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The BMC Brief

The BMC Brief - Volume 8, Issue 6

June 26, 2019

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Fighting Resident Burnout With Primary Care

While burnout can be a danger in any profession, it is particularly widespread and impactful for physicians and physician trainees. Research has suggested that over 45% of residents experience long-term and unresolvable job stress, exhaustion, or lack of personal connection to work.

Burnout is associated with a higher rate of medical errors and more adverse events for patients. It can also lead to provider mental health problems. Physicians may choose to leave the field due to burnout, contributing to the growing shortage of providers.

Burnout in trainees is driven by many factors. Residency often entails long working hours in high pressure situations which can be physically and emotionally draining, while also performing extensive clerical duties. In addition, trainees may neglect their own healthcare, often due to their busy schedules or a lack of a primary care physician. All these issues can lead to burnout.

“Being an intern and being a resident is really hard,” says Jeff Schneider, MD, an emergency room physician and chairman of Graduate Medical Education at Boston Medical Center. “Our interns, residents, and fellows may be working 80 hours a week to care for patients and their families. Over and above the work that they do in the clinics and in the hospital, they think about these patients and families, and worry about them. In no other job in the world do they cap you at 80 hours. When you tell people about that, they say that's ridiculous.”

Burnout at BMC

While BMC recognizes these challenges and works hard as an institution to increase trainee and employee wellness, the prevalence of burnout is still high, as it is at most institutions. To help address this issue, BMC has launched a program offering primary care appointments to the class of interns – first-year residents – that just started in mid-June.

“If there are things we can do to address burnout, we should,” says Schneider. It's better for our trainees. It's better for faculty. And probably most importantly, it's better for patients.”

According to Schneider, data from previous wellness vitality surveys at BMC shows one of the biggest drivers of resident wellness and burnout is inability to take care of their own healthcare. Those data prompted the first discussions around this initiative, and led to the decision to offer primary care appointments to interns during orientation.

“Most of our interns are 20-or- 30-something and healthy, so they don’t take advantage of routine healthcare very often,” says Schneider. “But we wanted to make it easier for residents to take care of their healthcare when they need to.”

Departments across the hospital were involved in setting up the program. The team worked with primary care practice managers to block schedules, and with the program directors that run departmental orientation to understand this is happening, so that people didn’t miss parts of their orientation. They also figured out what data they would need from incoming interns and how to collect it. Then Schneider and his team worked with Revenue Cycle to ensure that interns were not billed for their appointments, as their health insurance doesn’t start until they actually arrive and are hired.

Interns were given the choice of a Family Medicine or General Internal Medicine provider, a male or female provider, and to see a physician or advanced practice provider. The appointments may not have included a full exam, but did offer an opportunity to establish care, refill necessary medications, and hopefully serve as a first step in building a relationship with a primary care provider, so that interns have a familiar face to go to when they do need primary care at a later date. In addition, the appointments served as an introduction to some of the resources, both for medical and mental health care, that are available on campus for trainees.

More than eighty percent of the 144 interns signed up for primary care appointments.

“We weren’t sure how many people would sign up, so we had to work hard to get appointments for everyone,” said Schneider. “I can’t overstate how helpful our GIM and Family Medicine practice managers, provider, and front desk staff were in stepping up to the plate to help.”

While Schneider and his team plan to gather more official feedback, anecdotal evidence from both interns and providers has been positive. Providers noted that many of the interns needed help with medication refills and weren’t sure how they would otherwise get those in their new city, while interns noted the benefits of connection to a provider and the message that their health is important to the organization.

The Future of Trainee and Employee Health

In early May, BMC’s initiative gained widespread attention due to a tweet that Schneider posted. With 325 likes — more than twice his number of followers at the time — and over 30,000 views on the tweet, it’s clear that BMC is working on an issue of great importance to the healthcare community.

More importantly, offering primary care appointments during orientation is only a first step. Schneider and the team hope to look at whether these appointments change resident wellness in the future, as well as whether this program leads to continued contact with a primary care provider later in the year. If they can show the value of this initiative, then the next step is to try to expand to all residents and fellows.

“Some people have also asked if this should be part of onboarding for all new hires, because the health, resilience, and wellness of our employees is so important to us as an organization,” says Schneider. “We’ve done a lot of work to figure out other areas that we need to grow and expand to meet the needs of our employees. We hope make all aspects of mental health, physical health, and wellbeing easier for employees to access.”

