Megan Coder, Pharm.D., M.B.A., discusses the next steps for digital therapeutics to have a permanent place in the health landscape.

Making Digital Therapeutics Last

Our popular podcast, Data Book, features a discussion on bringing EHRs to surgery centers.

Making Tech Ambulatory 

An Interview with Dean Augustine Choi of Weill Cornell Medicine by Associate Editor Samara Rosenfeld.

Talking Diversity in Academic Medicine

 shows a substantial number of a health system’s 

 experienced major stress and work disruptions due to the COVID-19 pandemic.

Previous research shows that as U.S. workers transitioned to remote work in March 2020, many were required to provide childcare and schoolwork assistance for children. “Employed women, in particular, were likely to face greater burdens because they spend 22% more time on unpaid household and care work compared with their male counterparts, with Black or African American and Latina mothers spending nearly twice as much time as men on unpaid housework,” authors wrote.

Women also account for the majority of hospital employees and make up an important cohort of essential clinical workers. In addition, employees and trainees who must present to work or training in person can face new childcare expenses. These life changes have prompted concern for their impact on careers and well-being on faculty, staff, and trainees.

To better understand the associations of the pandemic with career development and subsequent work culture and childcare needs of employees and trainees, researchers conducted a survey study between Aug. 5 and 20, 2020 at the University of Utah Health.

A total of 27,700 faculty, staff, and trainees received a Qualtrics survey via email as part of a quality improvement initiative at the academic medical center, while 5,030 participants anonymously completed the entire survey. Although the survey was mostly quantitative, it did include several open-ended questions.

Mean participant age was 40 years. Despite more women completing the survey than men (75%), “the proportion is similar to that of women within the health system,” researchers wrote. The majority of respondents were also White or European American (86%) while 11% were Latino or Latina, Black or African American, American Indian, Alaska Native and Native Hawaiian or Pacific Islander and 6% were Asian or Asian American.

Around one-half of the sample reported working in a clinical setting and having at least one child aged 18 or younger. Sixty-six percent of those surveyed were staff, 16% were faculty and 13% were trainees.

Nearly one-half of parents reported that parenting (1,148 participants [49%]) and managing virtual education for children (1,171 participants [50%]) were stressors

Across all participants, 1,061 (21%) considered leaving the workforce, and 1,505 (30%) considered reducing hours

Participants who were younger, married, a member of an underrepresented racial/ethnic group, and worked in a clinical setting reported greater consideration for leaving the workforce

449 faculty (55%) and 397 trainees (60%) perceived decreased productivity, and 2,334 participants (47%) were worried about COVID-19 impacting their career development, with 421 trainees (64%) being highly concerned

Of 2,412 participants with children aged 18 years or younger, 1,589 (66%) reported that they did not have childcare fully available, and 783 of 2,747 (33%) reported being comfortable taking their child to school or a childcare facility

As the interaction between gender and having dependent child(ren) was significantly associated with consideration for leaving the workforce and reducing hours, results indicate the association between parenthood and career outcomes varies for mothers and fathers.

Furthermore, 1,932 of 2,456 participants (81%) reported “finding it somewhat or extremely difficult to balance childcare and work responsibilities.”

Helpful strategies listed for managing home and work-balance included the continued opportunity to work from home, flexibility in scheduling, and a better understanding of work-life struggles by the person to whom employees report.

Findings may not be generalizable to wider populations as they only represent respondents at one institution, while selection bias may have played a tole with regard to employees who chose to complete the survey, marking limitations to the study.

“Health systems must develop effective strategies to ensure that the workplace acknowledges and supports employees during this unprecedented time, not only within the work environment, but also in managing unanticipated childcare responsibilities due to lack of childcare or in-person school,” researchers concluded. “In doing so, health systems will improve the likelihood of retaining generations of well-trained clinicians, scientists, and staff.”

Articles

Survey responses illustrate the impact COVID-19 has had on health system employees, including considerations of leaving the workforce and concerns about childcare. 

Survey Highlights Pandemic’s Toll on Health System Employees’ Career Development, Childcare Needs 

More than 82 million people in the United States currently live in Health Professional Shortage Areas (HPSA)according to the 

Health Resources & Services Administration’s

 first quarter 2021 summary“Designated Health Professionals Shortage Areas Statistics.”

HPSA is calculated as the ratio between health providers and a particular area’s population. Classifications include geographic location, population served and available services. That puts roughly 25% of the U.S. population in regions without sufficient primary care, dental and mental healthcare providers. 

