Uberization of Nursing

“Uberization" is a catchphrase that has quickly become part of common parlance in discussions about the pandemic-induced economy. Uberization is the movement by organizations to “replace fixed wage contracts with ‘dynamic pricing’ for labor” (Davis, & Sinha, 2021).  It is transforming many elements of the economy and replacing employees employed by the organization with a type of self-employed or contract employee. In essence, it allows businesses to “recruit labour at a large scale in new ways” (Davis, & Sinha, 2021). 

The global business community has had a range of responses to the trend of uberization (Babali, 2019), as has the healthcare industry in particular.  Yet as health systems emerge from the pandemic, Bloomberg reports that “the ongoing elevated costs of [healthcare] workers are causing profit warnings” (KHN, 2022; Court, & Coleman-Lochner, 2022). Regardless of one’s resistance or acceptance of uberization, healthcare employment is in crisis. Change must occur to keep health systems from financial disaster.

It seems that the tide of uberization in the healthcare industry is already rising. An increasing number of employees are contracting with hospitals and health systems via a staffing agency. This trend is likely to evolve, with a portion of staff employed directly by the hospital, and the remaining employees self-contracting with hospitals or health systems with short-term or even daily contracts. In fact, hospitals are reporting that rather than temporary “travel nurses” coming from other states to work on a contract basis, nurses are taking short-term contract work at hospitals a short drive from their own homes rather than pursue permanent employment with these organizations.  We are witnessing the uberization of nursing, which will eventually extend to other healthcare occupations.

Why uberization?

The healthcare workforce shouldered the heavy burden of fighting the COVID-19 pandemic. Yet a collaborative study from Indiana University, the nonprofit Rand Corp., and the University of Michigan that analyzed the changes in the U.S. healthcare workforce during the COVID-19 pandemic found that “the average wages for U.S. healthcare workers rose less than wages in other industries during 2020 and the first six months of 2021” (Toler, 2022; Cantor, Whaley, Kosali, & Nguyen, 2022). According to a February 2022 report by the U.S. Bureau of Labor Statistics, only about 35 percent of healthcare and social assistance organizations “increased wages and salaries, paid wage premiums, or provided bonuses because of the COVID-19 pandemic” (U.S. Bureau of Labor Statistics, 2022).

Due to the media attention the “Great Resignation” has received, it is common knowledge that workers across industries have been leaving their jobs at higher rates than before the pandemic (Parker, & Horowitz, 2022).  Yet by October 2021, when the “quit rates” were at their highest recorded levels, healthcare and social assistance job resignations had increased to 35% higher than they had been before the pandemic, slightly higher than the increase of resignations among all workers in the same period (29%) (Wager, Amin, Cox, & Hughes-Cromwick, 2021).  

Over the last ten years, “the salary of registered nurses increased by 1.67 percent in the United States” (Michas, 2021). Whereas healthcare executives make on average eight times more than their hourly employees (Saini, Garber, & Brownlee, 2022). The pandemic has rebalanced the scales in favor of those underpaid for many years. The salary landscape has changed, and in response many hospital systems blindly grasp to the pre-pandemic state of agency staffing. This, combined with near flat salary increases, contribute to the uberization of healthcare.

For many healthcare professionals, the combination of work-related stress and incommensurate compensation was the final straw. However, in addition to fair salary, flexibility has become a top demand of employees—even in healthcare. “Gone are the days when job security or pay was everything. Workers now are giving more thought to how their jobs fit into their lives. Ambition for ambition’s sake is being reassessed” (Buckingham, & Richardson, 2022).

A recent survey articulated “higher pay and dissatisfaction with management were also key drivers of nurses changing work settings in 2020 or 2021,” with 28% of respondents saying they've changed work settings (Lagasse, 2022). The percentage of nurses considering changing employers increased by 6% from 2020 to 2021, with 17% saying they are contemplating making an employment change. The percentage of nurses who are “passive job seekers – not actively looking for a new job but open to new opportunities – also increased, from 38% in 2020 to 47% in the current survey” (Lagasse, 2022).

The moment: contractor or non-contractor

As the trend of uberization continues to spread beyond the transportation industry, the global business community should be watchful of challenges that the trendsetter Uber is facing to understand future implications of this movement in their own industry. For example, recent legal battles regarding the employment status of Uber drivers will likely impact the cost-benefit analysis of those considering traditional employment or independent contracting. While an independent contractor is free to offer services to anyone and doesn’t have the limits on their freedom that comes with being an employee of a single organization, the U.S. National Labor Relations Board decision that Uber drivers are independent contractors means that drivers have no federal right to unionize (HyreCar, 2021; Fishman, 2020). In Europe, however, Uber drivers are considered employees and not independent, which could mean that unionization could occur en masse.

The future

The future of healthcare employment could be via an app on smart phones. Imagine: daily staffing supplemented by workers employed and credentialed through the app. The healthcare worker could choose their rate and shifts, and the hospital could determine the desired experience, quality, and patient experience reviews for the open position. It could shift the future of employment healthcare significantly.

The rate of change in today’s workplace is accelerating whether it is through the uberization of healthcare workers or advancements in workers’ rights. A recent New York Times article entitled “The Revolt of the College-Educated Working Class” states: “The support for labor unions among college graduates has increased from 55 percent in the late 1990s to around 70 percent in the last few years, and is even higher among younger college graduates” (Scheiber, 2022).  

This may have a ripple effect on the healthcare workforce. Years of stagnating salaries and organizations’ undefined workforce vision has primed the industry for action with record job-quits within healthcare. This has proven especially true in rural markets where recruitment of permanent and agency staff has posed numerous challenges. Our current climate potentially opens the door for workers to leverage themselves via the advocacy of a union.   

Summary

The labor supply and demand are out of balance. The long-term effects on the health sector labor market from the pandemic are unknown, but changes in healthcare delivery (such as the growth of telehealth) may lead to lasting shifts in the healthcare industry. Fierce competition for healthcare workers means that employers must go beyond good pay and benefits to attract the best candidates. Healthcare recruitment is a zero-sum game. There isn’t a pool of healthcare workers lying idle, and so recruitment is often at the cost of a competitor. The employee knows that this demand exists, and this could further drive the uberization of healthcare workers. However, there is potential for this new movement to benefit both parties. As limited number of employees equates to skill scarcity which drives salaries, hospitals could utilize their skilled workforce based on need and demand. 

Resources

Babali, B. (2019). What is Uberization? The Business Year.

Buckingham, M., & Richardson, N. (2022). What’s Really Driving the ‘Great Resignation’. Barron’s.

Cantor, J., Whaley, C., Kosali, S., & Nguyen, T. (2022). US Health Care Workforce Changes During the First and Second Years of the COVID-19 Pandemic. JAMA Health Forum. 2022;3(2):e215217.

Court, E., & Coleman-Lochner, L. (2022). ‘Unsustainable’ Squeeze Grips U.S. Hospitals on Covid Labor Cost. Bloomberg.

Davis, G., & Sinha, A. (2021). Varieties of Uberization: How technology and institutions change the organization(s) of late capitalism. Sage Journals, 2(1).

Fishman, S. (2020). Uber Drivers are Contractors Not Employees According to the NLRB. NOLO.

HyreCar (2021). Are Uber Drivers Employees or Independent Contractors: Explained. HyreCar

KHN (2022). Hospitals Losing Money, Thanks To Covid-Driven Cost Increases. KHN Morning Briefing, April 28, 2022.

Lagasse, J. (2022). Almost 30% of nurses are considering leaving the profession. Healthcare Finance News.

Michas, F. (2021). Average annual salary of registered nurses in the United States from 2011 to 2020. Statista.

Parker, K., & Horowitz, J. (2022). Majority of workers who quit a job in 2021 cite low pay, no opportunities for advancement, feeling disrespected. Pew Research Center.

Saini, V., Garber, J., & Brownlee, S. (2022). Nonprofit Hospital CEO Compensation: How Much Is Enough? Health Affairs.

Scheiber, N. (2022). The Revolt of the College-Educated Working Class. The New York Times.

Toler, A. (2022). Health care wage growth has lagged behind other industries, despite pandemic burden. Indiana University.

U.S. Bureau of Labor Statistics (2022). 24 percent of establishments increased pay or paid bonuses because of COVID-19 pandemic. U.S. Bureau of Labor Statistics.

Wager, E., Amin, K., Cox, C., & Hughes-Cromwick, P. (2021). What impact has the coronavirus pandemic had on health employment? Peterson-KFF Health System Tracker.

A mission statement must be more than a PR tactic

By Dr. Seleem R. Choudhury, December 2, 2021

Each one of us has deeply held beliefs that motivate us to action.  This is part of what it is to be human.  It is embedded in our humanity to pursue virtue, or a habitual and firm disposition to do good. Our character is inextricably linked with virtue, because good character is built through the practice and habituation of virtues (Newstead, Dawkins, & Martin, 2019).  

It is no wonder, then, that mission-driven organizations have become so desirable to today’s workforce. Working for a mission-driven organization offers a powerful avenue for the exercise of virtues through the expression and implementation of positive contributions to society (Maciariell, 2006).

I recently transitioned from NYC Health and Hospitals to Adventist HealthCare. During this transition process, it became abundantly clear that the organization’s mission is a determining factor before working in any organization. Both organizations have mission statements that align with my personal values and virtues. NYC Health and Hospitals, the largest public health care system has the mission “to extend equally to all New Yorkers, regardless of their ability to pay, comprehensive health services of the highest quality in an atmosphere of humane care, dignity, and respect,” and Adventist HealthCare, is a faith-based health system providing Christ-centered care to meet the need of quality and accessible healthcare for the local community by “extending God’s care through the ministry of physical, mental and spiritual healing” (NYC Health and Hospitals, 2021; Adventist HealthCare, 2021).

The importance of a compelling mission statement

At its best, an organization’s mission “defines and upholds” what an organization stands for (Craig, 2018). Several studies suggest that there is a positive correlation between mission statements and organizational performance. In fact, the highest performing organizations are often the ones with more comprehensive mission statements—speaking to corporate philosophy, self-concept, public image, and financial performance (Kadhium, Betteg, Sharma, & Nalliah, 2021; Bartkus, Glassman, & McAfee, 2006; Rarick & Vitton, 1995; Desmidt, Prinzie, & Decramer, 2011; Ranasinghe, 2010).

The mission statement of a healthcare organization is an essential strategic tool that captures an organization’s “enduring purpose, practices, and core values” (Trybou, Gemmel, Desmidt, & Annemans, 2017; Bart & Hupfer, 2004). Individuals are attracted to an organization as their personal motivation aligns with the mission and intrinsic factors meet individual interests. A compelling shared mission keeps everyone’s focus on the greater primary purpose and goal of the work they are doing. It also provides guardrails and direction for decision-making in times of unpredictability or conflict (Ansary, 2019). Collaborating between leadership and staff on how to unite and put into practice the organization’s mission is a sign of a truly mission-driven, successful and healthy organization (Trybou, Gemmel, Desmidt, & Annemans, 2017).

Finding the “why”

Simon Sinek, leadership guru and founder of SinekPartners, states: “The value of our lives is not determined by what we do for ourselves. The value of our lives is determined by what we do for others” (Sinek, 2014).

A mission statement should articulate why you are doing what you are doing.  For example, NYC Health and Hospitals is “committed to the health and well-being of all New Yorkers” (NYC Health and Hospitals, 2021). This statement expresses the importance of community and how being part of a community can make us feel as though we are a part of something greater than ourselves. NYC Health and Hospitals’ why is to create a healthy community.  By starting there, the how of building a healthy community—social-connectedness, overall well-being, satisfaction in life, work, and play—all become clearer (Caulfield, 2015). 

Adventist HealthCare’s mission focuses upon faith, desiring to “extend God’s care through the ministry of physical, mental and spiritual healing” (Adventist HealthCare, 2021). It is faith that “gives people a sense of meaning and purpose in life,” or as discussed above, their why (Moll, 2019). A faith-based care approach understands the wholeness and health of a person through the ministry of physical, mental, and spiritual healing. 

Relationships are important to humans and a mission that supports connectedness speaks to the why. Close connection to the people, activities, etc., that we love yields feelings of happiness, contentment, and personal satisfaction with our lives (Sharry, 2018). There is more than sufficient scientific evidence to show that involvement in social relationships have a benefit upon health (Umberson & Montez, 2010). In healthcare, a mission statement’s emphasis on relationships, whether through community or faith, creates a connection and gives the organization a strong why.

The benefit to organizations

A clear, inspiring mission statement is essential to the health of an organization. Without it, strategic planning of any kind is impossible (Alegre, Berbegal-Mirabent, & Guerrero, 2019).  Mission statements also show the intent and purpose of an organization, providing a roadmap and an element of predictability concerning whether opportunities should be pursued or services offered, and making expectations clear for executives and staff within the organization (Salehi-Kordabadi, Karimi, & Qorbani-Azar, 2020). It also determines what criteria would be most effective to measure achievement (Bryson & Alston, 2005).

Furthermore, the mission imbues the work of every single employee with meaning and purpose. It helps them see how their job fits into the bigger picture and gives them a why that will inspire them (Sinek, 2009). This inspiration is a core component of organizational performance. Data shows that the design of mission statements are crucial for organizations’ growth, profitability, and shareholder equity.

However, studies also indicate that “almost 40 percent of employees do not know or understand their company’s mission” (McMillan). This suggests that leaders must embrace the task of helping employees view their work in light of the mission and understand how it contributes to the organization’s larger efforts.

A mission statement is essential to communicate the purpose and goals of an organization, and is crucial to success in effective strategic management (Hieu & Vu, 2021; Bart, Bontis, & Taggar, 2001). To be effective and inspiring, it should define the basic question of why the organization exists and what it hopes to achieve. A strong mission statement is a guiding light for the strategy and operations of the organization, attracting individuals whose virtues and motivation aligns with the organization, and paving the way for organizational success.

