Open Letter to Senate HELP Committee
Bernard Sanders, Chair
Bill Cassidy, MD, Ranking Member
Senate HELP Committee
Washington DC 20510-6300
March 17, 2023
Dear Senators Sanders and Cassidy and other members of the HELP Committee –
As you know, the American Association of Medical Colleges (AAMC) 2021 published data includes estimates of a physician shortage (37,800-124,000) and a surgeon shortage (15,800-30,200)7 in the United States (U.S.) by 2034. With growing numbers of medical schools and training programs in the U.S., we must ask ourselves: why is there an impending workforce shortage? Rather than just turn towards increasing medical schools and training programs, we urge the Senate to consider the retention of physicians in training and practice.
We write this invited response to your March 2nd, 2023 letter as stakeholders and Physician Just Equity (PJE), a collective of 40 physician and surgeons who have organized to support colleagues suffering from workplace injustices, that have either disrupted or prematurely ended their careers. Physician Just Equity (PJE) is a 501(c)3 organization founded in October 2020 with the pillars of support, advocacy, education, and research. Workplace injustices, are being defined as gaslighting, harassment, discrimination, and/or retaliation in the medical workplace and are commonly experienced in aggregate by those Under-Represented in Medicine (URiM) and/or by whistleblowers.5
Being the target of workplace injustice leaves clinicians at very high risk of attrition from the workforce, and this attrition is usually not the result of PTSD from experiencing these harms but rather from workplace traumatic stress, unethical, corrupt and often illegal actions (but sanctioned under HCQIA) executed by the leadership of Academic Medical Centers, health systems, hospitals and/or medical groups resulting in restraint of trade/practice – now being referred to as the Corporate Medical Playbook.14
In response to this epidemic of attrition,8,9,15,19,20, PJE implemented an innovative individualized and independent peer-support service for colleagues experiencing Workplace injustice to help mitigate the harms, by Championing a Balanced Resolution to conflict in the workplace. This support service commenced in February 2021 and was established in response to the 6th of 15 recommendations outlined in the 2018 NASEM report on the Sexual Harassment of Women, Climate, Culture and Consequences in Academic Sciences, Engineering, and Medicine.15 After 24 months providing peer-support and more than 75 cases, our knowledge about the causes, demographics, processes, and outcomes of Workplace injustice has informed the basis of this letter. Workplace injustices exist as a driver of attrition and hence contribute to the tragic and unacceptable loss of diverse talent from the U.S. healthcare workforce and will exacerbate the projected workforce shortage.
The 6th recommendation in the National Academies Of Sciences, Engineering, and Medicine (NASEM) report15 is Support for the Target because it has been proven that academic medical centers are failing to support reporters of Workplace injustice by making them the targets of retaliation (e.g. OHSU Covington Report7). Our pilot study entitled Peer Support Helps Physicians Navigate Workplace Conflict was just published online in the Journal of General Internal Medicine2 and captures a snapshot of experiences by targets of Workplace injustice. Retaliation was disclosed by 78% of our pilot study participants and is prevalent in the literature in the setting of reporting unlawful behavior. The current lack of accountability (aided by the lawful use of non-disclosure agreementss) allows these behaviors to continue with impunity. Much like Lloyd Austin has ordered an Independent Review Commission to take bold action to address sexual assault and harassment in the military by taking prosecution out of the hands of commanders10 the U.S. Senate must order that investigation of Workplace injustice be conducted by an independent body. Healthcare institutions have proven time and again that they are not capable of fairly policing themselves nor embracing restorative justice principles to facilitate healing, reduce long term harm, and promote the retention of valued clinicians in the workforce.
