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Viewpoint
September 30, 2022

The Dr Lorna Breen Health Care Provider Protection Act: A Modest Step in the Right Direction

Author Affiliations
  • 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
  • 2Brown University, Providence, Rhode Island
JAMA Health Forum. 2022;3(9):e223349. doi:10.1001/jamahealthforum.2022.3349

During the first wave of the COVID-19 pandemic, Lorna M. Breen, MD, cared for patients in the emergency department at the NewYork-Presbyterian Allen Hospital. An overburdened Dr Breen soon became dispirited and expressed thoughts of harming herself. During and after a subsequent inpatient psychiatric admission, Dr Breen worried about the potential professional consequences of seeking care, including the risks of losing her medical license and workplace ostracism.1 Although mental health treatment is generally effective in helping those with suicidal ideation, Dr Breen died tragically by suicide on April 26, 2020. Growing recognition of the burnout crisis and its deleterious effects on mental health among health care professionals in the US contributed to the enactment of the Dr Lorna Breen Health Care Provider Protection Act, signed into law by President Biden on March 18, 2022. In this Viewpoint, we discuss the influence of burnout on American health care professionals, review components of this new law, and offer recommendations to further improve the working conditions in US health care organizations.

The US Surgeon General has described burnout among US health care workers as “an occupational syndrome characterized by a high degree of emotional exhaustion and depersonalization (ie, cynicism), and a low sense of personal accomplishment at work.”2 Although the causes of burnout among US physicians are myriad, workplace factors are paramount.3 Surveys administered before the COVID-19 pandemic suggested a rate of burnout of approximately 40% to 50% among US physicians, which has substantial consequences for patients and physicians alike.2,3 The Surgeon General noted that burnout can undermine the relationship between patients and their physicians, lead to staffing shortages, and increase the rate of harmful medical errors.2

Additionally, burnout has been associated with poor physical and mental health among health care workers. The US Surgeon General noted that chronic stress at work has been linked to a variety of adverse mental health outcomes, including anxiety, depression, and substance use disorders. Moreover, US physicians are more likely to die by suicide than their counterparts elsewhere.2 Many physicians eschew mental health treatment, often citing professional stigma and concerns over disclosure to state medical boards (SMBs) as barriers.3,4

Despite the profound mental health consequences of burnout among US physicians, few steps have been taken to address the problem. Some medical centers have established wellness programs that primarily focus on mental health. In so doing, they have tended to shift the burden of maintaining health to individuals, thereby minimizing institutions’ role in fomenting underlying burnout.5 The Accreditation Council for Graduate Medical Education, which accredits US residency training programs, has responded slowly to the challenge. The approval of new resident duty-hour limits in 2002 was driven only in part by concerns over resident well-being.6 Meanwhile, federal efforts have proven sparse. Notably, however, the Biden administration recently awarded $103 million from American Rescue Plan funds to 45 grantees to address burnout and promote mental health in the nation’s health care workforce.

Given this history, the Dr Lorna Breen Health Care Provider Protection Act is groundbreaking. Funded with $135 million over 3 years, the law includes several components to improve the mental health of health care professionals nationwide. First, it requires the Secretary of Health and Human Services (HHS) to establish and share evidence-based strategies to improve mental health and prevent suicides among health care professionals within 2 years. Second, it funds the creation of a national education and awareness initiative to encourage health care professionals to pursue mental health and substance use treatment and to reduce the stigma of doing so. Third, it authorizes the Secretary of HHS to award 3-year grants or contracts to health care entities and training institutions to create new initiatives aimed at improving the mental health of health care professionals. Lastly, the law requires the Secretary of HHS and the US Comptroller General to review the effectiveness of the funded programs and submit reports to Congress within 3 and 4 years, respectively.7

The Dr Lorna Breen Health Care Provider Protection Act is a promising step. As the first dedicated federal effort aimed at improving the mental health of US physicians, the law is an acknowledgment of the need for intervention and will generate considerable public awareness. The new strategies and interventions it funds may ultimately help many US physicians and other clinicians. However, it largely leaves the systemic workplace factors that drive the underlying burnout crisis unaddressed. Thus, a more comprehensive approach will be needed, requiring the cooperation of federal agencies, governing bodies, health insurers, and medical institutions.

