially quit, which you will see a lot of. And then you’re going to have an increase in health burden, and you’re going to reach a crisis point, or another crisis point, at which ultimately, at some point in time, you might need to consider, if not already, some form of radical system change in which you just kind of retool the thing from the start. It depends on who you talk to, but that’s what I personally think you will see. And actually, I think we’ve been seeing this. It’s actually not what we’re going to see; it’s actually happening right now, this very moment. And I think if you talk to many health care providers, they’ll tell you the same thing.
Kevin Pho: But are we seeing some of this burden already taking effect and impacting patient care at George Washington?
Lorenzo Norris: I would certainly say that in the DMV area, we absolutely are seeing it. All you have to do is look at how challenging it is to recruit health care providers, whether it’s nurses, social workers, or physicians. Everybody is doing their level best to recover from COVID and keep doing what they’re doing to give patient care. I mean everybody, my colleagues at different hospitals in the DMV region, which is DC, Maryland, and Virginia, for those of you who aren’t in the DC area. Everyone is doing that. But with that being said, the challenges are quite significant, because there’s also the business aspect of health care, and people will tell you, if you speak to hospital CEOs, it is so challenging because the margins, quote unquote, are so tight in terms of keeping everything going. So yes, I would dare say that we absolutely are. COVID was a crisis point. We have navigated that, but we’re still in crisis mode and trying to navigate how we come out of this and continue to serve patients across multiple systems.
Kevin Pho: I’m going to ask each of you one last question now: just your take-home messages to the KevinMD audience. Jessica, why don’t you go first?
Jessica Singh: Sure. Big picture of life, this article is on suicide. The big take-home message is, no matter where you are on your career path, no matter what else is going on, the first and foremost important thing is your well-being, your health, and your safety, and that’s paramount to caring for others. And so there’s so much out there now being done to try to address stigma, and even though it’s still unfortunately such a part of our culture, there are confidential ways to seek mental health access. And so the big take-home message is that change is happening. More is being spoken about. I think that was one of the silver linings of COVID: Now more of this stuff is being spoken about in the open. And so seek support whenever it’s needed.
Kevin Pho: And Lorenzo, tell us some of your take-home messages for the KevinMD audience.
Lorenzo Norris: This is an opportunity, depending on where you’re at, to either advocate or to be part of the discussion at an organizational level in your system, whether it’s your own private practice or whether you’re part of a bigger organization, either academic, private, or nonprofit. This is the opportunity. It is work. It is grinding. It is hard. But this is an opportunity that we haven’t seen before to actually make some significant change.
Kevin Pho: Jessica, Lorenzo, thank you so much for sharing your time and insight, and thanks again for coming on the show.
Lorenzo Norris: Thank you.
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