As a first world country known for access to top-rate medical services, how does the United States find itself with a quarter of the population experiencing distinct dislocation of critical care services? According to the University of Southern California’s 

, four critical factors come into play as to whether an area will likelyexperience a healthcare worker shortage:

 As the baby boomer population ages, this group is developing chronic health conditions, causing anincrease in their health care needs. The Health and Aging Policy Fellows estimatesthat by2030, the youngest baby boomers will have reached age 65, which will equate to 71 million people and 1 in 5 Americans. This increasing number of older patients in addition to the American Association of Medical College (AAMC) 

 that over one-third of practicing physicianswill also be 65 or older by 2027, results in an increasing number of aging Americans while the number of available physicians decreases.

A large aging and retiring heathcare workforce.

 The number of physicians meeting retirement eligibility is detailed in a study reporting that in 2016, 42% of physicians were aged 55 years old, meaning close to half of all U.S. physicians are in the at-risk demographic for COVID-19, a concern that has some doctors choosing to leave their professions or retire early rather than place their physical and financial health at risk. A survey by the California Medical Association revealed that currently 87% of doctors are financially concerned about their practices, despite eight of 10 offices having switched to telehealth options to accommodate patients in the midst of the COVID-19 pandemic. In addition, some offices have had to curtail staff due to a one-third drop in in-office visits. Other practices are facing revenue losses reaching 50%, while specialties have been especially hard hit by the repercussions of the pandemic, with some seeing losses reaching nearly 40%.

The rising incidence of chronic diseases.

 suffer from a chronic disease, and four in 10 are battling two or more chronic diseases, the most common of which are heart disease, chronic lung disease, cancer and diabetes. Because the likelihood of acquiring a chronic disease increases with age, meeting the needs of the baby boomer population will prove daunting to the healthcare industry and especially those living in HPSAs. AAMC CEO and President Darrell G. Kirch, MD, finds “the projected shortage is especially troubling, since as patients get older they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe.”

 Magnifying the previous three factors is a report by the 

American Association of Colleges ofNursing

 (AACN) that found, in 2019, nursing schools in the United States were forced to deny admission to 80,407 skilled applicants due to a lack of clinical and classroom space, restrictive budgets and the most common reason--faculty shortages. Further complicating thissituation is a report by 

that contends one-third of nurses will retire in roughly thenext decade, a figure that may increase more rapidly due to COVID-19 burnout.

Currently, several organizations are taking action to alleviate these anticipated shortages takingplace in HPSAs, and indeed, across the healthcare industry. Under the U.S. Department of Health and Human Services, the Health Resources and Services Administration (HRSA) assistswith matching healthcare professionals to jobs in HPSAs, which helps first-rate carefor people living in isolated areas who are financially burdened or medically at risk. Managedby HRSA, the Bureau of Health Workforce provides these healthcare workers, many of whom are nurses, with loan forgiveness, scholarships,and access to training and grants.

Other organizations providing HPSAs with quality healthcare include the following:

1. The National Health Service Corp (NHSC) focuses on increasing the number of healthcareworkers in HPSAs. It offers scholarships to nursing and other healthcare students and loan repayment for licensedhealthcare providers, including those in behavioral health, for a two-year commitment to work in an approved facility located in HPSAs that meet the needs of underserved populations.

2. Love Volunteers matches registered nurses and nursing student volunteers with one of33 medical internship programs based on their interests, skills and experience,including in substance use rehabilitation and public health services.

3. AgriSafe Network offers a nursing program for healthcare workers interested in servingagricultural workers. The AgriSafe Nurse Scholar program offers training in a niche specialty, focusing on treatment and prevention specific to those involved in agricultural work.

In May 2019, the American Medical Association named its first Chief Health Equity Officer to lead a task force focused on addressing practices, processes and innovation forHPSAs.

Technologies Including Telehealth Bridge the Gap

The recent COVID-19 pandemicthrust patients and providers into the already burgeoning prospect of remote solutions for limited healthcare access (patients struggling with distance and transportation issues as well as socio-economic variances that make them unable to access other health care options.)

In 2020, state legislatures worked to loosen the outdated and stringent regulations that limitreimbursement for telehealth visits. Because it is delivered quickly and easily, telehealth has become popular with people of all ages, notably for the convenience in obtaining appointments, the efficiency of the zero-commute and the comfort of meeting from home. A study from the

found that in a poll of 2,052 adults aged 20 and older, only15% were using telehealth for behavioral health when the pandemic began, but this percentage rose to 53.6% by May 2020. And ithas been working well. In a National Poll on Healthy Aging, 72% of2,074 participants aged 50 to 80 showed interest in follow-up telehealthappointments with their providers.