First, the culture of health care must fundamentally change. The goal of preventing workforce burnout should become a core mission of every medical institution. As noted by the US Surgeon General, physicians should not be forced to work in unsafe conditions, as they did at the start of the COVID-19 pandemic when personal protective equipment was scarce or unavailable.2,8 Additionally, a dedicated, executive-level position should be created at each organization to focus on fostering an engaged and healthy workforce. Given the link between burnout and educational debt, federal agencies should consider offering debt relief to the most burdened physicians.9

Second, excessive physician workloads must be addressed by reducing their time spent on administrative tasks, a key driver of physician burnout. The burden of documentation in electronic medical records should be reduced.8 Expectations that physicians spend substantial time at home on work-related tasks outside of regular working hours should be eliminated. The Accreditation Council for Graduate Medical Education should ensure that residency programs are adhering to existing duty hour regulations and consider further work hour restrictions if needed to protect resident physicians.

Third, physicians who need mental health or substance use treatment must be encouraged to seek it without incurring adverse consequences. Many physicians who do not pursue mental health treatment cite concerns over disclosure to SMBs, which could potentially affect licensure.3,4 Although the Federation of State Medical Boards recommended that SMBs limit the scope of their queries about a physician licensure applicant’s mental health and substance use in 2018, most SMBs have not yet adopted its recommendations.10 Moving forward, all SMBs should swiftly adopt the Federation of State Medical Boards’ recommendations. Health care organizations should also ensure that their employees have access to affordable mental health care and provide scheduling flexibility to allow them to seek such care.2

The burnout crisis in American medicine has negatively influenced patient care and the physical and mental health of US physicians. As the first dedicated federal effort aimed at improving the mental health of US physicians, the Dr Lorna Breen Health Care Provider Protection Act is noteworthy. Given the current paucity of effective, evidence-based interventions to address burnout and improve the mental health of US physicians, further research will be required in the future to evaluate the efficacy of the new programs funded by the act. In the interim, health care organizations must prioritize employee well-being, excessive physician workloads must be reduced, and physicians should be encouraged to seek mental health care as needed. Time is of the essence: the lives of physicians, other health care professionals, and patients are at stake.

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Article Information

Published: September 30, 2022. doi:10.1001/jamahealthforum.2022.3349

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Sindhu KK et al. JAMA Health Forum.

Corresponding Author: Kunal K. Sindhu, MD, Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, 1184 Fifth Ave, New York, NY 10029 (kunal.sindhu@mountsinai.org).

Conflict of Interest Disclosures: None reported.