Reference

Alegre, I., Berbegal-Mirabent, J., & Guerrero, A. (2019). Mission statements: what university research parks tell us about timing. Journal of Business Strategy.

Bartkus, B., Glassman, M., & McAfee, B. (2006). Mission statement quality and financial performance. European Management Journal, 24(1), 86-94.

Bart, C. K., & Hupfer, M. (2004). Mission statements in Canadian hospitals. Journal of Health Organization and Management.

Bart, C. K., Bontis, N., & Taggar, S. (2001). A model of the impact of mission statements on firm performance. Management decision.

Beaton, E. E. (2021). No margin, no mission: How practitioners justify nonprofit managerialization. VOLUNTAS: International Journal of Voluntary and Nonprofit Organizations, 32(3), 695-708.

Bryson, J. M, Alston, F.K. (2005). Creating and implementing your strategic plan, San Francisco: Jossy-bass.

Craig, W. (2018). The importance of having a mission-driven company. Forbes.

Desmidt, S., Prinzie, A., & Decramer, A. (2011). Looking for the value of mission statements: a meta‐analysis of 20 years of research. Management Decision.

Hieu, V. M., & Vu, N. M. (2021). Linking Mission Statements Components to Management Effectiveness. Webology, 18(Special issue on Management and Social Media), 39-48.

Lilja, T. M. (2021). Far Away on an Important Mission: Considerations on Branch Manager Regulation. Copenhagen Business School, CBS LAW Research Paper, (21-03).

Maciariell, J.A. (2006). Peter F. Drucker on Mission-Driven Leadership and Management in the Social Sector. Journal of Management, Spirituality & Religion, 3(1-2).

McMillan, A. Mission and Vision Statements. Reference for Business.

Newstead, T., Dawkins, S., Macklin, R. and Martin, A. (2020a), “We don’t need more leaders – we need more good leaders. advancing a virtues-based approach to leader (ship) development”, The Leadership Quarterly, pp. 1-11.

Newstead, T., Dawkins, S., Macklin, R. and Martin, A. (2020b), “The virtues project: an approach to developing good leaders”, Journal of Business Ethics, pp. 1-18.

Ranasinghe, D. N. (2010). Impact of formality and intensity of strategic planning on corporate performance. In Proceedings of International Conference on Business Management (Vol. 7).

Rarick, C. A., & Vitton, J. (1995). Corporate strategy: Mission statements make cents. Journal of Business Strategy.

Salehi-Kordabadi, S., Karimi, S., & Qorbani-Azar, M. (2020). The Relationship between Mission Statement and Firms’ Performance. International Journal of Advanced Studies in Humanities and Social Science, 9(1), 21-36.

Trybou, J., Gemmel, P., Desmidt, S., & Annemans, L. (2017). Fulfillment of administrative and professional obligations of hospitals and mission motivation of physicians. BMC health services research, 17(1), 28. https://doi.org/10.1186/s12913-017-1990-0

Umberson, D., & Montez, J. K. (2010). Social relationships and health: a flashpoint for health policy. Journal of health and social behavior, 51 Suppl(Suppl), S54–S66.

Developing Excellence in Primary Care

By Dr. Seleem R. Choudhury, October 13, 2021

Nearly half of all Americans suffer from at least one chronic disease, and that number is growing (American Association of Retired Persons; Fried, 2017; Tinker, 2017).  Chronic diseases—including cancer, diabetes, hypertension, stroke, heart disease, respiratory diseases, arthritis, obesity, and oral diseases—can lead to hospitalization, long-term disability, reduced quality of life, and death.  Additionally, chronic diseases often require a long period of supervision, observation, or care (Rothman, & Wagner, 2003). To make matters more complicated, many patients have multiple morbidities, creating particular challenges for healthcare providers (Braillard, Slama-Chaudhry, Joly, Perone, & Beran, 2018).

As Reynolds, et al, explain in their 2018 article, “the defining features of primary care (including continuity, coordination, and comprehensiveness) makes this setting suitable for managing chronic conditions” (Reynolds, Dennis, Hasan, Slewa, Chen, et al., 2018).  High-performing primary care teams keep the “quadruple aim” of primary care—enhancing the care experience, improving the health of the population, reducing costs, and improving the work-life of the team—at the forefront of their work (Haverfield, Tierney, Schwartz, Bass, Brown-Johnson, et al, 2020). Studies repeatedly bear this out, demonstrating that an integrated approach with an aim to improve the quality of life of patients—as well as those caring for them—can enhance chronic disease outcomes and management.  As the healthcare industry continues to evolve, it cannot afford not to invest in primary care.

Bodenheimer’s Building Blocks

Current literature discussing characteristics of best primary care practices supports three well-proven methods:

1. Patient-Centered Medical Home (PCMH) standards from the National Committee on Quality Assurance (Hahn, Gonzalez, Etz, & Crabtree, 2014),
2. the Peterson Center on Health Care’s “America’s Most Valuable Care: Primary Care” (Peterson Center on Health Care, & Stanford Medicine Clinical Excellence Research Center, 2014), and
3. the Building Blocks framework commonly known as Bodenheimer’s Building Blocks. (Bodenheimer, Ghorob, Willard-Grace, & Kevin Grumbach, 2014).

Each of these models is similar, often reinforcing one another yet each with its unique benefits.  Inspired by a conversation with Tanya Kapka, MD, MPH, FAAFP, a leader in healthcare transformation, this article will focus on four specific areas within Bodenheimer’s Building Blocks: Engaged Leadership, Data-Driven Improvement, Empanelment, and Team-Based Care (see graphic). These four blocks are foundational in the quest for clinical excellence in primary care.

 

Block 1: Engaged leadership

One of the most commonly cited reasons for failed PCMH change efforts is a lack of leadership support (Qureshi, Quigley, & Hays, 2020).  Active, engaged, supportive leadership is not a new necessity, nor is its importance limited to healthcare. The role is critical in Comprehensive Primary Care transformation (Altman Dautoff, Philips, & Manning, 2013). Leaders are the ones who drive and inspire change.  Without a leader to champion the change and navigate teams through its complexities, then the aspiration for developing excellence will never be attained.

Block 2: Data-Driven Improvement

 Evidence of what constitutes quality care is always evolving; this is a good thing for patients and the health of our communities. This necessitates that providers regularly re-evaluate and change their practices in order to stay current (Agency for Healthcare Research and Quality, 2018).  This, of course, assumes that this evidence will lead to improved patient care and outcomes.  The challenge is typically about finding a balance regarding data. When making choices about care practices, too much data becomes daunting, too little leads to uncertainty. The goal is to hit a sweet spot where all members of the team feel like they have enough data to make informed decisions to enhance clinical excellence (Coppersmith, Sarkar, & Chen, 2019).

Block 3: Empanelment

Empanelment is a foundational strategy for building or improving primary health care systems by linking patients to a primary care provider. This strategy is a “critical pathway” for achieving optimal outcomes, effective universal health coverage, and population health management (Bearden, Ratcliffe, Sugarman, Bitton, & Anaman, 2019). To effectively promote patient engagement or, in some circumstances, patient re-engagement, the care team must remain coordinated, data must be up to date, and patient coordination and communication consistent. These elements are essential for excellence in primary care (McGough, Chaudhari, El-Attar, & Yung, 2018).

Block 4: Team-Based Care

The concept of a team approach in primary care is not new. However, it is often assumed that it is occurring. And though team-based care may occur, few organizations effectively and regularly evaluate its success and consider how their care teams might become even higher-performing.  Namely, organizations should assess whether the required knowledge, skills, and abilities are present on the team (Larson, 2009), the team members are in their optimal roles (Luig, Asselin, Sharma, & Campbell-Schererand, 2018), and the team is striving for improvement together (Shukor, Edelman, Brown, & Rivard, 2018).

The identity of High-Quality, Comprehensive Primary Care, mid- and post-COVID

The past year and a half of providing care in a pandemic has starkly highlighted the importance of primary care. “During a pandemic, primary care is the first line of defense. It is able to reinforce public health messages, help patients manage at home, and identify those in need of hospital care” (Krist, DeVoe, Cheng, Ehrlich, & Jones, 2020).

At the onset of the pandemic, primary care was forced to transform from a person-visiting-a-clinic modality to a telemedicine program (Jaklevic, 2020). Interestingly, healthcare systems and primary care practices had tried to coax this change prior to the pandemic, but many experienced resistance.  The reasons for this resistance were complex and varied, yet literally overnight these changes occurred (Nittari, Khuman, Baldoni, Pallotta, Battineni, et al, 2020; Kaplan, 2020). Some would say the change occurred too quickly.

Initially, these programs demonstrated success with continuity of care, improved or plateaued outcomes, and reimbursement from payers (Rosen, Joffe, & Kelz, 2020). However, cracks present within team cohesion before the pandemic combined with overnight forced change highlighted vulnerabilities and tension in teams that were inadequately lead, staffed, managed, and skilled. It is evident that while teams with the aforementioned gaps struggled or continue to struggle today, high-performing teams pre-pandemic continued to transition successfully (Contreras, Baykal, & Abid, 2020).

The characteristics of high-quality primary care in the midst of COVID and post-COVID requires providers to get back to basics. Providers need to set their sights on the quadruple aim of enhancing the care experience, improving the health of the population, reducing costs, and improving the work-life of the team, as well as ensuring that the foundational building blocks of the Bodenheimer model are firmly in place.  

Health systems must invest in the primary care infrastructure. This begins with team leadership that endorses engagement and satisfaction, sufficient and easily-accessible data, the appropriate application of a patient panel that promotes appropriate ratio of patient acuity that leads to population health management in and out of the clinic, and a fully staffed team that fosters cohesion, camaraderie, and continual desire to improve.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com

Reference

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Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 building blocks of high-performing primary care. Annals of family medicine, 12(2), 166–171. https://doi.org/10.1370/afm.1616

Braillard, O., Slama-Chaudhry, A., Joly, C., Perone, N., & Beran, D. (2018). The impact of chronic disease management on primary care doctors in Switzerland: a qualitative study. BMC family practice, 19(1), 159. https://doi.org/10.1186/s12875-018-0833-3

Coppersmith, N. A., Sarkar, I. N., & Chen, E. S. (2019). Quality Informatics: The Convergence of Healthcare Data, Analytics, and Clinical Excellence. Applied clinical informatics, 10(2), 272–277. https://doi.org/10.1055/s-0039-1685221

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Safety Net Medical Home Initiative. Altman Dautoff D, Philips KE, Manning C. Engaged Leadership: Strategies for Guiding PCMH Transformation. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013. https://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Engaged-Leadership.pdf

Shukor, A. R., Edelman, S., Brown, D., & Rivard, C. (2018). Developing community-based primary health care for complex and vulnerable populations in the Vancouver Coastal Health region: HealthConnection Clinic. The Permanente Journal, 22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6141648/

Tinker A. How to Improve Patient Outcomes for Chronic Diseases and Comorbidities. [(accessed on 30 December 2017)]; Available online: http://www.healthcatalyst.com/wp-content/uploads/2014/04/How-to-Improve-Patient-Outcomes.pdf

The Necessary Insecurity of Healthcare Leadership

By Dr. Seleem R. Choudhury, July 8, 2021 

Years ago, I accepted a job even though I was told that the team I was to lead didn’t want me as their leader. During my tenure, I received anonymous threats to leave, as well as episodes of sabotage and unhelpful behavior. Despite this, I was convinced that I could win them over with my leadership skills. Instead of improved conditions, however, things got worse. It became clear that the team was just waiting for me to make a mistake. Like all leaders (and indeed all humans), I eventually did. 

Rather than having a supportive team, I instead experienced attempts to oust me from the position. It was an untenable position, and eventually I left. Afterward, many others in the organization voiced concerns that I was a victim of racism.  While it is possible that my colour may have been one strand of motivation, I believe that the deeper issue was the unmanaged insecurity of the organization’s leaders that may have driven the negative behaviors from the start.

Motivation and theory

Most professionals have their own stories of working for organizations with difficult or unhealthy leadership. In fact, being on the receiving end of negative leadership behaviors rooted in insecurity is especially likely if you are competent (Davey, 2017).

Studies have found that conflicts with leadership are a “critical driver of loss of high-performing talent” (Kutty, 2020).  Often, when faced with insecurity, individuals can become more rigid and show reduced creativity, resulting in products, solutions, or work habits that are less than innovative (Probst, Stewart, Gruys, & Tierney, 2007). The irony of these behaviors and methods intended to “re-secure” often go unchecked, which reinforces the leader’s thinking that this leadership method works (Lubans, 2007).

There are many reasons why behaviors like this continue to present themselves in top leaders across organizations and industries. I believe the main reason we continue to see insecure behavior in leadership is that we are all insecure leaders. We all demonstrate that insecurity differently through various characteristics; however, it’s how we manage that insecurity and even our awareness of that insecurity that determine whether subsequent leadership behaviors will be positive or negative.

As a leader, I often feel insecure in my abilities and position, and over the years I have learned that I am not alone in this. Firstly, insecurity is simply fear. As Arash Javanbakht and Linda Saab explain in their 2017 Smithsonian Magazine article:

“Fear starts in the part of the brain called the amygdala. When our ‘thinking’ brain gives feedback to our ‘emotional’ brain and we perceive ourselves as being in a safe space, we can then quickly shift the way we experience that high arousal state, going from one of fear to one of enjoyment or excitement” (Javanbakht, & Saab, 2017).

So, if fear leads to insecurity, then being insecure is a normal reaction. But if it is natural—even expected—to experience insecurity, then why doesn’t our culture embrace leaders who are insecure? We live in a world where we are surrounded by fear-inducing stimuli, propagated by media and our experience, to name just a couple sources. Though these fears are nearly always unsubstantiated, a fear response is tolerated because fear is part of the human experience (Holtz, 2015).  Our expectations of our leaders should be no different.