Virtual medical visits are not feasible for all physical tests (like lab draws and cardiacstress tests), but for behavioral health, the security, affordability and convenience of “zooming in” might be just what the doctor ordered. And it certainly eases the strain in areas with health professional shortages, making timely and quality intervention a possibility in remote areas and with aging populations.

Health Professional Shortage Areas present a complex logistic issue requiring a multifaceted solution; therefore, healthcare professionals continue to piece together permanent answers to the increasing demand for equitable healthcare services.

Loraine Daugherty is chief executive officer at Integrated Medical Case Solutions (IMCS) Group, soon to be Ascellus Behavioral Health, where she provides analytical decision-making, strategic planning and executive leadership. IMCS – Integrated Medical Case Solutions – is the leading provider of work-related trauma prevention and treatment with a proven track record of transforming workers’ compensation cases with notable success in early return-to-work outcomes.

As a first world country known for access to top-rate medical services, how does the United States find itself with a quarter of the population experiencing distinct dislocation of critical care services?

Can Health Professional Shortage Areas Be Alleviated Through Telehealth?

Mary Caffrey is the Associate Editorial Director of AJMC/Managed Care for MJH Life Sciences. Her editorial responsibilities include 

As more people get vaccinated, pent-up demand for travel and commerce has increased--and more governments are discussing the idea of asking workers or travelers to obtain a pass that would signal who is unlikely to spread COVID-19.

Known by different names around the globe—from vaccine passports, or green passes, to New York State’s “Excelsior Pass,” –or by commercial names such as 

—the various digital certificates confirm vaccination and negative SARS-CoV-2 test status through “confidential data transfers,” according 

 that discussed the ethics and practicality of digital health passes.

“Digital health passes offer health and economic benefits until herd immunity is achieved,” write Lawrence Gostin, JD; Glenn Cohen, JD; and Jana Shaw, MD, MPH; who argue that besides offering benefits to the people who get them, the presence of a digital health pass can encourage people to get vaccinated if they otherwise would balk, whether they need the electronic document for work, travel, or both.

There are some practical challenges to such a system. It is unclear yet how long immunity lasts after getting vaccinated or contracting COVID-19, although the authors write this will become clear as the original participants from the clinical trials for the Pfizer-BioNTech, Janssen, and Moderna vaccines are followed, along with results seen in real-world studies.

Technical challenges must be overcome, including the need to ensure authentication; and in the United States, there are jurisdictional issues because state are the primary health regulators, although President Biden would regulate their use at international airports.

Constitutional questions may arise. “While the Supreme Court grants WPINT

public health agencies wide discretion, it is more protective of First Amendment freedoms, including religion, speech, and assembly,” the authors wrote, noting that the court has already struck down restrictions applied to houses of worship.

The authors note that employers have the right to require COVID-19 vaccines to return to work to ensure that employees do “not pose a direct threat to health or safety,” and employers could use passes as proof of vaccination; this would not violate the Americans with Disabilities Act or the Genetic Information Nondiscrimination Act. Providing proof of vaccination would be unlikely to violation privacy laws, including HIPAA, as they do not share any other information.

However, civil rights laws must be followed, and reasonable accommodations would need to be made for those with health conditions or those who hold a “sincere religious

Governments and employers, the authors say, must address the historic lack of trust among minority groups toward the health system that might prevent them from getting vaccinated. Also, richer countries signed advance agreements with vaccine manufacturers, and thus may have more early supplies than poor countries, which could contribute to global inequity.

High-income countries could help ameliorate inequities through funding and donating vaccine doses,” to central global distribution hubs, while building manufacturing capacity in low- and middle-income countries, they write.

Success of a global digital health pass program requires equitable administration, the authors say, “ensuring that everyone has a fair chance to return to a normal life.”

Known by different names around the globe, from vaccine passports or green passes, various digital certificates confirm vaccination and negative SARS-CoV-2 test status through “confidential data transfers."

Digital Health Passes: Useful, if Equitable, JAMA Authors Say

In March, Illinois Governor JB Pritzker (D) has 

 an equity-driven health care and hospital 

 plan into law, which aims to increase access to community-based health services and create innovative collaborations through investments in underserved communities.

The state will initially invest $150 million into collaboratives to fill health care gaps and focus on underlying conditions in these areas. Funds will be matched by the federal government.

Data show the nation’s most vulnerable residents have consistently borne the brunt of the COVID-19 pandemic and highlight the myriad of imminent health challenges facing these populations.

Under the bipartisan law, investments will be directed to areas ranked high on the CDC’s 

 (SVI)—a system consisting of 15 U.S. census variables grouped into four themes, including socioeconomic status, household composition, race/ethnicity/language, and housing/transportation. Communities disproportionately affected by the COVID-19 pandemic and areas served by critical access and safety net hospitals, including rural parts of Illinois, will also receive funding.

