In this episode of MedBoard Matters, Host, Jean Fisher Brinkley talks with Clare Studwell, Founder & CEO of Flow Strategy about the survey results from our 2023 Licensee Survey. The Board asked providers to weigh in on topics ranging from their employment challenges to changes in opioid prescribing to implementation of telemedicine in their practices. Listen in and see what we learned.
Visit our website to access some of the resources discussed on the episode.
Host: Jean Fisher Brinkley
Guest: Clare Studwell, Founder & CEO of Flow Strategy
Producer: Sylvia French-Hodges
Follow the North Carolina Medical Board on X (formally Twitter), Facebook, and LinkedIn.
Email your questions to: podcast@ncmedboard.org.
In this episode of MedBoard Matters, Host, Jean Fisher Brinkley talks with Clare Studwell, Founder & CEO of Flow Strategy about the survey results from our 2023 Licensee Survey. The Board asked providers to weigh in on topics ranging from their employment challenges to changes in opioid prescribing to implementation of telemedicine in their practices. Listen in and see what we learned.
Visit our website to access some of the resources discussed on the episode.
Host: Jean Fisher Brinkley
Guest: Clare Studwell, Founder & CEO of Flow Strategy
Producer: Sylvia French-Hodges
Follow the North Carolina Medical Board on X (formally Twitter), Facebook, and LinkedIn.
Email your questions to: podcast@ncmedboard.org.
Episode 34 – 2023 Licensee Survey Results
Intro music: 0:00
Podcast introduction: 0:09
Hello and thank you for listening. This is Jean Fisher Brinkley, Communications Director for the North Carolina Medical Board, and this is MedBoard Matters. On this episode we are taking a look at the results of a recent survey completed by the physicians and PAs we license. About a decade ago, the Board began doing a licensee survey every few years just to tap into the collective minds of the medical professionals it regulates. Over the years the information we get has proved to be not just interesting but actually useful. For example, in a past survey licensees indicated that they could use help educating patients about opioids. So, we developed resources explaining North Carolina’s prescribing limits for acute and post-surgical pain. We also created a tear sheet that advises patients on safe medication storage and disposal and made it available at no cost to licensees. The most recent licensee survey, which was conducted in August, documented both high rates of professional burnout and a high instance of post-pandemic telemedicine practice among licensees. Those findings influenced Board Members and staff to select professional burnout and telemedicine as the topics for a recent Board retreat. I have asked Clare Studwell, Founder and CEO of Flow Strategy, the company that NCMB has worked with on both licensee and public surveys, to talk with me about the 2023 NCMB Licensee Survey.
Interview with Clare Studwell: 1:43
JFB: Clare, welcome and thank you for joining me.
CS: Thank you so much. It's great to be here with you today.
JFB: I always like to start by asking my guests to tell me a little bit about themselves. Would you do that? And also tell me a little bit about your company, Flow Strategy.
CS: Sure. So, I am the CEO and founder of Flow Strategy. We are a boutique market research firm located here in beautiful North Carolina. I've worked in the market research field for almost 20 years, leading both qualitative and quantitative research initiatives for companies of all sizes and across all verticals, including health care. I founded the business just over four years ago to fill what I saw as a gap in the industry. What makes us different is our high touch approach to all research initiatives and what I lovingly refer to as a chain of custody throughout the entire project process. So that means nothing we do gets outsourced from survey development to survey programing and scripting to data collection. All of that stays in-house. I have seen as projects get handed off, I've seen so many things drop through the cracks and that was not how I wanted to run my business. And I actually had the pleasure of working with the North Carolina Medical Board on this project, not just this year, but also in 2018. So, thank you for having me today.
JFB: Oh, of course. Well, thank you for that history. I actually did not know that you had participated in the earlier survey, so that's great to know. So, we're here today to discuss the results of the survey of licensed physicians, and PAs that you conducted for the Board I believe it was this August and I know in anticipating results from that survey that both Board members and staff have been really particularly interested in seeing the results simply because this is the first licensee survey that we have conducted since the coronavirus pandemic. Obviously, that was something that just really dramatically impacted health care along with everybody else in every other sector. And I find myself wondering if this is something that you've noticed with other organizations. Have other organizations wanted to see where their audience or their constituents are post-pandemic the way that we have?