Being a secure leader is a myth. Instead, strong leaders are adept at managing their insecurities (Weber, & Petriglieri, 2018). When insecurities interfere with your leadership skills and methodology, they can become a danger to your team and your organization (Coveney, 2018).  But insecurities are not inherently threatening. Insecurity allows leaders to self-reflect by reviewing situations, rethinking a process, and shapes leaders into someone with the capacity to evolve and grow, and act in ways that are conscientious of other people’s feelings (Leonard, 2018).

If being insecure is a normal human trait that improves our thinking, makes us more empathetic, and helps us to grow, it seems one could even call it an asset, not a hindrance.  Being insecure as a leader can improve leaders by enhancing their opportunity to lead, making them more mindful of their team, understanding what needs to be done, and ultimately delivering thoughtful, high-performance results. Perhaps the realization of these assets is less commonly seen in leadership because leaders don’t acknowledge that they are insecure. Rather, they deal with their insecurities by over-managing situations or teams, or over-compensating as they try to come across as secure to their employees. 

Managing insecurity

I believe that an insecure leader is a good leader. Behaviors resulting from insecurity are a spectrum, with one side making you more aware and emphatic, and the other side making you angry, controlling, and difficult to work with.

The bottom line is that it’s okay to be insecure as a leader. It is easy to look at other leaders and think everyone else is confident, secure, transformational, and amazing, and feel that lack in ourselves, which perpetuates the insecurity. This is often because among leaders it is rare to find anyone who discusses their own insecurities openly. In many circles it is mistakenly portrayed as a negative leadership trait. Rather, acknowledging one’s own insecurity will help both seasoned and developing leaders to see insecurity as a natural part of leadership and something that must be named and managed.

At every level, good leadership hinges upon emotional health. Our integrity and our ability to be honest about our insecurities and leverage them effectively is especially important in times of crisis (Sager, 2020).  The main driver of insecurity is fear, which typically manifests in feelings of inadequacy, failure, uncertainty, resistance to change, and being judged (Morin, 2020). This list is not comprehensive, but these often appear in leaders with low emotional health and unaddressed insecurities.

The first step in using your natural insecurity as a tool to grow as a leader is to acknowledge the insecurity, and to get comfortable with feeling that way often (Coveney, 2018). The second step is understanding the source of why you feel insecure (Ball, van Dijk, & Mecozzi, 2016). The better you understand the reason, the easier it can be to overcome and leverage for the good of your organization and those you lead (Schawbel, 2013). Thirdly, get feedback from people you trust.

 The majority of management literature is focused on helping to recognize or coach the insecure leader, rather than how to harness insecurity to become a better leader.  Leadership literature negatively portrays insecurity as an all-encompassing term—either you are an insecure leader or a secure one—rather than viewing insecurity from a more humanistic perspective that permits us to experience and often times demonstrate insecurity.  If we can experience insecurity in our personal and professional lives through relationships, parenting, exams, job applications, job evaluations, or our daily work, yet learn and grow from those experiences as a “work in progress,” then we should embrace insecurity in leadership as well.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

Resources

Ball, R., van Dijk, M., & Mecozzi, V. (2016). Fear. Thnk.

Coveney, N. (2018). Don't Let Your Insecurities Dictate How You Lead. Forbes.

Davey, L. (2017). The scariest, most anxiety-provoking bosses to work for—and how to cope with them. Quartz.

Hendriksen, E. (2018). Why Everyone Is Insecure (and Why That's Okay). Scientific American.

Holtz, C. (2015). It Is Ok to Be Afraid. HuffPost.

Javanbakht, A., & Saab, L. (2017). What Happens in the Brain When We Feel Fear. Smithsonian Magazine.

Kutty, S. (2020). How To Mitigate The Destructive Force Of Insecure Leaders. Forbes.

Leonard, E. (2018). Beautifully Insecure. Psychology Today.

Lubans, J. (2007). “I’ll Ask the Questions:” The Insecure Boss. Library Administration and Management, 21(4). 

Morin, A. (2020). Almost everyone fears they're not good enough, according to a psychotherapist. Here's how to overcome that fear. Business Insider. 

Probst, T.M., Stewart, S.M., Gruys, M.L., & Tierney, B.W. (2007). Productivity, Counterproductivity and Creativity: The Ups and Downs of Job Insecurity. Journal of Occupational and Organizational Psychology, 80(3):479 – 497.

Sager, D. (2020). The Blight of Insecure Leaders. Word & Way.

Schawbel, D. (2013). Brene Brown: How Vulnerability Can Make Our Lives Better. Forbes.

Weber, S., & Petriglieri, G. (2018). To Overcome Your Insecurity, Recognize Where It Really Comes From. Harvard Business Review.

COVID Wars: Attack of the Variants

By Dr. Seleem R. Choudhury

As an increasing portion of the global population continues to receive the COVID vaccine, public health experts, government officials, and healthcare professionals continue to monitor variants emerging around the world. With recent spikes of infections in India that have brought devastating death tolls and an overwhelmed healthcare system, it is clear that reaching the “end” of COVID and moving forward into a sense of normalcy will not be a straightforward process.

What are mutations?

Mutations are tiny errors in our genome sequencing, and are often drivers within evolution (Carlin, 2011). As a child I was occasionally naughty, and as punishment I recall having to write lines. I would have to write and repeat whatever words were deemed necessary for me to learn my lesson and change my behavior. However, as I wrote the lines, slight changes in my handwriting occurred on a word here or a letter there. Though the message remained the same, these accidental small changes caused some lines to look different.

All viruses evolve and change over time.  This allows a virus to not only survive, but thrive (Tajouri, 2020).  Just like my handwriting, these changes, or mutations, happen accidentally and cause the virus’s genome sequence to look different. When a virus undergoes one or two mutations, this is called a “variant.”  Occasionally, the virus will mutate in such a way that the virus can copy itself more efficiently or enter our cells more easily (Cleveland Clinic, 2021). With more than 141 million infections worldwide at the time of this publication—a number that continues to climb—the virus has ample opportunity to mutate.

Current COVID mutations

Currently, there are many different versions, or variants, of COVID circulating. As with any virus, most variants come and go; others persist but don’t spread widely among the population. However, several prominent variants present themselves and gain notoriety, and eventually cause concern.

It is important in any discussion of variants of this virus to make clear that while variants are referred to as “the U.K. strain” or “South African variant,” the actual origin of any given mutation is difficult to prove, and individual countries should not be blamed for variants bearing their name (Ellyatt, 2021).

The World Health Organization (WHO) calls the variants in the graphic above “variants of concern,” signifying “strains that pose additional risks to public health” (Gale, 2021). Recently joining the list of variants of concern is the Indian variant called B1617 (Roberts, G., 2021).  The WHO has also coined the term “emerging variants of interest” for mutations that “warrant close monitoring because of their potential risk” (Gale, 2021).

These variants of concern are worrisome for varying reasons and degrees, but are primarily related to ease of transmission, severity of the illness for those infected, the likelihood the variant will infect people who have already contracted COVID, potential impact on vaccination efficacy, and the prevalence of the mutation in the population (Gale, 2021; Centers for Disease Control and Prevention, 2021).

Tracking these variants is vitally important in order to improve the design of vaccines to be effective against new variants. However, changes to those vaccines take several months, and are a mid- to long- term solution. More pressing in the short term is the increase of sequencing efforts, which experts have criticized for being “small and uncoordinated,” in order to “adequately track where variants are spreading and how quickly” (Zimmer, 2021; Zimmer, & Weiland, 2021).

The vaccine and mutation

There is anxiety regarding the unpredictability of COVID variations and the efficacy of the vaccine against such mutations. While data on the Indian variants is scarce at the time of this article’s publication, a recent study of people worldwide who had received the Pfizer vaccine, including 44,000 people in South Africa who were predominantly exposed to the B.1.351 variant, found that the vaccine was 100 percent effective against severe disease and death (Business Wire, 2021). Additional Pfizer data showed that the vaccine is “97 percent effective against symptomatic COVID-19, hospitalizations, and death” (Business Wire, 2021). The vaccine also “held up against the B.1.1.7 variant” (Ries, 2021). The Moderna, AstraZeneca, and Johnson & Johnson data demonstrated similar levels of effectiveness (Business Wire, 2021; Laguipo, 2021; Deutsche Welle, 2021). 

There are also ongoing trials with unpublished data that demonstrates a booster shot given to previously vaccinated individuals improved the antibody titer responses against several variants of concern (Hippensteele, 2021). Moreover, leading pharmaceutical companies have discussed adapting the vaccine to deal with variants. Recently the first “tweaked vaccine” announced by Moderna successfully neutralized several variants in lab trials (Boseley, 2021).

In short, vaccines offer effective protections against the variants of concern, especially in terms of preventing serious symptoms and death (Ries, 2021).  The World Health Organization states that the COVID “vaccines that are currently in development or have been approved are expected to provide at least some protection against new virus variants because these vaccines elicit a broad immune response involving a range of antibodies and cells.  Therefore, changes or mutations in the virus should not make vaccines completely ineffective (World Health Organization, 2021).”

The future of the virus

One of the challenges for public health experts is understanding what the end of the virus will look like and, furthermore, how it will be measured: daily deaths, hospital admissions, vaccination rates, percentage of the population who have been vaccinated, etc. Regardless of the measurements used, variants have a major impact on the endpoint. Rather than widespread, rapid transmission of the virus, we may see more “sporadic and localized” outbreaks (Joseph, & Branswell, 2021). 

Vaccine hesitancy around the globe, in addition to the emergence of new variants, makes herd immunity unlikely (Aschwanden, 2021). However, there is growing evidence that vaccines not only protect people from contracting COVID, but also reduce transmission of the virus (Joseph, & Branswell, 2021).  Even so, the probability exists that the only way to mitigate outbreaks is with regular booster vaccines due to more transmissible future mutations of the virus (Faulconbridge, 2021).  Though COVID will not be eliminated in the near future, there is a strong likelihood that it can be managed.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com    

Resources

Aschwanden, C. (2021). Five reasons why COVID herd immunity is probably impossible. Nature.

Boseley, S. (2021). Tweaked Moderna vaccine ‘neutralises Covid variants in trials.’ The Guardian.

Business Wire (2021). Moderna COVID-19 Vaccine Retains Neutralizing Activity Against Emerging Variants First Identified in the U.K. and the Republic of South Africa. Business Wire.

Business Wire (2021). Pfizer and BioNTech Confirm High Efficacy and No Serious Safety Concerns Through Up to Six Months Following Second Dose in Updated Topline Analysis of Landmark COVID-19 Vaccine Study. Business Wire. 

Business Wire (2021). Real-World Evidence Confirms High Effectiveness of Pfizer-BioNTech COVID-19 Vaccine and Profound Public Health Impact of Vaccination One Year After Pandemic Declared. Business Wire.

Carlin, J. L. (2011) Mutations Are the Raw Materials of Evolution. Nature Education Knowledge 3(10):10.

Centers for Disease Control and Prevention (2021). Global Variants Report. Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention (2021). SARS-CoV-2 Variant Classifications and Definitions. Centers for Disease Control and Prevention.

Cleveland Clinic (2021). What Does It Mean That the Coronavirus Is Mutating? The Cleveland Clinic.

Deutsche Welle (2021). WHO experts advise J&J jab for coronavirus mutants. DW.

Ellyatt, H. (2021). Coronavirus mutations: Here are the major Covid strains we know about. CNBC.

Faulconbridge, G. (2021). Exclusive: Regular booster vaccines are the future in battle with COVID-19 virus, top genome expert says. Reuters.

Gale, J. (2021). Why the Mutated Coronavirus Variants Are So Worrisome. Bloomberg Quint.

Hippensteele, A. (2021). Moderna Releases Positive Initial COVID-19 Vaccine Booster Data Against Variants of Concern. Pharmacy Times.

Joseph, A., & Branswell, H. (2021). The short-term, middle-term, and long-term future of the coronavirus. Stat News.

Laguipo, A.B.B. (2021). Oxford-AstraZeneca vaccine effective against B.1.1.7 SARS-CoV-2 variant. News Medical.

Ries, J. (2021). COVID-19 Vaccines Are Still Effective Amid Rising Number of Variants. Healthline.

Roberts, G. (2021). Everything we know about the Indian COVID-19 variant so far. World Economic Forum.

Roberts, M. (2021). What are the Indian, Brazil, South Africa and UK variants? BBC News.

Tajouri, L. (2020). What is a virus? How do they spread? How do they make us sick? The Conversation.

Woodward, A. (2021). One chart shows how well COVID-19 vaccines work against the 3 most worrisome coronavirus variants. Business Insider.

World Health Organization (2021). Tweet: Will #COVID19 vaccines work against new virus variants? Twitter: 1/19/2021.

Zimmer, C., & Weiland, N. (2021). C.D.C. Announces $200 Million ‘Down Payment’ to Track Virus Variants. New York Times.

Zimmer, C. (2021). U.S. Is Blind to Contagious New Virus Variant, Scientists Warn. New York Times.U.S. Is Blind to Contagious New Virus Variant, Scientists Warn

Organizational culture change as renovation, not demolition

by Dr. Seleem R. Choudhury, April 15, 2021

An organization’s “culture” is simply defined as the expected way to behave within an organization. Stated more simply, organizational culture is “the way things are done around here” (Deal & Kennedy, 2000).  Culture is not written rules or guidelines, but rather the way we act and how we get work done. The values of a particular organizational culture are engrained into the life of the organization.  When culture is found to be ineffective or, worse, toxic, leaders discover that it is extremely difficult to change.

Many organizations start in the wrong place by making sweeping changes to the staff or executive team or attempting to overhaul every aspect of the current culture. Changing culture is more than a matter of changing the players, and seeking to change everything about an organization’s culture will inadvertently remove elements of the organization that are working well.  Rather than taking a demolition approach, leaders would increase the possibility of successfully changing their organization’s culture by thinking of culture change as a renovation.