“Inequities in the health care system existed long before the COVID-19 pandemic, and if we don't take action now, they will exist after the pandemic too. Our responsibility now is to expand accessible and equitable health systems all across Illinois and there's no time to waste,” Gov. Pritzker 

All entities looking to receive funding in the first round must submit a 

 by April 9. Those not ready to submit proposals or who need assistance can access support services through the Illinois Department of Healthcare and Family Services (HFS) and can apply for future rounds of funding, with the second round scheduled for later this year. Funding is also available to entities eligible to bill the state’s Medicaid program.

According to HFS, the plan consists of 4 key components:

​Focus on community needs, for all levels of health care, with an emphasis on addressing social and structural determinants of health.

Improve health and wellness for individuals and communities.

Tailor solutions to meet the unique needs of individual communities.

Invest in projects, large and small, that improve outcomes, decrease disparities, and are sustainable over time.

“This [law] creates an opportunity for communities across the state to come up with health care solutions that reduce disparities, are community focused and remove obstacles that exist to accessing quality care," said House Majority Leader Greg Harris (D-Chicago). "If we've learned anything from the pandemic, it's that we need to prioritize a health care system that reaches all Illinoisans, and these collaboratives will work to do just that."

Community focus groups, conducted as part of research and development, revealed residents in the state’s vulnerable communities wish to have more of a voice in creating solutions to meet their unique needs. Taking this into account, the bill requires providers consider barriers residents have faced when seeking quality care. All partnerships will also be evaluated through a racial equity lens before funds are awarded.

Applications, reports, outcomes and best practices learned will be posted on the HFS website, while the law also stipulates the creation of a working group to help guide safety net hospital designations and racial equity factors.

The legislation “encourages the design of better, more collaborative care and creates a pathway to better health outcomes in distressed communities across Illinois, particularly in communities of color most impacted by the COVID-19 pandemic," said HFS Director Theresa Eagleson.

“Improving access to quality health care and creating better outcomes is at the heart of this legislation. I'm eager to see what these collaboratives create and the solutions they find to get to better health outcomes for communities across Illinois,” said Sen. Ann Gillespie (D-Arlington Heights).

A new bipartisan law signed by Illinois' governor aims to tackle health disparities seen in the state's most vulnerable populations. 

Illinois Law Invests $150 Million to Tackle Health Care Disparities 

Nearly two-thirds of the nation’s healthcare workers say worry or stress has had a major impact on their lives, according 

 that finds most are experiencing disrupted sleep, nearly a third having headaches or stomach problems and 16% admitting to heavy use of alcohol or drugs. Only 13% are getting mental health care, however, and another 18% say they might need services but did not get them.

The KFF/Washington Post Frontline Health Care Workers Survey, released today, is based on interviews with 1,327 frontline healthcare workers form hospitals, doctors’ offices, outpatient clinics, nursing homes, and assisted care facilities. The survey includes a comparison survey of 971 adults who do not work in healthcare. The survey took place from February 15 to March 11, 2021.

A year after COVID-19 began overwhelming the US hospitals, and four months after the first vaccine received FDA’s blessing to be administered in the United States, some healthcare workers see an end in sight. But with less than half of the workers having been vaccinated and some suffering long-term effects from the stress of the past year, it’s clear from the survey results that the effects of the pandemic will be with health workers for months or years to come.

The survey captured statements from workers that describe life during the pandemic, and reveal the nature of the day-to-day stress. One 33-year-old woman who handles patient treatment and diagnosis in Missouri said:

“The extra steps needed when I come home from working with COVID patients. [I] have to undress in the garage and straight to the shower. Sometimes making my son sleep overnight at his grandmas when I have seen COVID patients that day.”

Young workers, those aged 18-29, appear to be hardest hit by the pandemic. The survey found:

Three-fourths of younger frontline healthcare workers report worry or stress related to COVID-19 has had a negative impact on their mental health.

Seven in 10 of the youngest workers say they feel “burned out” about work.

45% report assisting with patient care such as bathing, cleaning, and housekeeping

13% of the youngest frontline health care workers say they had at least 10 patients in their direct care who died as a result of COVID-19.

More than half of the workers (56%) say their hospital or workplace has been over capacity at some point of intensive care unit (ICU) beds, and 34% of workers at hospitals and nursing homes said that at some point during the pandemic, their workplace ran out of personal protective equipment. While most said their employer is “doing the right amount” or “going beyond” in providing leave to employees who have COVID-19 or getting workers vaccinated, the survey also reveals that setting matters: A majority who work in patients’ homes (56%) say their employer is “falling short” in providing extra pay for workers who are in high-risk situations.