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Community Narcan Training Extends Our Life-Saving Capacity

Originally patented in 1961 by scientists searching for a treatment for constipation caused by chronic opioid use, naloxone quickly began being used for a markedly different purpose — as the premier antidote to opioid overdose.

But it wasn’t until the last decade, as the opioid crisis snowballed into an epidemic of unprecedented magnitude in the US, that naloxone began making headlines — and often controversial ones. Some critics of naloxone have suggested that it enables people with substance use disorder to use drugs without fear of a fatal overdose.

Alex Walley, MD, MSc, wants to put that argument to rest.

"Naloxone not only reverses an overdose, it reverses the euphoria and can even cause withdrawal. It's the last thing that people who use opioids would want," says Walley. "The only thing it enables is saving lives."

How Naloxone Works in the Opioid Epidemic

Naloxone — also referred to by brand names Narcan, Evzio, and Nalone — is an opioid antagonist. In simple terms, it can quickly go to the receptor site where an opioid such as fentanyl, heroin, or oxycodone is active and knock the opioid off. It then sits on that receptor so the opioid can’t bind and cause the overdose to recur.

Walley, the director of the addiction medicine fellowship program at Boston Medical Center — one of the four sites headquartering NIDA’s recently-announced $350 million study — considers naloxone one of the cardinal tools in curbing the epidemic and is a staunch proponent of making it widely available.

Read more on HealthCity

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What do you do, Center for Transgender Medicine and Surgery?

In 2016, BMC started the Center for Transgender Medicine and Surgery (CTMS) to coordinate care and provide a wide range of services for our transgender patients. The Center was the first of its kind in New England, and now, with hundreds of new patients per year, is considered a model of transgender care.

The BMC Brief sat down with Luisa Gomes, operations manager for CTMS & Plastic Surgery, and Pamela Klein, RN, MSN, ACRN, nurse liaison for CTMS – both of whom are 2019 Be Exceptional Award winners – to learn more about the Center.

What do you do at BMC?

Klein: I’m the nurse liaison for the CTMS. I was working at Boston Health Care for the Homeless, and had collaborated closely with BMC over the years on care for transgender patients. Because of this work, I was initially hired to help the Center get going back in 2016. I actually still work at BHCHP half-time.

The job has evolved a lot since that time. In the beginning, I worked on a lot of protocols, setting up systems, and education and training.

As the program got going and we started actually seeing patients, I work a lot more on the clinical side. But I still do a lot of education and training, including presentations outside of BMC. I also help coordinate between patients and providers, and between a patient’s different providers.

Gomes: I’m the operations manager for Plastic Surgery and the CTMS. I do anything from helping book patients for clinic, deal with insurance issues and authorizations, and help with patient flow to overseeing payroll, hiring, and other clinic operations.

Can you tell us about the history of the CTMS and how it came to be?

In 2014, Medicare said they weren’t going to deny health care services based on gender identity. This paved the way for the Massachusetts Division of Insurance to change their policy and have public insurance coverage in MA match what Medicare did.

Meanwhile, an endocrinologist at BMC – Josh Safer, MD, who has since left – had been talking with some surgeons here about setting up a center of excellence for transgender health at BMC. We already provided a lot of care for transgender patients, including primary care, breast augmentation and chest reconstruction, orchiectomies, behavioral health, and endocrinology.

Despite all the services we offered, we weren’t providing them in any sort of coordinated way. So when the insurance change happened and made genital surgery accessible to everybody, there was the idea to offer that too. And with that, providers wanted to provide coordinated care and become a kind of one-stop-shop for our transgender and non-binary patients.

That was the impetus for Dr. Slama in Plastic Surgery and Dr. Oates in Urology to get trained in vaginoplasty surgery in particular, which was the catalyst for the Center to get set up.

Simultaneously, BMC was setting up a transgender task force that was very symbiotically connected to what was becoming the CTMS. The task force really helped guide the development of the CTMS.

What services does the CTMS offer?

We have an intake process for any patient who identifies as transgender or gender non-binary. That process asks if they need primary care, surgical services, hormones or other endocrinology services, behavioral health, voice therapy, pelvic floor therapy, gynecology, or other services. We also have the Child and Adolescent Center for Transgender Health (CATCH).