The importance of culture

A 2017 Harvard Business Review article compares organizational culture to the wind: “[Culture] is invisible, yet its effect can be seen and felt” (Walker & Soule, 2017).  Harnessing the power of organizational culture is one of the keys to getting good work done. A recent conversation with friend, colleague, and mentor Brian Dolan, OBE, RMN, RGN, highlighted that it is a leader’s responsibility to understand this power, and determine if the current organizational culture is effective or ineffective in helping the organization fulfill its mission. For better and worse, culture and leadership are intricately interconnected (Groysberg, Lee, Price, & Cheng, 2018).  Leaders, whether they do so intentionally or passively, are shaping the culture of their organizations. They should be capable of actively shaping culture to the benefit of everyone on the team and the realization of the organization’s goals (Craig, 2018).

Interestingly, though there is a plethora of articles, discussions, and research that focuses on cultural change, much controversy exists on whether it is possible to make these changes successfully. Undoubtedly, changing the culture of an organization is a steep challenge. It requires much more than recognizing a problem and leaders who are committed to making a change. It takes significant effort and investment at every level of the organization.

Still, despite the challenges to making a successful culture change, the outcomes regarding building the right culture are indisputable. Organizations that can turn the tide and maintain a “drive towards lasting improvement in performance and organizational health,” regularly outperform competitors (McKinsey, 2021).

“Culture renovation,” not “culture change”

Terms like “culture change” or “organizational transformation” tend to carry a negative connotation. These phrases often imply that nothing good exists in the organization, and so everything must change, bringing to mind the idiomatic expression, “throwing the baby out with the bathwater.” The danger of culture transformation efforts is making a change that impacts many elements of the organization, including things that are working for the organization or are core to its identity.  A goal of leaders in culture change processes is to ensure that the organization does not lose something important while trying to get rid of unwanted elements of its culture.  Changes to a company’s culture, then, should be carefully and thoughtfully engaged, not left to chance (Patel, 2017).

Kevin Oakes, CEO and Co-founder of i4CP and author of Culture Renovation, proposes a different strategy when exploring the need to transform your culture. In an interview with HR Executive, Oakes describes cultural change as restoring an old 100-year-old house by considering what exists, then deciding what to keep and what to change (Ramirez, 2021).

Oakes states:  

“With a historic house, there are elements that are timeless that you want to hang on to. You keep those elements, while upgrading for the future with new technology and new ways of doing things that increase the value of your house long-term. The same concept applies to companies. Successful companies don’t transform their organization. They renovate their culture, meaning they keep the values and traits that have made them successful, build upon them and recognize what they need to create to increase the value of the organization long-term” (Ramirez, 2021).

This metaphor resonates strongly with me.  When I was a child, my parents bought a Victorian house in London. The house was huge and beautiful. My parents wanted to preserve and honor the Victorian elements of the home, but also wanted to modernize elements within. This was not an easy feat, and the work required to renovate the house felt nearly endless. Yet, it never occurred to my parents to rip down the house and build it anew; rather, they wanted to keep what was good and focus their efforts on areas that needed changing or upgrading.

Organizational culture is quite similar. It is not a one-and-done process. Leaders must also know this and be willing to invest the time, money, and work necessary for the renovation, recognizing that it is a continuous improvement process. 

Perhaps that is why, according to a 2019 study from i4CP, only 15% of the companies studied said their culture change efforts had been successful (Goodridge, 2019). Oakes believes that those organizations that are successful know that no one can truly change their culture; rather, they “intentionally [renovate] their culture” (Fagan, & Prokopeak, 2021). Just like my parents’ Victorian House, organizations should keep what they want, understand what they need, and add what is required.

In his book Culture Renovation, Oakes guides organizations through this process, laying out an evidence-based, three-step process to effectively renovate a culture plan. However, he cautions organizations not to make any changes until they perform a full assessment to evaluate the “readiness and maturity level on the organization's culture change journey” (Oakes, 2021).

It was Peter Drucker who coined the phrase, “Culture eats strategy for breakfast.” While it is certainly true that a thriving culture is essential for organizational success, these sorts of maxims on culture change often drive leaders to feel that a wholesale, top-to-bottom culture overhaul is necessary. In my experience, this is rarely the case.

Before leaders decide if the culture needs to be changed, begin first with an assessment (Dooley, 2021).  Just as in the old house analogy, it is likely that much of the structure is contributing to the organization’s success and should be kept, renewed, or strengthened. Only elements that pose a danger to the structure should be replaced for the health of the organization.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com    

References

Brené Brown Education and Research Group (2021). Brené with Kevin Oakes on Cultural Renovation. Brené Brown.

Craig, W. (2018). 10 Ways Leaders Influence Organizational Culture. Forbes.

Deal, T. E., & Kennedy, A. A. (2008). The new corporate cultures: Revitalizing the workplace after downsizing, mergers, and reengineering. Basic Books.

Dooley, R. (2021). Episode 357: Culture Renovation with Kevin Oakes. Brainfluence Podcast with Roger Dooley. 

Fagan, S., & Prokopeak, M. (2021). Get Reworked Podcast: Why Now Is the Perfect Time for Culture Renovation. Get Reworked Podcast.

Goodridge, N. (2019). Only 15% of Organizations Succeed in Transforming Their Cultures. I4CP.

Groysberg, B., Lee, J., Price, J., & Cheng, J. Y. (2018). The Leader’s Guide to Corporate Culture. Harvard Business Review.

McKinsey (2021). Culture & Change. McKinsey.

McLaren, S. (2019). How Microsoft “Renovated” Its Culture by Following These 3 Steps. LinkedIn Talent Blog.

Oakes, K. (2021). Culture Renovation: 18 Leadership Actions to Build an Unshakeable Company.

Patel, S. (2017). The Importance of Building Culture in Your Organization. Inc.

Ramirez, J.C. (2021). Here’s how HR can lead a ‘culture renovation.’ Human Resources Executive.

Walker, B., & Soule, S.A. (2017). Changing Company Culture Requires a Movement, Not a Mandate. Harvard Business Review.

A global pandemic calls for global response: The importance of equitable global vaccine distribution

By Dr. Seleem R. Choudhury, March 11, 2021

According to the United Nations, 75% of all COVID-19 vaccinations have been administered among just 10 countries, while 130 countries have not received even a single dose of the vaccine, as of mid-February 2021 (Al Jazeera, 2021). Global health and political leaders have condemned this unbalanced distribution of vaccines and are taking action to ensure vaccine equity. Dr. Tebros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), said in a recent address, “The world is on the brink of a catastrophic moral failure—and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries” (United Nations, 2021).

Vaccine equity is the global intent to ensure that all have fair access to the COVID vaccine in order to overcome the virus that is threatening every nation. Unless the roadblocks to success for international cooperation on equitable vaccine access and delivery are removed, the world risks prolonging the pandemic by creating a two-tier vaccine system—the haves and the have-nots, the eternal battle of rich versus poor. Many rich nations have set the lofty goal of vaccinating at least 80% of their populations. Even if these countries were to achieve this goal, without the equitable distribution of vaccines to poorer nations, they run the risk in a global economy of contracting a COVID-19 variant more immune to the vaccine and bringing it back to their own nation, thus perpetuating the pandemic.

The movement to increase the distribution of vaccines to poorer nations has gained momentum under WHO’S 100-day challenge (United Nations, 2021). In February 2021, G7 leaders pledged to intensify cooperation on COVID-19 and increase their contribution to vaccine-sharing initiative COVAX (Parker, Williams, Peel, & Chazan, 2021). As the WHO’s January 2021 Vaccine Equity Declaration states:

“We must act swiftly to correct this injustice. Multiple variants are showing increased transmissibility and even resistance to the health tools needed to tackle this virus. The best way to end this pandemic, stop future variants, and save lives is to limit the spread of the virus by vaccinating quickly and equitably, starting with health workers.” (World Health Organization, 2021).

The data of equity

As of this article’s publication, over two million people have died from COVID-19. As a New York Times article puts into perspective, that is more than the population of the state of Nebraska, and nearly equal to the population of the entire country of Slovenia (Santora & Wolfe, 2021).

Though it has been several months since the first COVID vaccine was administered, the virus continues to spread despite the vaccine, especially in the poorer nations. Vaccine supplies are low due to richer countries purchasing more vaccines than they could distribute in the required time frame.  As a result, some experts predict that many low-income countries may not be able to reach mass immunization until 2024. Worse, some nations may never get there (Safi, 2021).

To support the equitable distribution of the vaccine moving forward, the WHO established the Covid-19 vaccine allocation plan—known as COVAX—at the end of 2020 (World Health Organization, 2020). COVAX’s goal is to ensure that the research, purchase, and distribution of any new vaccine is shared equally between the world’s richest countries and those in the developing world.  According to the WHO, 172 economies are engaged in discussions about participation in the COVAX initiative (World Health Organization, 2020).

The variants

Catalyzing vaccine distribution in poorer countries is essential to prevent the development of new variants of COVID that could cost more lives around the world. It is the natural state of RNA viruses such as the coronavirus to evolve and change gradually. The flu, for example, is an ever-adapting virus, which is why people must receive a new vaccination each year.  Viruses are primed to change, but occasionally a mutation occurs that alters how rapidly the virus spreads, its level of infectiousness, or the severity of the disease (Gray, 2021).

This is the primary concern with new variants of COVID emerging in different countries. The most recent variations of the disease in South Africa and Brazil are concerning epidemiologists as they show signs that the virus may be “adapting to evade immunity in some people” (Gray, 2021).  To stay ahead of the evolution of the virus, scientists are evaluating each new mutation to determine which ones are likely to be most impactful (Callaway, 2020).

We have established that a partially immunized population runs the risk being impacted by variants that are transmitted more easily and are more likely to result in death for those infected with the virus (Toy, 2021).  Embracing vaccine equity is the best solution to guard against this.  If nations insist on focusing only on their own populations, new variants will perpetually threaten them, necessitating changes to the vaccine.  If countries continue to choose not to share, then this ludicrous process starts again.  If everyone has immunity through vaccination, then variants’ effects will be diminished, with virtually no virus circulating or adapting (Toy, 2021).

Next steps

The COVAX initiative is a good start to addressing vaccine equity.  It has gained strength now that the US has joined under its new presidential administration (The White House, 2021). Additionally, at a virtual G7 meeting, leaders pledged $7.5 billion to the WHO-led collaboration (Parker, Williams, Peel, & Chazan, 2021).  This crucial financial backing will allow COVAX to accomplish its aim of securing and equitably allocating 2 billion doses of COVID vaccines, starting with healthcare workers and other high-risk groups as defined by the WHO, by the end of 2021 (Kettler, 2021).

While equitable distribution is being addressed globally, individual nations must also grapple with the challenges of vaccine distribution within their own populations (Liao, 2021).  The WHO has proposed a “Roadmap For Prioritizing Uses Of COVID-19 Vaccines In The Context Of Limited Supply” to aid countries in their own vaccine equity efforts. The Roadmap considers priority populations for vaccination based on epidemiologic setting and vaccine supply scenarios (World Health Organization, 2020).

Summary

Interestingly, several countries are filling the gap created by the United States and the other G7 countries. India, Russia, China and Israel appear to be waging a strategy of soft power towards global health (Mashal & Yee, 2021). It is hard to imagine populations of countries not being grateful to those that help towards timely vaccinations, and it could leave recipients obligated to repay in other ways. This could potentially realign global alliances and change geopolitics.

It is hard to ignore WHO Director-General Ghebreyesus’s concerns about the irreconcilable cost of the moral failure of continued inequitable vaccine distribution.  The world’s poorest countries will be disproportionately affected, and richer nations will continue to have on-again-off-again economies as variants of the virus wreak havoc on the health of their own populations.

The immediate sharing of doses will reduce the chance of ongoing variants and begin to revive the global economy.  The only way to vaccinate the majority of the world’s population with urgency is to do it together.  A global pandemic requires a global neighbourhood philosophy and response with no strings attached.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com  

Resources

Al Jazeera (2021). ‘Wildly unfair’: UN boss says 10 nations used 75% of all vaccines. Al Jazeera.

Callaway, E. (2020). The coronavirus is mutating — does it matter? Nature.

Gray, R. (2021). This is how new Covid-19 variants are changing the pandemic. BBC.

Haseltine, W. (2021). How The Covid-19 Virus Changes. Forbes.

Hernandez, J. (2021). Two Members of W.H.O. Team on Trail of Virus Are Denied Entry to China. New York Times.

Kettler, H. (2021). What is COVAX? Path.

Liao, K. (2021). What Is Vaccine Equity? Global Citizen.

Mashal, M. & Yee, V. (2021). The Newest Diplomatic Currency: Covid-19 Vaccines. New York Times.

Parker, G., Williams, A., Peel, M., & Chazan, G. (2021). G7 leaders vow to boost vaccine supplies to developing world. Financial Times.

Safi, M. (2021). Most poor nations 'will take until 2024 to achieve mass Covid-19 immunisation.’ The Guardian.

Santora, M. & Wolfe, L. (2021). Covid-19: Over Two Million Around the World Have Died From the Virus. New York Times.

The White House (2021). National Security Memorandum on United States Global Leadership to Strengthen the International COVID-19 Response and to Advance Global Health Security and Biological Preparedness. The White House.

Toy, S. (2021). Covid-19 Vaccination Delays Could Bring More Virus Variants, Impede Efforts to End Pandemic. The Wall Street Journal. 

United Nations (2021). WHO chief warns against ‘catastrophic moral failure’ in COVID-19 vaccine access. UN News.

World Health Organization (2021). Call to Action: Vaccine Equity Declaration. World Health Organization.

World Health Organization (2021). COVID-19 Vaccine Equity Declaration. World Health Organization.

World Health Organization (2020). Fair allocation mechanism for COVID-19 vaccines through the COVAX Facility. World Health Organization.

World Health Organization (2020). WHO SAGE Roadmap For Prioritizing Uses Of COVID-19 Vaccines In The Context Of Limited Supply. World Health Organization.