More than half (61%,) said that most Americans are not taking enough precautions to prevent the spread of COVID-19. Sentiments were higher among Black health care workers, and younger health care workers ages 18-29.

6 in 10 frontline workers say they anticipate the pandemic to be controlled in the United States by 2022 to resume a normal life

47% say a normal life may come by mid-fall or sooner

With less than half of the workers having been vaccinated and some suffering long-term effects from the stress of the past year, it’s clear from the survey results that the effects of the pandemic will be with health workers for months or years to come.

Pandemic Exacts Huge Toll on Healthcare Workers, Survey Finds

A nonprofit created by the Mississippi Hospital Association and other advocacy groups has filed paperwork with the hope that voters in this poor state will do what the legislature has not: expand Medicaid and bring healthcare to an estimated 200,000 working-class, low-income residents.

Mississippi is among the 12 states that has not expanded Medicaid, and the hospital group is among those hoping to leverage the $1 billion a year in federal funds that the Biden administration is offering to get more people covered, having sweetened the pot to get holdout states on board.

The American Rescue Plan Act, which President Joe Biden signed into law last month, calls for federal government to pitch in an extra 5% of costs for new expansion states.

“Hospitals and our working poor across the state of Mississippi cannot keep waiting,” MHA President Tim Moore told the news outlet 

 on Monday. “There’s all the federal money we are leaving in D.C., our taxpayer dollars that we need to bring back to help our citizens. We do that with everything else, accept federal help, but for some reason not with this. It’s time to let the Mississippi voters decide.”

 for Medicaid expansion in other Republican-leaning states, including Nebraska and Oklahoma.

In Mississippi and elsewhere, hospital groups are front and center in efforts to expand Medicaid. Failure to adopt expansion is both hard on poor patients and precarious for hospital finances due to the way federal funding flows to hospitals since the passage of the Affordable Care Act. The law envisioned direct aid being replaced by payments from coverage for individual patients, who would seek preventive care instead of showing up in the emergency room. 

But when states went to court and won the right to avoid expansion, hospital finances in many poor states were turned upside down, and many rural areas have lost hospitals.

In Missouri, where voters approved a constitutional amendment to adopt expansion, the legislature 

 for coverage that is scheduled to begin July 1, 2021.

In Missouri, single adults cannot receive Medicaid coverage at all, and parents cannot make more than 21% of the federal poverty level, or $5,400 in 2021 for a family of three. But an amendment approved last year was scheduled to take effect and extend healthcare to single adults who made less than $17,770.

That didn’t sit well with Rep. Cody Smith, the Republican chair of the House budget committee, who set money for Medicaid expansion aside into a separate bill, calling Medicaid expansion “wrong for Missouri,” despite the new commitments for the federal government to cover 90% of costs for those covered under expansion.

Smith said, “the federal government has no money — there is only taxpayer dollars. They are federal-deficit-spending at a rate that is unprecedented at this point.”

Another Republican, Rep. Justin Hill said, “Even though my constituents voted for this lie, I am going to protect them from this lie.”

Should the legislature fail to fund expansion in the face of a voter-approved constitutional amendment, court challenges are a certainty, Missouri’s Republican Gov. Mike Parson has said. He included expansion in his proposed budget.

Meanwhile, Mississippi Gov. Tate Reeves remains steadfastly opposed to expansion. Last week, the state legislature could not even 

 for a limited proposal to extend Medicaid for a full year for new mothers after giving birth, despite the state’s high infant and maternal mortality rate.

The Twists and Turns of Taking Medicaid Expansion to the Voters

Use of big data is allowing researchers to better understand a nurse’s risks for a near miss (NM) based on workload variables. A NM is an event that could have caused harm for the patient but ultimately did not, either because it was caught or simply through chance. NMs are similar to medication errors.

“NMs also occur as the result of the same systemic, organizational, and personal problems that cause errors, but occur more frequently, with estimates of NMs occurring 300 times more frequently than full-fledged errors,” the researchers wrote.

They conducted a literature review on past studies to understand the factors that increase medication administration errors and NMs. There were six workload factors commonly found across in-patient clinical hospital settings:

A the medical-surgical unit of a private, medium-sized hospital participated in the study. The nursing staff was observed across shifts and times throughout the day. Data on gender, employment status, and each of the six workload factors was pulled from electronic health records, call lights, and bar-code medication administration (BCMA) systems. The data was collected over a 60-day period.

Over the study period, data was collected on the workload of 23 nurses caring for 389 patients. There were 11,595 tasks were assigned and 26,150 medications ordered. However, the study only included oral medications, which dropped the number of medications to 18,104. Tasks that could be completed by nurse assistants were also removed, dropping the number of tasks reviewed 6,605.