The failure of ethical and lawful governance over undergraduate medical education, graduate medical education, and medical staff disciplinary processes undermines the integrity and just practices within the medical profession, moral leadership, and our calling to do no harm. Talented, ethical physicians and surgeons are unduly harmed by the weaponization of processes that were originally designed to protect patients. This harm is legally sanctioned as healthcare entities are afforded significant protections under the Health Care Quality Improvement Act of 1986 (HCQIA).19 These unchecked institutional practices include physician improvement plans (PIPs), physician health programs (PHPs), sham peer review, and reporting to the national practitioner data bank. Subjecting competent ethical medical professionals to these punitive retaliatory processes for reporting and/or speaking up against an injustice leads to moral injury, mental anguish, burn out, and in too many cases, death by suicide.
The lack of safety in reporting Workplace injustice, the absence of due process rights, and the failure to hold perpetrators of injustices and those complicit in injustice accountable for their actions is a significant driver of attrition and will prevent intelligent learners and talented clinicians from choosing and staying engaged in a medical career respectively. The opportunity and financial cost of failing to intervene and protect diverse clinicians is insurmountable and would be tragic especially in the context of a workforce shortage.
Although only 5% of practicing clinicians identify as Black or African American1, justifying the use of the phrase URiM (U.S. population 14%)16 the pervasive occurrence of constructive discharges, dismissals/terminations, reputational harm, and being “Black Balled” from the profession, is a driver of attrition at the learner and attending level that cannot be ignored and therefore is addressed specifically in this letter about workforce shortage. Links to a number of the cases that have made it into the media are included in Appendix 1. Apart from racial discrimination impacting the workforce shortage, the U.S. will never realize healthcare equity and racial justice without supporting the URiM.
A short list of potential solutions are suggested below:
1) Revision of HCQIA to prevent the abusive use of immunity clauses that harm and sometimes end the careers of talented clinicians through the use of sham peer review process
2) Legislation that offers protection to clinicians from the abuse of power wielded by leadership within Academic medical centers and Healthcare Systems.
3) Additional protection under the 2022 Lorna Breen Healthcare Provider Protection Act to support and protect providers from harm at the hands of hospital and medical group administration and Medical Licensing Board who “punish” learners and practicing clinicians who seek mental health support.
4) An external independent agency resource comprised of peers educated and skilled in conflict resolution to review all cases of peer review as a result of known bias and discrimination that leads to sham peer review, referral to Physician Health Programs sanctions by Medical Licensing Boards and reporting to the national physician data bank
5) Mandate that the national physician data bank no longer enter subjects into the database until a period of appeal that employs independent vetting of a reporting entities claims of unprofessionalism
6) Mandate that the national physician data bank maintain demographic data that reflects protected class identities to track the breakdown and proportion of subjects who are URiM and claim protected class identities
7) Independently fund and staff external support programs that provide help to the targets of workplace injustice
8) Legally mandate healthcare institutions complete public national score cards that reflect their annual success at promotion, retention, and metrics of physician well-being and satisfaction with their workplace environment, culture, and leadership
9) Require reporting of annual promotion and graduation of every CMS funded trainee to track progression and entrance into the workforce
10) Mandate that WI’s that result in an adverse action as defined by the clinician be investigated by an independent body
11) Eliminate termination without cause, non-compete, and non-disclosure agreement clauses in clinician employment and separation contract and separation agreements respectively
We welcome the opportunity to meet with and work with Congress, or it’s designee, to facilitate this joint venture of resolving and ameliorating the anticipated health care shortage.
Pringl Miller MD, FACS Kellie Lease Stecher, MD
Sandra B. Cadichon MD, MMI, FAAP Melissa Blaker, DO
Deborah Verran MBChB Karuna Dewan, MD FACS
Ursula Barghouth DO, MHA, MSPH, CWSP Michael Sinha, MD, JD, MPH, FCLM
Karyn L. Butler MD, FACS, FCCM Roberta E Gebhard D.O
Carmen E. Quatman, MD, PhD, FAAOS Arianna L Gianakos DO
Erin King-Mullins, MD, FACS, FASCRS
Brianna Clark DO, MPH, CNPM,CLC
Sudeep Taksali, MD, FAAOS
Micheline Goulart, MD
Physician Just Equity
Email: firstname.lastname@example.org and email@example.com