CS: Oh, absolutely. As you know, the pandemic changed everything about how we lived, how we shopped, how we worked, how we played, and how we approached health care. And some of those changes have dissipated. But many are here to stay. Much of what I've been doing since 2020 has focused on changes to shopping behavior and consumer decision making. But I also just wrapped up another project for an insurance company and a key objective of that research, it was among both employers and employees, and it was trying to understand how both of those audiences make decisions about health insurance. How to access health care, and whether or not to provide or purchase supplemental insurance products. So, you certainly are not the only organization focused on how the COVID 19 pandemic changed our whole lives.
JFB: Yeah, that's interesting. I certainly know my shopping behavior changed. I was already a committed online shopper, and I am even more so now to the point where we have a second recycling bin for all of the cardboard boxes. I'm not sure I should admit to that. But anyhow, so back to the medical board survey. I know one of the core topics that we asked our licensees about is professional challenges. Can you talk about some of the top challenges the survey respondents mentioned?
CS: Yes. So, the professional challenges that we measured centered on the challenges that medical practitioners face today in providing clinical care. So, among our licensees, almost half or 44% mentioned burnout as a key professional challenge. We also saw that challenges related to administrative work were fairly common. More than a third expressed frustration with having to obtain prior authorizations and electronic health records.
JFB: Okay. Anything else that's worthy of mention or that was surprising to you?
CS: We did see a minority mentioning treating difficult patients or noncompliant patients. But really burnout and those administrative challenges rose to the top.
JFB: Okay. And I understand you did look at respondents by license type. Were there any differences between challenges mentioned by physicians as opposed to challenges cited by PAs?
CS: Yes, definitely. We did see statistically significant differences between those two audiences on some metrics. Physicians are more likely to cite those administrative challenges. So, things like electronic health records, reimbursement, state and federal regulations and maintaining their licensure. PAs on the other hand, were more likely than physicians to express frustration with some of those things that relate more directly to patient care. So specifically, treating difficult patients and treating noncompliant patients. They also were more likely than physicians to mention burnout as one of their challenges.
JFB: Okay. Interesting. So, there was another question, a separate question we asked licensees about is employment challenges. Can you say a little bit about how that's different from professional challenges? And also, what are licenses named among the most pressing issues in employment?
CS: So, the employment challenges we measured sort of took a step back from the topic of providing clinical care and look more holistically at workplace struggles in general. So, we can almost think of professional challenges as being unique to the medical field, whereas the employment challenges might be more broad and could really be faced in any workplace environment as well.
JFB: Gotcha. That makes sense. Thank you.
CS: Of course. And for our licensees, the top challenge, which was selected by 48% of all practitioners surveyed, was dealing with the impact of inadequate staffing. So, if we think about this as being a broader workplace challenge, that's not particularly surprising. We all know that staffing has been a challenge across all sectors. Think about airlines, think about hospitality, think about even retail. So that is not surprising that that rose to the top. We also saw work life balance and inadequate compensation being mentioned by about a third of all licensees.
JFB: Okay. And here again, were there some differences between physicians and PAs as far as what rose to the top for each of those license types?
CS: Yes, there were. And those differences do tend to follow a similar pattern to what we observed with the professional challenges. So, physicians were slightly more likely to mention things that are a bit more on the administrative side. So, things like increased administrative or management responsibilities and increased number of quality metrics being tied to their compensation. And one that concerns me a little bit is a loss of independent clinical judgment. Whereas PAs were more likely to say that work life balance is a challenge. So that was the top mention across the board. But that impacts PAs even more so than it did impact physicians. And this ties in with them being more likely to say that burnout is one of their top professional challenges. Right.
JFB: Yeah, sure. That does make sense. Now, one finding that really jumped out at me has to do with violence in the workplace.
CS: Yeah.
JFB: We found with the survey that almost one in three licensees reported that they'd either been involved in or witnessed a violent incident with a patient within the last 12 months.
CS: Yeah, this jumped out at me as well. And I mean, candidly, I was pretty horrified when I saw this number. This was a new question in the survey this year. So, we don't have the historical data to trend it against. That said, I do hypothesize that there probably is an upward trend in these types of incidents. If we think about other industries, I was thinking specifically this morning about the airline industry. We know that unruly behavior and violent incidents on airplanes has increased over the past few years. So, it wouldn't surprise me if we did have historical data on this question to see a similar upward trend in the health care industry as well.