The data was reviewed for two-hour time periods since medications were typically not ordered more frequently than that. The majority of the nurses were female (87%) and they accounted for 88% of the two-hour blocks worked and 86% of the blocks with NMs. The three male nurses accounted for 12% of the blocks worked and 14% of the blocks with NMs.

The authors noted that while such gender disparity is common in the nursing workforce, there was no significant association between gender and NMs, nor was there a significant association between the full-time nurses (3 males and 15 females) and part-time nurses (5 females).

In total, there were 1,174 NMs associated with the oral medications flagged by the BCMA database. The majority (91%) of the NMs were of scanning the wrong dose-time-medication and the remaining NMs were flagged as the wrong patient.

Over the 60 days, the majority (78%) of two-hour time periods “were devoid of any NM,” the authors noted. Of the periods with at least 1 NM, 60% had only one NM, 27% had two NMs, 6% had three NMs, and 7% had four or more NMs.

Regarding the 6 workload factors, the researchers found considerable variation among the two-hour blocks. There was no significant correlation among the independent variables. A comparison of the workload factors among the nurses showed significant differences for each factor “indicating considerable variation in factors recorded from nurse to nurse.”

According to the researchers, the findings suggest the risk for an NM is impacted by a combination of variables, which means systemic and organizational changes that impact only a few factors would have only a moderate impact in reducing NMs. Instead, interventions to reduce NMs must be customized to each nurse’s risk profile.

They added that data on nurse workloads is already being gathered at hospitals and can be used to identify the risk for NMs.

“It is time that researchers and managers harness this vast amount of data and use it to improve the quality of care nurses are providing,” the authors concluded. “This can be done successfully if the data that are currently fragmented and locked away inside different clinical systems can be brought together and used to improve patient care.”

Interventions to address and prevent near miss events must be customized to a nurse's individual risk profile.

Big Data Can Identify Risks for Near Misses Among Nurses

. Thomas Van Gilder, MD, JD, MPH, will step down from his role as Walmart’s first chief medical officer on May 15, the 

 also reported that Roshan Parikh, DDS, the head of dentistry, has also left the company. The pair were involved in plans for Walmart Health, a vehicle for opening clinics within the stores that offered primary care, optometry services, dental care, and counseling. The pandemic upended Walmart’s plans, and 22 clinics have opened thus far, fewer than the pace of 30 to 50 that were set to be open by 2021. Walmart has declined comment in news reports, which were based on memos released to health team employees this week.

After 13 years,Will Ferniany, PhD, will retire as chief executive officer of University of Alabama-Birmingham Health Systemat the end of 2021, according to an announcement made Thursday. Ferniany is also CEO of the new UAB/Ascension St. Vincent’s Alliance, overseeing a $5 billion, 11-hospital system. He served in an earlier stint at UAB from 1988 to 1992, as CEO of UAB Psychiatric Hospital and in strategic planning and market development of UAB Health. During his tenure as CEO, the health system has grown from five hospitals to 11, and revenue has more than doubled from $2.3 billion to $5.8 billion. He created an Office of Patient Experience and Engagement to measure, support and enable improvements across the organization, which led to steady annual improvements in patient satisfaction measures across UAB’s ambulatory clinics. In 2020, UAB Hospital was named a Consumer Loyalty Best in Class Hospital by NRC Health, placing the hospital in the national top 10 for patient experience and brand loyalty for the second consecutive year.

Departures at Walmart signal setbacks in plans for in-store clinics.

MED MOVES: Walmart CMO to Step Down; Had Role in Clinics

Serving as a combat physician in Iraq, where for 15 months I treated seriously injured soldiers while sometimes under enemy fire, proved an ideal laboratory to effectively demonstrate leadership under extreme stress.

Stress is a natural bodily reaction; it evolved to help us survive and thrive in trying—and even dangerous—circumstances. We can’t avoid stress, but we can decide how we handle it, which has everything to do with the mindset that creates the stress response.

When I was stateside working as an emergency physician, I was accustomed to hospitals having all the supplies I needed, including bags of blood for transfusions and an atmosphere where doctors could break the tension with cheesy jokes and light banter. But in combat, I was the 

I functioned like an ambulance on the scene, doing raids with the soldiers, where my practice theater included a military vehicle taking me into the action and my limited supplies stuffed into my backpack, not neatly stacked on shelves. Not just 

 the hospital. At other times, the action came to me—helicopters brought me bleeding patients who had undergone amputations and teetered between life and death.