World Health Organization (2020). 172 countries and multiple candidate vaccines engaged in COVID-19 vaccine Global Access Facility. World Health Organization.172 countries and multiple candidate vaccines engaged in COVID-19 vaccine Global Access Facility

Setting yourself up for success in a new healthcare leadership role

By Dr. Seleem R. Choudhury, February 18, 2021

The uncertainty brought on by leadership transitions can be hard on employees and organizations (Keller & Meaney, 2017). Staff members wonder: Will the new leader understand the mission? What changes will they implement—and will that impact my ability to do my work and find fulfillment in this job? 

But leadership transitions are tough on the incoming new leaders too.  An IMD survey of 1350 HR professionals shows that transitions into new roles are the most difficult times in leaders’ professional lives (Watkins, Orlick, & Stehli, 2014).  They face pressure to make a good impression, instill confidence in their selection across the organization, and perform the balancing act of learning about the company while attempting to shape it (Watkins, Orlick, & Stehli, 2014).   

The first 30 days in a new role matter immensely, and can set the tone for a leader’s tenure in their organization. 

Four Principles for a Leader’s First 30 Days 

1. Focus on connection.  

In your first weeks in a new senior leadership role, you will likely be given many opportunities to speak to larger groups of people as you’re introduced at meetings with your team, staff, or board of directors. It is important to remember that while these opportunities to build face recognition are important, more is required. You must ensure you are taking the time to talk with each person in your organization individually (Knight, 2020). 

The importance of one-on-one connection cannot be overstated.  This allows you to build trust with your team, which will be essential to long-term success in your new role, and for the organization as a whole.  Start by making an effort to learn every person’s name. One of the best ways to make a great “second” impression with those we manage is by confidently recalling their name the next time we see them (Hedges, 2013). 

This can be a particular challenge for leaders who are more reserved or introverted (Isakson, 2015).  After getting to know your new team, continue to reach out to unfamiliar coworkers who you may not interact with as regularly (Rollag, 2015). It requires vulnerability, but the risk will not go unrewarded.

 2. Learn first, act second. 

Manage the urge to start making your mark on the organization in your first month on the job.  It is natural to be eager to prove your worth to your new colleagues and employees, but—in the wise words from the Harvard Business Review article, “Why New Leaders Should Make Decisions Slowly”—it is critical to “learn first, and act second” (Dierickx, 2019). 

Instead of taking every opportunity to share your opinion or plan of action, do the opposite in your first 30 days (Biro, 2013).  Ask questions about your team’s observations. Learn what has or hasn’t worked in the past, and why. Find out what they believe their strengths and weaknesses are (Rapid Start Leadership, 2020). As the old management adage goes, good leaders avoid being the smartest person in the room (Executive Forum, 2020).  Becoming infatuated with yourself and your own thoughts will cause your tenure to be dead on arrival (Dowling, 2019). 

As you ask questions of your team, listen actively. This is a crucial skill. It can be tempting to formulate a response or rebuttal as someone is speaking, but this prevents you from comprehending and responding to their entire message (Hersh, 2018).  Tuning out information from your co-workers deprives you of the opportunity to know and develop trust in your team, which will in turn stunt your and your team’s ability to engage in a rewarding and fulfilling workplace (Biro, 2013).

3. Create the kind of work environment you want to be part of. 

In a 2014 survey of 19,000 employees, only 25% of those surveyed believed their workplace’s leadership modeled “sustainable work practices” (Schwartz & Porath, 2014). The survey also found that the employees of leaders who engaged in sustainable work practices were “55% more engaged, 72% higher in health well-being, 77% more satisfied at work, and also reported more than twice the level of trust in their leaders” compared to other respondents (Wingard, 2020). 

The work practices of new leadership are an indicator to others of that leader’s expectations of them—whether they intend for it to be or not. Modeling a healthy work-life balance, even in your first 30 days in your new role, gives your employees permission to seek a sustainable lifestyle as well. The data on the impact this can have on employees’ quality of life, productivity, team dynamics, and overall wellness are well-documented. 

Additionally, the character you display in the early days as a senior leader sets the tone for your entire tenure.  You may have a misunderstanding with a new co-worker or make a mistake. To be human means to miss the mark once in a while, after all.  Yet your response should be carefully considered. The difference between “good leaders and great ones lies in how they handle those mistakes” (Daskal, 2018).  It’s important to know when to apologize, and when to remain firm (Kellerman, 2006). 

4. Internalize the mission. 

Use your first month on the new job to solidify your understanding of your new organization’s “why,” or their reason for being, as Simon Sinek says in his 2009 book, “Start with Why.”   

The heart of any company is its mission, vision, and values (Groscurth, 2014).  When you’re new on the job, it is easy to get wrapped up in the “what”—products or services, industry, or competitors—and the “how”—processes, methods, unique differentiators (Ranadive, 2017).  When you feel stuck in your new position, you don’t have to reinvent anything. Look to the mission as your guide. 

Even in your first weeks leading an organization, new leaders can actively be creating a culture conducive to success (Rihal, 2017; Shaffer, 2015).  Invest your time in forming genuine connections with your new colleagues and employees.  Listen well, and learn everything you can about the company and your team’s capabilities.  Even in the busyness of getting caught up to speed in a new position, model sustainable work practices and prioritize your overall well-being.  Take time to fully understand the mission, and allow it to propel you forward.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

Resources:

Biro, M.M. (2013). 5 Leadership Lessons: Listen, Learn, Lead. Forbes. 

Craig, W. (2018). The Importance Of Having A Mission-Driven Company. Forbes. 

Daskal, L. (2018). 4 Impressive Ways Great Leaders Handle Their Mistakes. Inc Magazine. 

Dierickx, C. (2019). Why New Leaders Should Make Decisions Slowly. Harvard Business Review. 

Dowling, M. (2019). What Not to Do as a Leader. Northwell Health. 

Executive Forum (2020). Never Be the Smartest Person in the Room. Executive Forum. 

Groscurth, C. (2014). Why Your Company Must Be Mission-Driven. Gallup. 

Hedges, K. (2013).  The Five Best Tricks To Remember Names. Forbes. 

Hersh, E. (2018). Using Effective Listening to Improve Leadership in Environmental Health and Safety. Harvard School of Public Health. 

Isakson, T. (2015). 5 Habits Of Effective Introverted Leaders. Fast Company. 

Keller, S., & Meaney, M. (2017). High-performing teams: A timeless leadership topic. McKinsey Quarterly. 

Kellerman, B. (2006). When Should a Leader Apologize—and When Not?. Harvard Business Review. 

Knight, R. (2020). How to Talk to Your Team When the Future Is Uncertain. Harvard Business Review. 

Marie, L. (2019). The Art of Taking People and Things at Face Value. Human Parts. 

O’Hara, C. (2014). What New Team Leaders Should Do First. Harvard Business Review. 

Patel, D. (2017). Big Brands and business Are Aligning their Missions with Millennial and Gen Z Consumers. Forbes.  

Ranadive, A. (2017). The Power of Starting with Why. Medium. 

Rapid Start Leadership (2020). New Leader Checklist: 4 Questions to Ask if You Want to Lead Effectively. Rapid Start Leadership. 

Rihal, C.S. (2017). The Importance of Leadership to Organizational Success. NEJM Catalyst. 

Rollag, K. (2015). 3 Things Every New Leader Should Do Their First Week On The Job. Fast Company. 

Schwartz, T., & Porath, C. (2014). Your Boss’s Work-Life Balance Matters as Much as Your Own. Harvard Business Review.

 Shaffer, J. (2015). A Leader’s First 30 Days Are Free. Jim Shaffer Group. 

Sinek, S. (2009). “Start with Why.” Portfolio. 

Watkins, M.D., Orlick, A.L., & Stehli, S. (2014). Hit the ground running: Transitioning to new leadership roles. IMD. 

Wingard, J. (2020). Want To Be A Good Leader? Go Home!. Forbes.

Monitoring the safety and effectiveness of COVID-19 vaccines

By Dr. Seleem R. Choudhury, January 14, 2021  

Next to clean water, no single intervention has had such a dramatic effect on decreasing mortality as has the widespread introduction of vaccines (Howson, Howe, & Fineberg, 1991). The World Health Organization (WHO) describes immunization as a “key component of primary health care and an indisputable human right,” as well as “one of the best health investments money can buy” (World Health Organization, 2020). Vaccines play a critical role in the prevention and management of the outbreak of infectious diseases.  The rapid spread of COVID-19 during the months-long wait for a vaccine have highlighted their importance to public health. 

If COVID-19 were a Shakespearean play, the administration of the vaccine would ideally be the final act, and widespread adoption and effectiveness, the epilogue. However, just like Shakespeare’s Timon of Athens, this play may be also be left unfinished. According to the WHO, at least 198 COVID-19 vaccines are currently in the development pipeline, with 44 currently undergoing clinical evaluation (2020). National Institute of Allergy and Infectious Diseases Director Anthony Fauci, M.D., recently stated a date to a possible “normal” is tricky at best (McCarthy, 2020). He explains: 

“If the vaccine is reasonably if not quite effective, but not a very large proportion of the population take it, then that would really be unfortunate because it wouldn’t provide that umbrella of protection over the community so that you could feel reasonably certain that when you go to a family function, a wedding, or the like, that there’s not going to be a couple of people in there that are actually infected.”

Continued monitoring: Reasons and methods

The effectiveness of the COVID-19 vaccine to usher in a “new normal” hinges on its widespread administration. Continuous and transparent monitoring is essential to encourage the maximum number of people to choose to be vaccinated.  This article was written fully acknowledging that the SARS-CoV-2 variant exists, yet the implications of the variant remains unclear and the impact upon the vaccines remains unknown (Public Health England, 2020). 

Reasons for monitoring the vaccine

The primary reason for conducting additional vaccine effectiveness assessments is to ensure a vaccine “protects people from getting a disease under real-world conditions, outside of the strict setting of clinical trials” (National Center for Immunization and Respiratory Diseases, 2020). Numerous factors, such as how a vaccine is transported, the method of storage, or even the way patients are vaccinated, can affect a vaccine’s effectiveness in real-world situations.  

Even after administration trials of the COVID-19 vaccine, organizations will continue to monitor longer-term safety and efficacy (Cyranoski, 2020).  Teams of experts will evaluate the effectiveness of the vaccine in real-world conditions, outside of more controlled clinical environments (WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation, 2020).  Furthermore, underlying medical conditions not present in patients who participated in the clinical trials can also change the effectiveness of the vaccine in real-world use, or in groups not included or represented in clinical trials, such as children under 12, or pregnant or lactating women (National Center for Immunization and Respiratory Diseases, 2020).   

Additionally, transparent monitoring will prove essential to improve the public’s trust in the vaccine so that people will choose to vaccinate. Public trust in the storied public health institutions cited above is now deeply compromised. According to recent polls, 62% of Americans worry the U.S. Food & Drug Administration (FDA) will rush to approve vaccines without adequately assuring safety and effectiveness because of political pressure (Hamel, Kearney, Kirzinger, Lopes, Muñana, & Brodie, 2020; Miller, Ross, & Mello, 2020).  Only 25% of Americans have “a great deal” of trust in the Centers for Disease Control and Prevention (CDC), and only 21% definitely plan to get vaccinated, while 49% probably or definitely will not (Tyson, Johnson, & Funk, 2020). 

Vaccine safety is a significant concern for many, given the uncommonly rapid development and testing process, underlying suspicion about vaccines in general among segments of the population, and mistrust of the government’s pandemic response thus far (DeRoo, Pudalov, & Fu, 2020).  Efforts to provide the population with ample information addressing these reasons for apprehension should be made before and during vaccine program rollout. 

In addition to widespread misinformation about vaccines, health organizations must also contend with mistrust of vaccines borne out of the U.S.’s historical mistreatment of people of color in the spread and prevention of infectious diseases. This includes actions such as using ethnic minorities as test subjects for medical advances in the 20th century, or giving blankets laced with smallpox to indigenous peoples in Jamestown in the 1700s, to name a few examples.  In fact, some studies link mistrust of the health care system and fears of experimentation among some African American people to historical and contemporary mistreatment and disparities in care (Yancy, 2020). 

Methods for monitoring the vaccine

Clinical trial results show whether vaccines are effective.  The FDA evaluates the data from the clinical trials, as well as manufacturing information, to assess the safety and effectiveness of vaccines, then decides whether to approve a vaccine or authorize it for emergency use in the United States (National Center for Immunization and Respiratory Diseases, 2020; U.S. Food & Drug Administration, 2018). 

However, even after a vaccine is approved by the FDA and released for public use, more assessments are necessary. According to the CDC, the goal of these assessments is “to understand more about the protection a vaccine provides under real-world conditions, outside of clinical trials” (2020).  This is accomplished by comparing groups of people who do and don’t get vaccinated, and people who do and don’t contract the COVID-19 virus to assess how well COVID-19 vaccines are working to protect people compared to other protection measures (National Center for Immunization and Respiratory Diseases, 2020). 

Future implications and vaccine resistance

These vaccine monitoring activities are the norm, but they will take place on a larger scale during this pandemic. The post-licensure vaccine evaluation will be a crucial component of an evidence-based vaccine program. This should include four aspects.

1. Collecting exposure data for COVID-19 vaccines.

The data when reviewing the efficacy of the trial is thus far encouraging and builds confidence in the continued effectiveness of the vaccine. Dedicated trials will be needed to deepen our understanding of the impact of COVID-19 vaccines among different groups, specifically children, pregnant women, and black, indigenous and people of color (Hodgson, Mansatta, Mallett, Harris, Emary, & Pollard, 2020). 