All our CTMS providers have specialized training and/or expertise in this area. Many are members of the World Professional Association of Transgender Health (WPATH), which publishes standards of care for this population.

If a provider is interested in working with us, we have mechanisms to provide mentorship and training, so that they can become competent to provide this type of care.

What’s something you want staff to know about the CTMS?

The CTMS is a virtual center. That means that everyone already has a full-time job, and then works with the CTMS on top of that. But we all believe in the mission, and we all work hard to coordinate our services.

We’d also like staff to know that we have a lot of patients. Many staff may not see these patients in their specialties, or may not know that their patients identify as transgender. But this care is as important as any other care we provide at BMC.

It’s also important for staff to know that many of our patients have been mistreated at other institutions or in their personal lives. They may be mistrustful of the health care system, which means our staff has been exposed to some pretty tough situations. But once you gain a patient’s trust, it changes everything. Staff just need to be aware that patients are just trying to advocate for themselves, because they’re not used to have someone advocating for them.

What are the top priorities for the CTMS this year?

Our main priority has always been to get as many patients who want it as possible through to surgery. We have a very big wait list right now, so we’re trying to find the best way to accommodate those patients as quickly as possible.

That means that one of our big goals is to expand the number of surgeries we can do. Last year, we were doing two to three a month, but now we’re doing one a week. So we’ve been able to double the number of surgeries.

We would also like to expand our services. For example, we currently don’t offer genital surgery to male-identified patients. That’s something we hope to do down the road. There are also different types of vaginoplasty surgeries, and we’d like to be able to offer more options.

You’re both Be Exceptional Award winners. Congratulations! What does that award mean to you?

Gomes: It provides validation that our work matters and that the hospital is behind it. And it’s great if the award gets more people talking about the CTMS.

Personally, it’s a huge honor. I’ve been here for over 13 years, starting at the front desk, and have moved up over those years. The award makes me feel that the work I’m doing is important.

Klein: For me, it’s a real validation by the institution that this care really matters and people are paying attention to it.

I’m very proud to be recognized in this way.

It really does feel like a team effort – you can’t pinpoint where one person’s work starts and another begins. We all work very closely together, so it feels like this award is for all of us.

What do you like most about working at BMC?

Gomes: The people I work with. You can work in any hospital, but the reason I like BMC is that I believe in our goals. And those goals start at the top. You hear Kate Walsh speak anywhere, and you believe in her and want to work with her to accomplish those goals. I don’t think I would get that anywhere else.

Klein: For me, it’s the people I work with, especially on the CTMS team. It’s really good to feel that everyone is on the same page in terms of the big picture. We all work together to move forward.

Working at the CTMS is exciting. We were the first ones in New England to offer genital surgery. We’re not the only ones anymore, but the competition is good. Having more hospitals offering surgery only helps our patients. We’re part of a consortium that helps us collaborate with institutions across New England, which is exciting as well.

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BMC Comes Together to Celebrate Exceptional Employees

Every day at Boston Medical Center, our over 7,000 employees go above and beyond to help ensure our patients get the best care possible. But each year, employees who truly represent our core values and priority goals are honored at the Be Exceptional Awards.

This year’s ceremony on June 14, was hosted by Kate Walsh, president and CEO, and Lisa Kelly-Croswell, senior vice president and chief human resources officer. Along with attendees, which included employees and families, Walsh and Kelly-Croswell honored these exceptional 20 individual winners and seven team winners.

“These awardees come from all over BMC, and hold many different jobs across the hospital,” said Walsh. “But they all share a deep commitment to BMC and to our patients. Not to mention they share the tremendous admiration of their colleagues. Every day, they help us meet our goals and embody what BMC is all about.”