JFB: Yeah, I mean, it seems like there is just a rise in incivility generally.
CS: Yeah.
JFB: Which is distressing, but especially in the health care setting where the stakes are arguably higher, you know, life and death issues to have to deal with violence on top of that at really such a high rate was surprising to me. Now, the survey actually also captured an interesting correlation between the finding about violent incidents with patients and burnout, namely that licensees who had witnessed or experienced a violent incident were significantly more likely to report that they're experiencing professional burnout. That is probably not particularly surprising, but still, I'm interested in what you can tell me maybe about that correlation.
CS: Yeah, that's correct. So, among those licensees who have witnessed or been part of a violent incident with a patient, 62% report having experienced burnout. Compare that to only, quote unquote, only 48% facing burnout among those who have not witnessed or experienced a violent incident. Now, what's really important to remember about correlation is that it is not the same thing as causation, right? So, we can't say that violent incidents are causing burnout. Nor can we say that burnout is causing violent incidents with patients. There likely are other co-morbid factors here, but it's definitely something that's important for us to both be aware of and continue to monitor as we repeat this survey in a few years, just to ensure that as more work is done to mitigate burnout in the workplace, there's really a focus on those environments where maybe there are more violent incidents happening.
JFB: Well, thanks for that reminder. Professional burnout was, of course, one of the featured topics that the medical board covered in this survey. And really to the surprise of no one, we learned that licensees are much worse off now than they were pre-pandemic, you know, which we captured in the 2018 survey. So, what did our licensees tell us about burnout and what are what are those trend lines look like?
CS: Yeah, this is really important. So, the survey is conducted every few years. So of course, anywhere we are able to, we seek to identify both upward and downward trends in the data. So, in 2016, 44% of our licensees reported ever having experienced burnout. Happily, in 2018, that number did decline, dropping to just 35% of licensees reporting burnout. But this year we have seen a dramatic upswing. Now, more than half or 52% of licensees are saying they've experienced burnout that lasted more than three months. And as we just mentioned, correlation and causation are not the same thing. So, we can't causally link this increase in burnout to the COVID 19 pandemic. But I can't help but think that it surely played a role in licensees experiences of stress. I mean, they were and remain critical frontline workers. And importantly, during the height of the pandemic, I'm actually happy that it's, quote unquote, only 52% saying they've experienced burnout because, you know, in the medical field and I have experienced.
JFB: Yes. I mean, I have definitely heard some stories. You know, it's…it's hard to imagine what it would be like to be doing your job, trying to help people, trying to make people better, and to have people fighting you, yelling at you, spitting on you, any number of things. And those are just the extreme reactions. The other side of just dealing with the disease burden that came with covid, I can certainly imagine that it would take a tremendous toll. So, what can you tell us about licensees who are experiencing burnout based on the survey respondents? Were you able to develop any kind of a profile based on the responses we received?
CS: Yeah. So, we do see that PAs are more likely than physicians to report experiencing burnout. Those who experience burnout also tend to be younger than average and are a bit newer to the medical field and are more likely to skew female than they are to skew male. One thing that's important to consider is if these characteristics are unique to those who are experiencing burnout or if it's unique to the people who might be more willing to, quote unquote, admit that they're experiencing burnout. So, we know that mental health and wellness has become more of a topic of conversation. Recently it's become more normalized. It's become safer to talk about. So it might be that younger, newer licensees find it safer or more socially acceptable to admit to experiencing these symptoms than those who are maybe a bit more old school or have been in their careers for longer.
JFB: Right. That's a really great point. I'm wondering, I'm thinking about the PA population. I was going to ask if you could say a little bit more about the differences between the physicians and the PA's. But I know that the PA population is both younger and more female than the physician population in North Carolina. So, you have to wonder if it is an issue of just generational and gender. You know that women are more, more willing to admit that they're struggling.
CS: Yea, it's more socially acceptable.
JFB: Hmm. Interesting. Were there any other significant differences between physicians and PAs regarding the burnout questions?