Additionally, data must be collected to assess the effectiveness of a promising administration method: heterologous prime-boost vaccination. A heterologous prime-boost vaccination is a “repeated immunization regimen designed to increase and sustain vaccine-induced immune responses” involving “sequential delivery of different vaccine platforms” (Jeyanathan, Afkhami, Smaill, Miller, Lichty, & Xing, 2020). This method has proven effective with vaccines for other diseases such as hepatitis B24 and Ebola virus (Logunov, Dolzhikova, Zubkova, Tukhvatullin, Shcheblyakov, & Dzharullaeva, et al., 2020). In past studies of other coronaviruses, “prime-boost regimens using different viral vectors expressing the same recombinant antigen proved very efficient in enhancing the target antigen-specific immune responses” (Schulze, Staib, Schätzl, Ebensen, Erfle, & Guzmana, 2008).

2. Adopting specific safety signal detection and management measures.

A vaccine safety signal is “information that indicates a potential link between a vaccine and an event previously unknown or incompletely documented, that could affect health” (World Health Organization, 2020). Experts monitor this data to decide whether changes are needed in U.S. vaccine recommendations in order to ensure that the benefits continue to outweigh the risks for people who receive vaccines (National Center for Immunization and Respiratory Diseases, 2020; European Medicines Agency, 2020). 

3. Using real-world evidence (RWE) from clinical practice.

At the beginning of the pandemic, there were well documented errors made by many countries, including notable errors in the U.S. from the CDC, the Trump administration, and hospitals (New York Times, 2020; Nather, 2020; Evans & Berzon, 2020). As a nation, the U.S. was slow to respond and react to an ever-evolving situation. Real-world evidence gathered from longitudinal studies of COVID-19 patients and vaccine recipients will play a crucial role in responding to new information quickly and effectively in clinical practice. 

4. Applying exceptional transparency measures.

The combination of data and technology makes it possible to conduct near real-time analyses of healthcare trends and, for the first time, create a more robust and accurate understanding of disease and treatments (Christian & Reynolds, 2020). This data will have to be shared in its entirety, with no detail withheld or deemed unimportant. The data must be open to criticism and analysis so that trust can be allowed to grow, and fear subsides (Nature, 2020).

Summary

Dr. Seleem R. Choudhury receiving his 1st dose of Pfizer COVID vaccine.

The COVID-19 vaccine will not be able to single-handedly eliminate the virus from our lives. It will not necessarily allow us to return to the life we led before the pandemic reared its ugly head, but it has great potential to save countless lives and make a way forward into a new normal.  The key to making this a reality is continuous monitoring of the vaccine’s effectiveness and high levels of transparency to build public trust. 

Research indicates that a majority of Americans may trust scientific research findings more if data and information were publicly shared (Funk, Hefferon, Kennedy, & Johnson, 2019; Miller, Ross, & Mello, 2020). It is essential to widen public access to information about vaccine clinical trial design, conduct, and data. This exchange of information will provide the necessary transparency and ease of interpretation of data.  

Big pharma will need to be comfortable understanding the public hesitancy and be prepared to counter this reluctance with openness and a level of transparency never seen before as the stakes could not be higher: “History has shown that once public trust in vaccines has been compromised it is difficult to win back” (Nature, 2020).

Read more from Dr. Seleem Choudhury at seleemchoudhury.com  

Resources:

Christian, J.B., & Reynolds, M.W. (2020). Combatting COVID-19 With Real-World Evidence. American Journal of Managed Care.  

Cyranoski, D. (2020). Why emergency COVID-vaccine approvals pose a dilemma for scientists. Nature, 588, 18-19. 

DeRoo, S.S., Pudalov, N.J., & Fu, L.Y. (2020). Planning for a COVID-19 Vaccination Program. JAMA Network. 

European Medicines Agency (2020). COVID-19 vaccines: development, evaluation, approval and monitoring. European Medicines Agency. 

European Medicines Agency (2020). Pharmacovigilance Plan of the EU Regulatory Network for

COVID-19 Vaccines. European Medicines Agency. 

Evans, M., & Berzon, A. (2020). Why Hospitals Can’t Handle Covid Surges: They’re Flying Blind. The Wall Street Journal. 

Funk, C., Hefferon, M., Kennedy, B., & Johnson, C. (2019). 3. Americans say open access to data and independent review inspire more trust in research findings. Pew Research Center. 

Hamel, L., Kearney, A., Kirzinger, A., Lopes, L., Muñana, C., & Brodie, M. (2020). KFF Health Tracking Poll - September 2020: Top Issues in 2020 Election, The Role of Misinformation, and Views on A Potential Coronavirus Vaccine. KFF. 

Hodgson, S. H., Mansatta, K., Mallett, G., Harris, V., Emary, K. R., & Pollard, A. J. (2020). What defines an efficacious COVID-19 vaccine? A review of the challenges assessing the clinical efficacy of vaccines against SARS-CoV-2. The Lancet Infectious Diseases. 

Howson, C.P., Howe, C.J., & Fineberg, H.V., editors. Adverse Effects of Pertussis and Rubella Vaccines: A Report of the Committee to Review the Adverse Consequences of Pertussis and Rubella Vaccines. (1991). Institute of Medicine (US) Committee to Review the Adverse Consequences of Pertussis and Rubella Vaccines. National Academies Press.

McCarthy, M. (2020). Fauci and Other Experts Debate When Our COVID-19 Lives Will Return to Normal. Healthline. 

Jeyanathan, M., Afkhami, S., Smaill, F., Miller, M.S., Lichty, B.D., & Xing, Z. (2020). Immunological considerations for COVID-19 vaccine strategies. Nature Reviews Immunology, 20. 

Logunov, D.Y., Dolzhikova, I.V., Zubkova, O.V., Tukhvatullin, A.I., Shcheblyakov, D.V., & Dzharullaeva, A.S., et al. (2020). Safety and immunogenicity of an rAd26 and rAd5 vector-based heterologous prime-boost COVID-19 vaccine in two formulations: two open, non-randomised phase 1/2 studies from Russia. The Lancet, 396(10255). 

Miller, J.E., Ross, J.S., Mello, M.M. (2020). Far more transparency is needed for Covid-19 vaccine trials. Stat News. 

Nather, D. (2020). Trump's war on the public health experts. Axios. 

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2020). Ensuring COVID-19 Vaccines Work. U.S. Centers for Disease Control and Prevention. 

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2020). Ensuring the Safety of COVID-19 Vaccines in the United States. U.S. Centers for Disease Control and Prevention. 

Nature (2020). COVID vaccine confidence requires radical transparency. Nature, 586(8). 

New York Times (2020). The Unique U.S. Failure to Control the Virus. New York Times. 

Public Health England (2020). PHE investigating a novel strain of COVID-19. Public Health England. 

Schulze, K., Staib, C., Schätzl, H.M., Ebensen, T., Erfle, V., & Guzmana, C.A. (2008). A prime-boost vaccination protocol optimizes immune responses against the nucleocapsid protein of the SARS coronavirus. Vaccine, 26(51). 

Tyson, A., Johnson, C., & Funk, C. (2020). U.S. Public Now Divided Over Whether To Get COVID-19 Vaccine. Pew Research Center. 

U.S. Food & Drug Administration (2018). Step 3: Clinical Research. U.S. Health and Human Services.

WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation (2020). Placebo-Controlled Trials of Covid-19 Vaccines — Why We Still Need Them. New England Journal of Medicine. 

World Health Organization (2020). Draft landscape of COVID-19 candidate vaccines.  

World Health Organization (2020). Investigation of safety signals. World Health Organization. 

World Health Organization (2020). Vaccines and immunization: Overview. 

Yancy, C.W. (2020). COVID-19 and African Americans. JAMA Network.

Overcoming barriers to provide patient-centered care

By Dr. Seleem R. Choudhury, December 10, 2020

The term "patient-centered care" is in vogue and utilized by health system administrators, marketing gurus, hospital staff, and clinicians alike. It's a catchy phrase that resonates with stakeholders, and it sounds like something every healthcare organization would heartily embrace. However, the heart of patient-centered care and its implications for how care is actually provided to patients is not well understood.

The Institute of Medicine defines patient-centered care as "providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" (HealthLeads, 2018; Wolfe, 2001). The goal of patient-centered care is focused primarily on the health outcomes of the individual rather than the entire population (NEJM Catalyst, 2017). However, by prioritizing the individual's health, populations' health outcomes are improved as well (Cramm & Neiboer, 2016).  Additionally, patient-centered care presents possible economic advantages for both hospitals and patients (David, Saynisch, & Smith-McLallen, 2018).

However, there are many barriers that must be overcome to live up to the aspirational definition of patient-centered care and experience the benefits this approach offers. 

Barriers to patient-centered care

An article released last year by Academy Health outlines many of the barriers to patient-centered care (Sinaiko, Szumigalski, Eastman, & Chien, 2019). It highlights that these barriers are "pervasive" within the healthcare system.  The current lack of agility within healthcare as an industry has limited the customizability of care delivery, and there are many broad sections of the population that are paying the price.

Reimbursements

Erasmus spoke of "the talking power of money," and it is true that "money talks" centuries later in today's healthcare system. Many healthcare systems continue to utilize fee-for-service. While this approach is hotly debated amongst healthcare professionals and economists, many believe fee-for-service models create incentives for providers to encourage face-to-face or volume building visits, and are widely indicted for promoting care that is inefficient, uncoordinated, and too often fails to meet the needs of patients (Agency for Healthcare Research and Quality, 2002). 

The fee-for-service system serves to drive up volume and encourages hospital and community health organizations to make money and support their healthcare system rather than the needs of the patient.  This may lead providers to perform unnecessary surgeries, x-rays, or lab work, to name a few common examples, in order to increase revenue, rather than focus on the patient's desire to receive only the care they need at a cost they can afford.

It is recognized, however, that the fault does not just rest with the organization. Often, the regulatory burden on providers and hospitals is unrealistic and cumbersome, stifling innovation (Secretary of Health and Human Services, 2018). This can lead to the tail wagging the dog with organizations feeling pressure to meet regulatory needs before addressing patient needs in order to gain reimbursements.

Organizational culture

Unsurprisingly, the culture of the organization impacts patient outcomes and the practice of patient-centered care (Hahtela, McCormack, Doran, Paavilainen, Slater, Helminen, & Suominen, 2017). It is not enough to simply tout a patient-centered approach in annual reports, periodic training, glossy posters, mission statements, email signatures, or quick notes in a staff meeting. Everyone associated within the organization—from executives to clinicians to non-clinical support staff to volunteers—must hold attitudes and beliefs consistent with patient-centeredness (Gorli, Liberati, Galuppo, & Scaratti, 2016; Agha, Werner, Reddem, Huseman, Long, & Shea, 2018).

The organization must become transformational to make patient-centered care a reality, not just a nice sentiment.  This will require training for all employees and a mindset shift from the top down.

Inadequate trust

Patients often do not trust their clinician's management of their health. This is due in part to a lack of transparency combined with the steadily rising cost of care over decades. Healthcare is the only industry in the world where consumers have no idea how much money they will be required to spend on a service prior to receiving it.  Clinicians are unable to tell their patients how much their care is going to cost—how could there not be a lack of trust?

We see evidence of this lack of trust consistently in issues with medication compliance among patients with chronic medical conditions.  According to a recent article in Practical Pain Management, "approximately 125,000 people with treatable diseases die each year in the U.S. because they do not take their medication as prescribed, while 10% to 25% of hospital and nursing home admissions result from uninitiated or incomplete prescribed treatment plans" (Cosio & Demyan, 2020).  Data suggests that if a stronger, more respectful, and trusting relationship exists with the patient, then the patient is likely to be more compliant with their treatment (Sladdin, Ball, Bull, & Chaboyer, 2017).

Social determinants of health

Social determinants of health include the social factors that impact a patient's ability to achieve health and wellness.  We live in an electronic age, and it seems bizarre that this crucial information is missing from patients' medical history. But the fact is that data on social determinants of health is not consistently collected, thus stunting patient-centered care efforts.

A lack of understanding or reliable methods for collecting this information translates to a lack of understanding of the needs of the patient.  When providers do not have information on what patients have and what they need—whether poverty, educational issues, or homelessness, for example—it impacts their ability to achieve positive health outcomes for their patients (Heath, 2017). 

Pandemic

A barrier not mentioned in the Academy Health article is the current global pandemic.  COVID-19 has impacted patient-centered care, especially as care delivery is focused on the most acute cases (Carlos, Lowry, & Sadigh, 2020). Staff are stretched too thin to take into account patient preferences.

Non-COVID treatment often comes with a list of precautions to prevent spreading the virus and less flexibility in care and support options.  Many hospitals have suspended visitors, so the patient is left alone without their loved ones, who often act as a support system and a channel of communication with care providers.

Strategies and solutions

Despite the many substantial barriers to implementing patient-centered care in the healthcare industry, hospitals and healthcare professionals are finding ways to overcome these obstacles and put the needs of the patient first.  A 2018 report supported by the Robert Wood Johnson Foundation, titled Moving Patient-Centered Care Forward: How Do We Get There?, identifies several actionable strategies.

Improve diversity.

Improved diversity among the healthcare workforce will result in increased opportunities for patients to receive care from someone who shares the same racial or ethnic background.  This is essential for improved individual health outcomes, as data has repeatedly shown that compliance with physician recommendations is heightened when patients identify with the ethnicity of their provider and clinical team (Khullar, 2018).

In addition, a study found that patients were more likely to give the maximum patient rating score and were more compliant with the treatment regime when they identified with their provider's ethnicity (Takeshita, Wang, & Loren, 2020). In addition to hiring a more diverse workforce, hospitals must also collect information regarding patient ethnicity, and take steps to take ethnicity into account in a patient's care.

Embrace innovation.

The healthcare industry needs to think outside the box not only when it comes to improving care, but also reimbursement for care. Patient-centered care is increasingly delivered in teams, both within healthcare systems and through referral relationships with other organizations. A lot of work goes on behind the scenes that is often not reimbursable. Developing an innovative system that rewards collaboration will help undo a payment system that does not adequately compensate for this work. 

Collaborate with community organizations.