References
1.
Dr. Lorna Breen Heroes’ Foundation. About Lorna. Accessed July 31, 2022. https://drlornabreen.org/about-lorna/
2.
US Surgeon General. Addressing health worker burnout: the US Surgeon General’s Advisory on building a thriving health workforce. Accessed June 10, 2022. https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf
3.
Yates  SW.  Physician stress and burnout.   Am J Med. 2020;133(2):160-164. doi:10.1016/j.amjmed.2019.08.034PubMedGoogle ScholarCrossref
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Adibe  B.  Rethinking wellness in health care amid rising COVID-19–associated emotional distress.   JAMA Health Forum. 2021;2(1):e201570. doi:10.1001/jamahealthforum.2020.1570Google ScholarCrossref
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Arnold-Forster  A, Moses  JD, Schotland  SV.  Obstacles to physicians’ emotional health—lessons from history.   N Engl J Med. 2022;386(1):4-7. doi:10.1056/NEJMp2112095PubMedGoogle ScholarCrossref
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Philibert  I, Friedmann  P, Williams  WT; ACGME Work Group on Resident Duty Hours.  New requirements for resident duty hours.   JAMA. 2002;288(9):1112-1114. doi:10.1001/jama.288.9.1112PubMedGoogle ScholarCrossref
7.
Dr. Lorna Breen Health Care Provider Protection Act, Pub L No. 117-105, 136 Stat 1118 (2022). Accessed April 21, 2022. https://www.congress.gov/117/plaws/publ105/PLAW-117publ105.pdf
8.
Murthy  VH.  Confronting health worker burnout and well-being.   N Engl J Med. Published online July 13, 2022. doi:10.1056/NEJMp2207252PubMedGoogle ScholarCrossref
9.
West  CP, Shanafelt  TD, Kolars  JC.  Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents.   JAMA. 2011;306(9):952-960. doi:10.1001/jama.2011.1247PubMedGoogle ScholarCrossref
10.
Saddawi-Konefka  D, Brown  A, Eisenhart  I, Hicks  K, Barrett  E, Gold  JA.  Consistency between state medical license applications and recommendations regarding physician mental health.   JAMA. 2021;325(19):2017-2018. doi:10.1001/jama.2021.2275PubMedGoogle ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    Another Way of Excluding Providers with Mental Health Conditions and Disabilities
    Nicholas Lawson, M.D., J.D. | Georgetown University Law Center
    The authors report a “rate of burnout of approximately 40% to 50% among US physicians, which has substantial consequences for patients and physicians alike.” They observe that “[t]he Surgeon General noted that burnout can undermine the relationship between patients and their physicians, lead to staffing shortages, and increase the rate of harmful medical errors,” conclude that the “burnout crisis in American medicine has negatively influenced patient care,” and believe that the Dr. Lorna Breen Health Care Provider Protection Act’s (“Act”) solution to the “burnout crisis” is essential because “the lives of physicians, other health care professionals, and patients are at stake.”

    The authors and the Surgeon General are wrong in that empirical research has not found physician “burnout,” let alone mental health conditions or disabilities, to be a meaningful predictor of quality of care or adverse patient events; most studies measuring adverse patient outcomes objectively have not found a statistically significant relationship between burnout and observed adverse patient outcomes (1). To the extent that a “rate of burnout of approximately 40% to 50% among US physicians” indicates increased prevalence of “physical and mental health [conditions] among health care workers,” such as “anxiety, depression, and substance use disorders,” that may be a good thing—if it suggests greater disability diversity among health care workers.

    The provisions of the Act cited by the authors (“requir[ing] the Secretary of Health and Human Services (HHS) to establish and share evidence-based strategies to improve mental health and prevent suicides among health care professionals”; establishing a “national education and awareness initiative to encourage health care professionals to pursue mental health and substance use treatment and to reduce the stigma of doing so”; providing “grants or contracts to health care entities and training institutions to create new initiatives aimed at improving the mental health of health care professionals”) are another way for employers and members of the workplace wellness industry and researchers to perform medical research on employees through HHS, circumvent their legal protections under the Americans with Disabilities Act and the Common Rule, and develop algorithmic screening tools that will further exclude these workers. See generally, Nicholas D. Lawson, Disability Affirmative Action Requirements for the U.S. HHS and Academic Medical Centers, 52 Hastings Ctr. Rep. 21, 24-25 (2022).

    It is important to note that 0.47% of the HHS workforce identifies as having a significant psychiatric disorder, only 2.65% of the Substance Abuse and Mental Health Services Administration so identifies, id. at 22, the Surgeon General does not identify as such, and there is little reason to trust that such an initiative on the part of HHS will be carried out in a way that will benefit those who are targeted.

    Reference

    1. Mangory, K.Y., Ali, L.Y., Rø, K.I. et al. Effect of burnout among physicians on observed adverse patient outcomes: a literature review. BMC Health Serv Res. 21, 369 (2021). https://doi.org/10.1186/s12913-021-06371-x

    CONFLICT OF INTEREST: None Reported
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