To do my job well, I had to adopt an entirely different perspective than what I was used to back home. When you’re thrown into a difficult situation—one that’s foreign to your previous experience—you have to see things through a different lens.

That’s what’s necessary in civilian life too, when people have unexpected stress grenades explode in their own worlds. A critical leadership lesson I learned in Iraq, is that being on the frontline lets you stop the bleeding quickly. Since 80% of the preventable combat deaths are caused by bleeding out, tying tourniquets on these soldiers at the first opportunity made all the difference.

The same thing applies in healthcare, for those in the trenches treating people seriously ill with COVID-19 and for those in customer-facing positions processing COVID-related claims. Each is a frontline position requiring a different perspective, and it’s imperative that the C-level executives understand those separate perspectives.

The most critical error that leaders make is losing touch with their front line, those who deal directly with patients and their families. If your C-suite can understand the problems, challenges, and needs of the folks on both sides of the front line—the employees and the customers they serve—then your organization can deliver outstanding customer service. But many leaders can’t, or don’t want to adopt or understand those perspectives. The most common problem seen in this regard is the disconnect between the leadership perspective and the frontline realities—and that can make leaders lose their edge.

This lesson goes to the heart of your value proposition too. Everybody who can do a Google search, including every patient, becomes an expert and questions what you’re doing. They’re like the category of patients we call “verticals,” the ones who walk into the emergency room under their own power instead of being borne in on stretchers. They’re the ones who fill out the patient satisfaction surveys. In effect, everybody looking at your work and your industry with a critical eye is a vertical.

Talk about stress! The way to convince these people of your worth is to see and appreciate their perspective, as people whom you serve and as making decisions that impact their lives on what 

Leadership that passes the stress test successfully deals with what is commonly known as the pain-in-the-ass (PITA) factor. This has a combat corollary, too. We used to set up free clinics in Iraqi villages where people would come to us seeking treatment for chronic ailments; however, not everybody in those villages welcomed us.

Some of those patients came in on stretchers. One day, one of those patients started fighting with one of our medics. At first I was confused about what was happening, until another medic yelled “He’s got a grenade!” Five of us immediately tackled the guy—one taking the head, the others each arm and leg. But when we pinned him to the ground, we couldn’t find any grenade —because he had shoved it up his rectum.

All five of us cared enough to spring into action, despite the danger, and all of us assumed our separate roles. Because of this, the bomb didn’t go off and I’m alive today to tell you the tale. The moral of the story is: you must recognize the pain-in-the-ass factor—in our case, literally— and tackle it to the ground.

Whatever the challenge is, you’ve got to make everybody in your organization care about tackling it, whether or not it benefits them or their family or their finances directly.

Training to Do What You Don’t Want to Do

In our professions, we have to steel ourselves to do extremely difficult, stressful tasks that we may recoil against, because that’s what we’re trained to do. In basic training, I had to learn how to rappel down a long, steep tower holding a rope, and land safely so that I would know how to disembark from a helicopter in a war zone. I failed repeatedly before I succeeded and I hated it, but it was necessary. Under pressure, you don’t rise to the level of the occasion, you sink to the level of your training. You prepare this way in peacetime for wartime.

Here’s a perfect case in point. One of my buddies in Iraq was fatally shot by an insurgent just hours after we had had breakfast together. I was the one who arrived on the scene and had to pronounce him dead. Then a few minutes later, I had to treat my next patient who was screaming and kicking and spitting at me—the insurgent who had murdered my friend. He didn’t want my care, and I didn’t want to give it. However, I had to since he a was a detainee under the control of U.S. forces. I had to steel myself to do what I hated to do, which I did once my training kicked in.

No one bargained for dealing with a pandemic — with clients who may be hard-pressed to cover treatments for COVID-related as well as non-COVID illnesses, with their employees who may be fighting their own or contending with a family member’s life-or-death battles with the virus and wondering if their insurance will pay for care for themselves or their loved ones. Nevertheless, leadership under this kind of stress demands the resourcefulness and psychological resilience to confront what had been unforeseen crises, sometimes on the fly. Remembering and falling back on your professional training is crucial to making this happen.

When we’re faced with multiple competing tasks to perform, it’s human nature to prefer doing the easier ones and avoiding entirely the tasks that are much harder but more necessary. Again, an example from my time in Iraq is pertinent.

I was the only physician on the scene one day, when a dozen men exploded bombs strapped to their bodies amidst a throng of thousands of people on a religious pilgrimage. The injured and the dead lay everywhere, and quick decisions about whom to triage had to be made. Some victims in excruciating pain didn’t have life-threatening injuries, while others were so grievously wounded that there was nothing I could do to save them. As tempted as I might have been to attend to the less seriously injured or try to comfort the dying, I had to move on to treating those victims who had a chance to survive. Likewise, successful leaders must recognize when to let go and take up the tougher, higher-priority tasks.