The African proverb, "It takes a village to raise a child," rings true for organizations that have embraced patient-centered care. Too often hospitals think they are the be-all-end-all of their patients' care, but in reality, there are many people and organizations, such as schools, food banks, and local agencies, to name a few, that contribute to a person's health.  Hospitals must change their focus from protecting their volume and growing their service line to embracing their role as a contributor to the health of their community for the sake of their patients.

Serve the "whole patient."

Transforming the culture of an organization to deliver care in a way that better serves the "whole" patient is a complex endeavor. To put a patient's needs first requires that the organization be willing to put its own needs second. A commitment within the organization to permit staff to address patient needs as they arise, even if the service is not in their job description, sounds good on a mission statement or strategic plan. However, it will require hospitals to invest in training their staff and creating a culture that focuses on customer service, respect, and patient empowerment.

Promote transparency.

A lack of transparency inevitably leads to a lack to trust, and we must listen to patients' and the government's demands for increased transparency in the healthcare industry. The 21st Century Cures Act, set to take effect in April 2021, will help all patients to have immediate electronic access to their detailed notes and records. The intent is to lower costs, create improved trust with transparent conversation between provider and the patient, and empower the patient to make more informed healthcare decisions. 

Transparency doesn't end there. There needs to be greater openness and ease in hospital billing practices, billing and cost understanding, and the ins and outs of the insurance reimbursement system. Hospitals' pay codes are indecipherable to patients trying to interpret their billing statements. Patients need to see actual costs if they are to be empowered to make wise decisions for their physical and financial health. 

Rethink compliance.

Regulations meant to ensure that all patients receive quality care have unwittingly turned the healthcare industry into a tick-box culture where hospitals are incentivized to provide care to the lowest common denominator to keep agencies off their back.

There is something for healthcare leaders to ponder in Amazon CEO Jeff Bezos's statement to shareholders in 2016: 

"Good process serves you so you can serve customers. But if you're not watchful, the process can become the 'thing.' This can happen very easily in large organizations. The process becomes the proxy for the result you want. You stop looking at outcomes and just make sure you're doing the process right."

In healthcare as well as in the tech sector, the process of ensuring regulatory compliance can too easily become the "thing," much to the chagrin of clinicians. As a result, care can become encumbered, slow, and legalistic, rather than dynamic, patient-focused, and friendly (Sims, Leamy, Levenson, Brearley, Ross, & Harris, 2020).

It is clear that to deliver patient-centered care organizations must not be held hostage to meeting regulatory requirements. Instead, they should look beyond the minimum and understand their patients when designing a patient-centric model that not only surpasses the minimum requirement for compliance, but also delivers clinical excellence.

Placing the patient in their rightful place at the center of all healthcare organizations do is an ongoing journey and not an endpoint.  Embracing patient-centered care is a paradigm shift that will require healthcare partnership, adoption and acceptance by every person in the healthcare organization, and openness to innovative approaches in an ever-evolving and complex healthcare system.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

References:

Agency for Healthcare Research and Quality (2002). Improving Health Care Quality.

Agha, A., Werner, R., Keddem, S., Huseman, T., Long, J., & Shea, J. (2018). Improving Patient-centered Care. Medical Care, 56(12).

Bezos, J. (2017). 2016 Letter to Stakeholders. Amazon News.

Brickley, B., Sladdin, I., Williams, L., Morgan, M., Ross, A., Trigger, K., & Ball, L. (2019). A new model of patient-centred care for general practitioners: results of an integrative review. Family Practice, 37(2).

Carlos, R., Lowry, K., & Sadigh, G. (2020). The Coronavirus Disease 2019 (COVID-19) Pandemic: A Patient-Centered Model of Systemic Shock and Cancer Care Adherence. Journal of the American College of Radiology, 17(7).

Cosio, D., & Demyan, A. (2020). Adherence and Relapse – How to Maintain Long-Term Gains in Patients with Chronic Conditions. Practical Pain Management, 20(6). 

Cramm, J. & Nieboer, A. (2016). Is "disease management” the answer to our problems? No! Population health management and (disease) prevention require “management of overall well-being.” BMC Health Services Research.

David, G., Saynisch, P., & Smith-McLallen, A. (2018). The economics of patient-centered care. Journal of Health Economics, 59.

Delaney, L. (2018). Patient-centred care as an approach to improving health care in Australia. Collegian, 25(1). 

Gorli, M., Liberati, E., Galuppo, L., & Scaratti, G. (2016). Promoting Patient Engagement and Participation for Effective Healthcare Reform. IGI Global.

Hahtela, N., McCormack, B., Doran, D., Paavilainen, E., Slater, P., Helminen, M., Suominen, T. (2017). Workplace culture and patient outcomes: What's the connection? Nursing Management, 48(12). 

Health Leads (2018). Patient-Centered Care: Elements, Benefits And Examples

Heath, S. (2017). Using Social Determinants of Health in Patient-Centered Care. Patient Engagement Hit.

Hughes, T., Varma, V., Pettigrew, C., & Albert, M. (2015). African Americans and Clinical Research: Evidence Concerning Barriers and Facilitators to Participation and Recruitment Recommendations. The Gerontologist, 57(2).

Khullar, D. (2018). Even as the U.S. grows more diverse, the medical profession is slow to follow. The Washington Post.

Moretta Tartaglione, A., Cavacece, Y., Cassia, F. and Russo, G. (2018). The excellence of patient-centered healthcare: Investigating the links between empowerment, co-creation and satisfaction. The TQM Journal. 30(2), pp. 153-167.

National Institutes of Health (2020). The 21st Century Cures Act.

NEJM Catalyst (2017). What Is Patient-Centered Care?

Ogden, K., Barr, J., & Greenfield, D. (2017). Determining requirements for patient-centred care: a participatory concept mapping study. BMC Health Services Research.

Robert Wood Johnson Foundation (2018). Moving Patient-Centered Care Forward: How Do We Get There?

Ruppar, T., Ho, P., Garber, L., & Weidle, P. (2017). Overcoming Barriers to Medication Adherence for Chronic Diseases. Centers for Disease Control and Prevention. 

Secretary of Health and Human Services (2018). Secretarial Response.

Sims, S., Leamy, M., Levenson, R., Brearley, S., Ross, F., & Harris, R. (2020). The delivery of compassionate nursing care in a tick-box culture: Qualitative perspectives from a realist evaluation of intentional rounding. International Journal of Nursing Studies, 107.

Sinaiko, A., Szumigalski, K., Eastman, D., Chien, A. (2019). Delivery of Patient Centered Care in the U.S. Health Care System: What is standing in its way?. Academy Health.

Sladdin, I., Ball, L., Bull, C., & Chaboyer, W. (2017). Patient‐centred care to improve dietetic practice: an integrative review. Journal of Human Nutrition and Dietetics, 30(4), 453-470.

Takeshita, J., Wang, S., Loren, A., et al. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open. 

Wall Street Journal (2015). Should the U.S. Move Away From Fee-for-Service Medicine?

Wolfe, A. (2001). Institute of Medicine report: Crossing the quality chasm: a new health care system for the 21st century. Policy, Politics, & Nursing Practice, 2(3), 233-235.

Yuan, S., Freeman, R., Hill, K., Newton T., & Humphris, G. (2020). Communication, Trust and Dental Anxiety: A Person-Centred Approach for Dental Attendance Behaviours. Dentistry Journal.Communication, Trust and Dental Anxiety: A Person-Centred Approach for Dental Attendance Behaviours.

Managing the effects of pandemic-induced burnout among healthcare professionals

By Dr. Seleem R. Choudhury

As the COVID-19 pandemic continues, healthcare workers face unprecedented levels of stress, fear, and anxiety. Situations that trigger chronic stress have always been present within the important and weighty work of caring for patients, but routine stressors are now intensified by the serious risks of working on the frontlines of a pandemic. Together, this creates a perfect storm of heightened risk of burnout.

Accounts of non-healthcare workers experiencing burnout from the challenges of working during a pandemic, such as learning to work remotely, constant technological mediation, and navigating new family schedules, are well documented. Though the phenomenon of burnout among healthcare professionals stretches back decades, the literature and recent data for U.S. healthcare workers during the pandemic is scarce (Jha, Shah, Calderon, Soin, & Manchikani, 2020).

Burnout: definitions and warning signs

The term “burnout” emerged in the early 1980s, and is defined by psychologists as “exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work” (Mathieu, 2012).  A definition from a recent study by Dr. Sachin Jha, et al., emphasizes the root cause of burnout as long-term job stress, resulting in a “mixture of fatigue, cynicism, and exposure to inefficacy” (2020). Though often thought of as a form of primarily emotional exhaustion, the impact of burnout can go beyond mental health, manifesting in physical ailments (Figley, 1995). 

Burnout among healthcare professionals specifically has long been a concern.  The Bureau of Labor Statistics projects 200,000 RNs will be needed per year over the next six years. But, according to Nursing Solutions Inc., since 2015, the average hospital has turned over nearly 90 percent of its workforce—these are all pre-COVID-19 numbers (2020).

Although burnout has been around for many decades, it has been exacerbated by the unique challenges of the pandemic, and exposes the insufficient methods that have historically been used to mitigate the symptoms of burnout among healthcare workers.

COVID-related burnout

Numerous personal accounts and experiences regarding providing care during COVID include feelings of being overwhelmed and powerless. According to a survey of nearly 60,000 nurses by the National Order of Nurses, a French nursing union, 57 percent of France’s nurses have described their condition as a “state of professional exhaustion” since the beginning of the pandemic (2020). 

In the U.S., median self-reported stress, measured on a scale from 0 to 10, among intensive care unit clinicians increased from 3 to 8 during the pandemic (Society of Critical Care Medicine, 2020).

There are many root causes of the skyrocketing levels of burnout during the pandemic. Feelings of powerlessness are practically inevitable when, despite you and your colleagues’ constant efforts to fight the virus, you continue to see the same symptoms and give the same diagnosis repeatedly.

An article from researchers at Texas A&M University explains other sources of stress:

“Health care workers are experiencing added stress from multiple areas. Many of them are working longer shifts and experiencing more loss of life. The lack of personal protective equipment (PPE) and training on how to use new equipment causes many professionals to question if they have been exposed. This leads to fear that they could infect their family and loved ones. In addition to those fears, there is anxiety surrounding job security. To reduce the spread of infection, many states have stopped elective procedures and consequently, many health care professionals have been laid off or had their hours reduced” (Salazar, 2020). 

Additionally, Amnesty International has released new data showing that an estimated 7,000 health workers have died due to COVID-19 around the world so far (2020).  As of September 2020, the United States has suffered the second-highest death toll worldwide with 1,077 health workers dying from COVID, while the United Kingdom has the next-highest number of deaths at 649 (McCarthy, 2020).  Working in such a high-risk job—especially when you entered into the profession assuming that it would not cost you your life—must have an impact on an individual's psychological well-being. 

Responding to burnout

These are stressful times to be a healthcare professional. At all times, but especially under current circumstances, it is essential to be proactive to remain healthy mentally and physically and prevent burnout.

Individuals may benefit from the following strategies:

• Focus on meaning. Remember why you chose the healthcare profession.
• Try to set boundaries. In a global pandemic this is especially challenging, but where possible set time to disconnect from work.
• Strengthen your resilience. Take a 5-minute breather. Focus inward through journaling, yoga, etc.
• Practice mindfulness. Many studies show that mindfulness programs mitigate burnout symptoms.
• Stay positive, but also be realistic. Burnout is worsened when you expect too much of yourself.
• Practice gratitude. Gratitude has the power to improve our psychological health. Studies have shown it increases personal and professional well-being, boosts happiness, and helps to prevent depression (Chowdhury, 2020).
• Reach out to trusted peers or friends and talk it out (Rogers, Polonijo, & Carpiano, 2016).

Though individuals must recognize the importance of guarding themselves against burnout, healthcare organizations bear a great weight of responsibility in caring for their employees, creating an empathetic and supportive work environment, and providing resources to help their employees cope with the stresses of the pandemic.

Organizations should consider adopting the following strategies:

• Where possible, make sure that staff and providers have the necessary resources and skills to meet expectations. This is a crucial consideration, especially in regard to PPE.
• Organizations must understand that if staff and providers are working many hours, burnout is inevitable, and so provisions and appropriate support must be provided (Centers for Disease Control and Prevention, 2020).
• Organizational leaders need to express authentic empathy (Moss, 2020).
• There should be a robust support mechanism that is known, supported, and promoted consistently by leaders.  This process needs to be ready to employ when a staff member expresses a need (Moss, 2020).
• Ask the question: “Are you doing ok?” Pause and listen for the response. Don’t be afraid to hear what is said, and don’t take the response personally. Associate no stigma with struggling with burnout.
• Prioritize and organize workloads. Be sensitive to what is happening and ensure that priorities match the situation. Be judicious with the number of priorities.

There are many factors that have contributed to the sudden increase in burnout among healthcare professionals, including issues with the initial management of the virus outbreak such as rapidly increased workload hours, inadequate PPE, and a lack of consistently updated guidelines (Wang, Zhou, & Liu, 2020). Even with some of these early issues resolved, many others remain, and I join many other healthcare leaders in our concern that “the constant exposure may result in a permanent fracture in the mental health of many healthcare professionals” (Wang, Zhou, & Liu, 2020).

As leaders of healthcare organizations, we must reprioritize what is important to us at the organizational level.  Trying to do and focus on too many things will overload our teams at such a fragile time for their mental health. We must listen to ensure we fully understand the essential needs of our frontline staff during COVID-19, as stressors may also exist outside work that may contribute to the feelings of powerlessness.

Navigating this pandemic brings prolific uncertainty. It is essentially impossible to get away from the constant stressors in and out of work, and even the most resilient among us are not immune to the effects of burnout. It is imperative for the long-term health of our teams and organizations that we go above and beyond to offer support and resources to our employees on a continual basis.