The 2019 Be Exceptional Award winners are:

Individual Winners

  • Carol Cahill, CNS, Psychiatric Clinical Nurse Specialist, Department of Psychiatry
  • Bob DeMayo, Director of Medical Staff Affairs and Credentialing, Medical Affairs
  • Myrna Estrada, CNA, Nursing Telesit
  • Jason Fox, NP, Nurse Practitioner, Addiction Consult Service
  • Angela Gaynor, LCSW, Licensed Clinical Social Worker, Care Management
  • Luisa Gomes, Practice Manager, Plastic Surgery / Center for Transgender Medicine and Surgery
  • Jose Gonzalez, Public Health Outreach Specialist, Infectious Disease
  • Zaiton Ibrahim, Housekeeper, Environmental Services
  • Pamela Klein, RN, MSN, ACRN, Nurse Liaison, Center for Transgender Medicine and Surgery
  • Pam Kuzia, RN, Pediatric Sedation Nurse
  • Anastacia Mbuthia, PAS 1, Patient Access
  • Carole Moloney, NP, Pediatrics – Infectious Diseases
  • Madison Moreau, Clinical Engineer
  • Susie Morin, Executive Assistant and Office Manager, Human Resources
  • Megan O’Brien, RN, Nurse Manager, Ambulatory Obstetrics and Gynecology
  • Gladys Obukwelu, Medical Assistant, Obstetrics and Gynecology
  • Robert B. Saper, MD, MPH, Director of Integrative Medicine, Family Medicine
  • Kellie Smith, MSN, RN, NE-BC, Senior Director/Associate Chief Nursing Officer
  • Kieu Thanh Ho, Medical Assistant, Family Medicine
  • Daniel Zariczny, Medical Case Manager, ARCH Program

Winning Teams

  • Antimicrobial Stewardship Team
  • Campus Consolidation Move Team
  • Emergency Department Pharmacy Team
  • Hematology/Oncology Patient Navigators
  • Legal Team
  • Patient Advocacy Team
  • Violence Intervention Advocacy Program

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Awards and Accolades

Nancy Gaden, DNP, RN NEA-BC, Receives Excellence in Nursing Leadership Award

Nancy Gaden, DNP, RN NEA-BC, a senior vice president and chief nursing officer, was awarded the Mary B. Conceison Award for Excellence in Nursing Leadership from the Organization of Nurse Leaders of MA, RI, NH, CT and VT. The award recognizes outstanding contributions made by a nursing service administrator and is the organizations highest award.

BMC Communications and Marketing Department Wins Four Lamplighter Awards

The Communications and Marketing Department has received four Lamplighter Awards from the New England Society for Healthcare Communications. The awards recognize excellence in communications, media relations, and marketing by New England healthcare institutions, health plans and agencies. BMC won an award for our new Hey Mama app, a Center for Transgender Medicine and Surgery ad campaign, a video on VIAP, and the infomercial used to launch the Hub.

BMC Receives Stroke Honor Roll Elite Plus Achievement Award

BMC is a recipient of the American Heart Association/American Stroke Association’s Get With The Guidelines® Target: Stroke Honor Roll Elite Plus Achievement Award. The award recognizes the hospital’s commitment to ensuring stroke patients receive the most appropriate treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence.

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News of Note

BMC Receives Hospital and Home Care Accreditations

Boston Medical Center has received three-year accreditations from the Joint Commission for both hospital and home care. These accreditations recognize BMC’s quality and safety of care for all patients.

Mourning the Loss of Louis E. Braverman

Lewis E. Braverman, MD, Professor of Medicine and former Chief of Endocrinology, Diabetes and Nutrition at BUSM/BMC, died on June 10 after a long illness. He was 88.

Braverman graduated from Harvard College, and received his MD from Johns Hopkins University School of Medicine. He did an internal medicine residency at Boston City Hospital and an endocrinology fellowship in the Thorndike Memorial Laboratory. He was Chief of Endocrinology at St. Elizabeth’s Hospital, founding Director of Endocrinology and Chief of Nuclear Medicine at University of Massachusetts Medical Center and Chief of Endocrinology, Diabetes and Nutrition at BUSM/BMC. He actively saw patients in the Endocrine clinic at BMC until his retirement in January 2018.

Braverman was a prolific thyroid researcher with over 600 publications, including the identification of a new genetic disorder. He also served as editor-in-chief of the Journal of Clinical Endocrinology and Metabolism and of Endocrine Practice. He was longtime co-editor of the leading thyroid textbook The Thyroid: A Fundamental and Clinical Text.

He served as secretary and president of the American Thyroid Association and was elected Master both of the American College of Endocrinology and the American College of Physicians. In honor of his lifetime of mentorship, the American Thyroid Association established the Lewis E. Braverman Distinguished Award Lectureship in 2011, which recognizes an individual who has demonstrated excellence and passion for mentoring fellows, students and junior faculty; has a long history of productive thyroid research; and is devoted to the ATA.

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