What I had to do, and what you need to do in order to make those painful choices, is listen to what’s coming from the frontal lobe of the brain — the seat of logical, rational thinking — rather than to the interior, more primitive part of the brain, which releases the feel-good substance known as dopamine. Too often, many of the decisions we make under pressure are driven by which option delivers the most dopamine. Following those dopamine surges can lead to bad, even stupid decisions.

When we’re confronted with these pressure-packed decisions, our emotions come into play thanks to another part of the brain—the amygdala—which connects an event that’s happening to a reflexive emotion. Frequently, the dominant emotion is fear. Whatever that fear is—of imminent danger, of falling, of failing, of being judged harshly—we can’t control that emotion, but we can control our active response to it. Heeding that frontal lobe admonition lets us master that clear space between the emotion felt and the action taken.

That’s what kicked in for me when I saw my mortally wounded friend and right after that, had to treat his killer. The starkest example of what this felt like, was the day a chopper landed nearby and deposited six men who approached me with a newly captured, disheveled, blindfolded, wheelchair-bound Saddam Hussein—the deposed Iraqi dictator responsible for his country’s ruin. I was responsible for giving him immediate medical care, and regardless of what I felt about the guy, the only decision that logic and reason would permit was to treat him. What it came down to was this: he’s just a patient, so I need to treat him like a patient.

My training had steeled me to anticipate and prepare for worst-case scenarios such as this. In a way, this was like what I’d seen in emergency room practice in downtown Chicago, where you might be presented with a street gang member who’d been shot or the guy who had shot him. You embrace these moments of stress rather than shrink from them. Accepting that discomfort and stress disposes you to make those uncomfortable decisions that leaders in healthcare frequently must render. Harvard University did a study along these lines; it found that people who viewed stresses as challenging handled them much better than people who viewed them as adversity.

Doing the right thing under pressure, however much you want to do otherwise, is what a leader does. Over time, those decisions are habit-forming, and those habits develop character — your character, which is what you need to lead your people and your organizations wisely and responsibly in this time of pandemic-defined crisis.

Sudip Bose, MD, a combat veteran of the U.S. Army, is an attending emergency physician and medical director. He is the founder of The Battle Continues, a nonprofit focused on helping veterans fight their battles beyond combat.

Leadership that passes the stress test successfully deals with what is commonly known as the pain-in-the-ass factor. 

From the Battlefield to the Pandemic: Leadership in Crisis Situations

Federal relief funds provided by Congress in 2020 to shore up hospital finances as COVID-19 hit fell disproportionately to the richest health systems, allowing some to finish the year healthier than ever, while some smaller, hard-hit rural hospitals struggled or even closed.

, which found a flaw in a key assumption of the 2020 Provider Relief Fund—which based aid to hospitals on 2019 revenues but did not require funds to be repaid if losses did not materialize. The report said the Biden Administration is re-evaluating how such funds should be distributed.

For some hospitals, the report said, finances did unravel quickly during the pandemic. Cancelled elective surgeries and spiraling costs for personal protective equipment (PPE) threw things out of balance, causing the rating agency Moody’s to downgrade 28 hospitals between March and December.

In February, the American Hospital Association asked Congress to replenish the near empty fund, after its consultants found that the median gain in 2020 was 2.7% for half its hospitals thanks to the aid, below the 2019 margin of 3.1%. But that figure belied the stark differences between the winners and losers, the KHN/

Giants like Baylor Scott & White Health, the largest nonprofit hospital system in Texas, which received $454 million in federal relief funds after laying off 1,200 employees, finished the year with a $815 million surplus, more than it had in 2019. Other winners included Pittsburgh’s UPMC, Mayo Clinic, and NYU Langone Health.

The for-profit health system HCA Healthcare returned unneeded federal funds when it became clear the worst had passed. But others spent the money or held on to it in case new costs emerged in 2021.

Critics of the 2020 HHS funding formula say it worked against hospitals that rely on revenue sources such as Medicaid, why by definition means those safety-net hospitals that serve the poor.

While some hospitals have been downgraded, others shut their doors for good.

Williamson Memorial Hospital in West Virginia’s coal country closed about a year ago. Its CEO wrote in a Facebook post that the institution had been trying to climb out of bankruptcy protection, but “unfortunately, the decline in volumes experienced from the current pandemic were to[o] sudden and severe for us to sustain operations.”

HHS' formula for the Provider Relief Fund based payouts on 2019 revenues, but did not require refunds if losses failed to materialize.