Resources

2020 NSI National Health Care Retention & RN Staffing Report. Published by: NSI Nursing Solutions, Inc. March, 2020.

Chowdhury, Madhuleena Roy, BA. The Neuroscience of Gratitude and How It Affects Anxiety & Grief. January 9, 2020.

Clinicians Report High Stress in COVID-19 Response. Society of Critical Care Medicine. May 2020. 

COVID19: The National Order of Nurses warns of the situation of 700,000 nurses in France as the epidemic accelerates again. Ordres National des Infirmier. October 11, 2020.

Employees: How to Cope with Job Stress and Build Resilience During the COVID-19 Pandemic. Centers for Disease Control and Prevention. May 5, 2020.

Figley, C.R. (Ed). (1995) Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Global: Amnesty analysis reveals over 7,000 health workers have died from COVID-19. Amnesty International. September 3, 2020. 

Jha, Sachin “Sunny”, MD; Shah, Shalini, MD; Calderon, Michael David, MS; Soin, Amol, MD; and Manchikanti, Laxmaiah, MD (2020). The effect of COVID-19 on interventional pain management practices: A physician burnout survey. Pain physician, 23, S271-S282.

Mathieu, F., (2012) The Compassion Fatigue Workbook. New York: Routledge.

McCarthy, Niall. Where Most Health Workers Have Died From Covid-19. Statista. September 3, 2020.

Moss, Jennifer. Preventing Burnout Is About Empathetic Leadership. Harvard Business Review. September 28, 2020.

Rogers, E., Polonijo, A. N., & Carpiano, R. M. (2016). Getting by with a little help from friends and colleagues: testing how residents’ social support networks affect loneliness and burnout. Canadian Family Physician, 62(11), e677-e683.

Salazar, Alexandra. Infecting the mind: Burnout in health care workers during COVID-19. ScienceDaily. May 13, 2020.

Simmons, Micha’le. Three things executives can do to get ahead of leader burnout amidst Covid-19. Advisory Board. April 7, 2020.

Wang J., Zhou M., Liu F. Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China [published online ahead of print, 2020 Mar 6]. J Hosp Infect. 2020; pmid:32147406

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

Management and Rehabilitation of Long-Term Effects of COVID-19

By Dr. Seleem R. Choudhury, October 12, 2020

As a society, we have been enduring life in a pandemic for over half a year. Though we have been feeling the effects of COVID-19 for a long time, medically speaking the disease is still very new to us. It is important to remember that our knowledge is still developing regarding the virus and much remains unknown—specifically the long-term effects of the disease.

There is a common misconception that once a patient infected with COVID has a negative test, the issue is resolved.  It is often repeated that according to the World Health Organization, about 80% of COVID-19 infections are mild or asymptomatic, and patients typically recover after two weeks (Carfì, Bernabei, & Landi, 2020). 

Yet there are tens of thousands of people who have joined support groups on Slack and Facebook, who call themselves “long-termers” or “long-haulers” who are wrestling with serious COVID-19 symptoms a month or more after being infected with the disease (Yong, 2020). 

There are essentially two types of COVID patients experiencing who appear to be experiencing long-term effects of the virus—those who were ventilated due to critical symptoms and those who have residual symptoms despite having “mild” symptoms while infected with the disease (Liu, Yan, Wan, Xiang, Le, & Liu, 2020).

Critical care teams know that the longer patients remain in the intensive care unit (ICU), the more likely they are to suffer “long-term physical, cognitive and emotional effects of being sedated” (Edwards, 2020). In fact, those effects have a name: "post-intensive care syndrome (PICS)," also referred to as post-ICU delirium. PICS is an ongoing challenge even in non-pandemic conditions. An article in 2019 described PICS resulting in cognitive impairment in 30–80% of ICU survivors, the severity may vary and often lasts for years (Colbenson, Johnson, & Wilson, 2019).

As a hypothesis based upon 2019 post-ICU delirium numbers together with an increased number of patients on ventilators due to COVID, and then combined with non-hospitalized virus survivors who are experiencing long-term symptoms, our current circumstances potentially present a public health crisis (Vittori, Lerman, Cascella, Gomez-Morad, Marchetti, Marinangeli, & Picardo, 2020).  This presents hospitals, community practices, and mental health support agencies with an opportunity to expand their care services to meet a growing—and likely lasting—need.

Long-term effects of COVID-19

Four-fifths of those diagnosed with COVID experience mild symptoms.  A “mild” case is defined as two weeks or more of symptoms such as fever, cough, sore throat, malaise, and myalgias.  Beyond these flu-like symptoms, some patients have gastrointestinal issues, including anorexia, nausea, and diarrhea (Gandhi, Lynch, & del Rio, 2020). 

But experts are finding that patients who had mild symptoms can experience more than just a decline in physical health. Between 30% and 50% of people infected with COVID that have clinical manifestations will face some form of mental health issues, according to an estimate from Dr. Teodor Postolache, a professor of psychiatry at the University of Maryland School of Medicine (Goldberg, 2020; Advisory Board, 2020).  Those affected may experience anxiety or depression but also “nonspecific symptoms that include fatigue, sleep, and waking abnormalities, a general sense of not being at your best, not being fully recovered in terms of the abilities of performing academically, occupationally, [and] potentially physically” (Cooney, 2020).

Anecdotally, this matches what healthcare professionals are hearing from “long-haulers.” In addition to widely-reported fatigue reported by those healing post-COVID, these patients are experiencing neuropsychological problems ranging from headache, dizziness, and lingering loss of smell or taste to mood disorders and deeper cognitive impairment. Early reports from clinicians in China and Europe describe those infected with the disease suffering from lingering depression and anxiety, and in some cases muscle weakness and nerve damage preventing the ability to walk (Cooney, 2020).

Some COVID patients experiencing critical symptoms such as difficulty breathing were admitted to an Intensive Care Unit and placed on a ventilator.  On average in the U.S., approximately 0.8 million people every year receive this treatment in critical care; it can be reasonably assumed that this number will drastically increase in 2020 with the spread of COVID (Jaffri, 2020).

There are years of substantial data indicating that people requiring mechanical ventilation experience adverse effects after they are discharged from care (Wunsch, Linde-Zwirble, Angus, Hartman, Milbrandt, & Kahn, 2010).  People who survive up to two years after discharge from critical care are readmitted to nursing care, a rehabilitation facility, or to an ICU at up to a rate of 80%. Patients who have similarities to morbidities and the acute respiratory distress experienced by COVID-19 survivors are readmitted into these types of care at a higher rate (Jaffri, 2020). 

Additionally, a study published by the American Thoracic Society found that other issues such as physical impairment, physical deconditioning, and muscle weakness can affect those who required mechanical ventilation for up to a year after their removal from the ventilator (Ruhl, Lord, Panek, Colantuoni, Sepulveda, & Chong, 2014). Some also report difficulties returning to work or maintaining financial stability.  According to a 2018 study, 33% of individuals placed on a ventilator are unable to drive, limiting their mobility and social responsibilities, even up to a year after being discharged from critical care (Ohtake, Lee, Scott, Hinman, & Ali, 2018).

Solutions and opportunities

There is growing consensus that COVID-19 has potentially serious long-term physical and mental effects for survivors, regardless of whether symptoms at the time of infection were mild or critical.  Simple analytics should be able to ascertain the need. This review is important as It is the responsibility and opportunity of the healthcare community to respond to this potential health crisis within its community. 

The European Respiratory Society and American Thoracic Society-coordinated International Task Force recommends that clinicians follow up with all COVID-19 patients who were hospitalized because of the infection 6 to 8 weeks after their discharge from care (Spruit, Holland, Singh, Tonia, Wilson, & Troosters, 2020).

In response, COVID-19 rehabilitation clinics are being formed to focus on assessing patients’ cognitive ability, mental health, mobility, and ability to perform daily activities. These clinics offer mental health, physical therapy, and occupational therapy services, as well as pediatric rehabilitation medicine to address the needs of those dealing with long-term effects of the virus (Spruit, Holland, Singh, Tonia, Wilson, & Troosters, 2020).

The Spaulding Rehabilitation Network has engaged a multidisciplinary physician-led team of physiatrists, physical therapists, occupational therapists, speech language pathologists, and case managers to establish a dedicated outpatient clinic for those who are recovering or were hospitalized for COVID-19.  The Kennedy Krieger Institute is introducing a rehabilitation clinic for those children and adolescents under age 21 who have “recovered from the virus but need additional support to regain lost neurological and physical function as a result of the illness.”  The Shirley Ryan Ability Lab has been offering rehabilitation services for decades, and has already opened their services to those dealing with impairments as a result of COVID-19.

“Long-haulers” are experiencing the effects of a debilitating illness, and it will be vitally important for them to receive rehabilitation care, whether in person or via telehealth, to return to full health and quality of life (Urban, 2020).  As was stated in the European Respiratory Journal: “Considering the expected high burden of respiratory, physical and psychological impairment following the acute phase of COVID-19, a huge number of patients should be referred early to a rehabilitation program” (Polastri, Nava, Clini, Vitacca, & Gosselink, 2020).

Early data from health authorities in the United Kingdom and Italy, two countries hit hard with COVID-19, has shown that a structured rehabilitation program in-clinic, in the home, or virtually can mitigate post-ICU symptoms for those treated for COVID-19, thus resulting in improvements in daily function and independence. This success can also be extended to those with milder symptoms and reduce alienation that victims of the disease have reported experiencing, and ensure physical, emotional and cognitive functioning and recovery.

In the U.S. hospitals have been so focused on the present crisis, that they have not developed the capacity to deal with patients and their post-COVID needs. This could create a potential health crisis down the road. It is time to transition out of crisis-mode and begin to form a strategy to serve the needs of patients who are experiencing long-term effects of COVID-19.

Resources:

• Coronavirus Disease 2019 Pandemic Acute Respiratory Distress Syndrome Survivors: Pain After the Storm?, by Alessandro Vittori, MD, Jerrold Lerman, MD, Marco Cascella, MD, Andrea D. Gomez-Morad, MD, Giuliano Marchetti, MD, Franco Marinangeli, PhD, MD, and Sergio G. Picardo, MD (2020), International Anesthesia Research Society
• COVID-19: Interim Guidance on Rehabilitation in the Hospital and Post-Hospital Phase from a European Respiratory Society and American Thoracic Society-coordinated International Task Force, by Martijn A. Spruit, Anne E. Holland, Sally J. Singh, Thomy Tonia, Kevin C. Wilson, and Thierry Troosters (2020), European Respiratory Journal
• COVID-19 and pulmonary rehabilitation: preparing for phase three, by Massimiliano Polastri, Stefano Nava, Enrico Clini, Michele Vitacca, Rik Gosselink (2020), European Respiratory Journal
• COVID-19 Can Last for Several Months, by Ed Yong (2020), The Atlantic
• COVID-19 Support Group (2020), Body Politic
• COVID-19 Survivor Corps (2020), Facebook
• 'Covid fog': The latest emerging, long-term symptom of Covid-19 (2020), Advisory Board
• COVID Recovery & Rehabilitation (2020), Shirley Ryan Ability Lab
• For long-haulers, COVID-19 takes a toll on mind as well as body, by Emma Goldberg (2020), The Baltimore Sun
• Health Care Resource Use and Costs of Two-Year Survivors of Acute Lung Injury. An Observational Cohort Study, by A. Parker Ruhl, Robert K. Lord, Julia A. Panek, Elizabeth Colantuoni, Kristin A. Sepulveda, Alexandra Chong, Victor D. Dinglas, Carl B. Shanholtz, Peter J. Pronovost, Donald M. Steinwachs, and Dale M. Needham (2014), Annals of the American Thoracic Society
• Long after the fire of a Covid-19 infection, mental and neurological effects can still smolder, by Elizabeth Cooney (2020), Stat News
• Mild or Moderate COVID-19, by Rajesh T. Gandhi, M.D., John B. Lynch, M.D., M.P.H., and Carlos del Rio, M.D. (2020), The New England Journal of Medicine
• Pediatric Post COVID-19 Rehabilitation Clinic (2020), Kennedy Krieger Institute
• Persistent Symptoms in Patients After Acute COVID-19, by Angelo Carfì, MD; Roberto Bernabei, MD1 Francesco Landi, MD, PhD; et al (2020), JAMA Network
• Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework, by Patricia J. Ohtake, Alan C. Lee, Jacqueline Coffey Scott, Rana S. Hinman, Naeem A. Ali, Carl R. Hinkson, Dale M. Needham, Lori Shutter, Helene Smith-Gabai, Mary C. Spires, Alecia Thiele, Clareen Wiencek, and James M. Smith (2018), Journal of the American Physical Therapy Association
• Post COVID-19 Outpatient Rehabilitation Program (2020), Spaulding Rehabilitation Network
• Post-Intensive care syndrome and COVID-19: crisis after a crisis?, by Abbis Jaffri (2020), Heart and Lung: The Journal of Cardiopulmonary and Acute Care
• Post-intensive care syndrome: impact, prevention, and management. Colbenson, G. A., Johnson, A., & Wilson, M. E. (2019). Breathe 2019
• Rehabilitation Care is Needed for Many COVID-19 Patients, by Kylie Urban (2020), University of Michigan Health Lab
• The epidemiology of mechanical ventilation use in the United States, by Hannah Wunsch, Walter T. Linde-Zwirble, Derek C. Angus, Mary E. Hartman, Eric B. Milbrandt, and Jeremy M. Kahn (2010), Critical Care Medicine
• 'They're Not Actually Getting Better,' Says Founder Of COVID-19 Long-Haulers Support Group by Robin Young and Serena McMahon (2020), wbur
• Viral dynamics in mild and severe cases of COVID-19, by Yang Liu, Li-Meng Yan, Lagen Wan, Tian-Xin Xiang, Aiping Le, Jia-Ming Liu, et al. (2020), The Lancet Infection Diseases
• Why some coronavirus patients could have problems after recovery, by Erika Edwards (2020), 7News

Read more from Dr. Seleem Choudhury at seleemchoudhury.com.