CS: Yeah, I think the symptoms and the impact are interesting to explore in terms of physicians versus PAs so among all licensees, the top symptoms of burnout mentioned by about two thirds are dreading the workweek, exhaustion that is not relieved after taking time off, and experiencing a negative outlook or some cynicism related to their jobs. PAs experience slightly more severe symptoms than do physicians. So not only are they more likely to say they've experienced burnout, but they're also more likely to say that when they do experience burnout, they are facing persistent exhaustion as well as panic or anxiety and an inability or lack of desire to chart their care. So, their symptoms appear either to be more severe or they're at least reported more often. But the impact is different for PAs and physicians. So, while symptoms might be more severe among PAs, we're seeing that physicians are far more likely than PAs to suggest that they're seriously considering retiring in the near future, whereas PAs are more likely to just say they're having a hard time charting their care. So, it's almost a more severe impact to the physician population, even though the symptoms are more reported among the PA population.
JFB: Okay. Now, just for clarification, when you say charting their care, do you mean creating records to document the care that they've provided?
CS: Yes.
JFB: Okay. Just wanted to make that clear. So, before we bring everybody in the listening audience down, I did want to just highlight that there was some good news on the burnout front. It looks like, based on our findings, that more licensees are seeking professional help for burnout. Tell me about that change and how it looks in the 2023 results compared to 2018.
CS: Yeah, this is huge. So, in 2018, we saw that only 17% of those who had experienced burnout sought professional support. This number has almost doubled in 2023, with 33% of licensees seeking professional help for their burnout. Now, this does still leave a huge group who isn't getting professional support. But I do like to see this increased willingness to seek help. And the other thing to keep in mind is that perception can become reality, right? So, we are we are seeing this huge jump in reported burnout from 2018 to 2023. But is that more people experiencing it? I'm sure partly it is, but also might be more people willing to again admit that they're experiencing it because it is a more common and acceptable topic of conversation. So, I think it's sort of a both and situation where there is probably more true burnout and there's probably more comfort in that saying that you're feeling burnout.
JFB: Definitely. And I think there are a lot of really important conversations happening at the system level. Employers, major institutions, looking at those systemic drivers of burnout. And I think that there is some progress in making it more acceptable for licensees to say, “Hey, I'm struggling and this is not a transient thing. It's…I need help. Something has to change. So, that's not the subject of this podcast. But clearly professional burnout is going to remain a challenge for many, many medical professionals for the foreseeable future. It is good to see that there is some positive change, that more people are getting help benefiting from it. And we as an agency at the North Carolina Medical Board, we're definitely going to continue focusing on professional burnout and what the health care community across North Carolina is doing to address it in future content. For now, though, I do want to shift our conversation to another area that was certainly impacted by the pandemic, and that is telehealth. So, I'm sure it is probably a surprise to no one again, that our licensee survey documented a huge, huge increase in the practice of telemedicine since 2018, which again, is when we last surveyed licenses. So, what did we learn about the rate of telemedicine practice?
CS: Yeah. So, telemedicine, as you mentioned, unsurprisingly, experienced a huge upswing. So, among our licensees, only 16% say they offered telemedicine prior to the COVID 19 pandemic. That number jumped all the way up to 77% during the pandemic. That's huge. And we might expect to see a significant downtrend today. But we're still seeing that 64% offer telemedicine currently. So, it appears that they have gotten comfortable with the technology. They've recognized the benefits and are continuing to incorporate it into their practices.
JFB: Yes, I had some similar thoughts. It was striking to me that so many licensed is have reported that they've continued to provide care. And I had speculated that, you know, a lot of people it's just because now they've gotten their feet wet. They know how to do it. So why not continue to do that? But I'm sure also that they're continuing to offer it because they see some value there, you know, both for their practices, for their patients. What did licensees name as some of the greatest benefits of telemedicine practice?
CS: Yeah. So, the top benefits really are patient focused. There are certainly are mentions that are focused on the practice, but that's among the minority. So, what we're seeing is that practitioners are recognizing that telemedicine dramatically improves access for patients. So, 74% say that care is now more accessible or more convenient for patients. But we're also seeing that 56% are saying that they're able to better monitor patients who are less mobile or live further away. And then about a quarter say that telemedicine gives their patients more access to specialists. So those are the top three mentions and they're all patient focused. There's some mention around reducing operational costs, reducing administrative or paperwork, but that's all under 10% mentioning those. So, it's really…the benefits really are patient focused versus practice focused.
JFB: Right. And I guess that's not too surprising. So, at the same time, I just wanted to point out that the vast majority of the licensees we surveyed, actually 98% indicated that they're practicing telemedicine as a supplement to their brick and mortar practices. So, it's not like telemedicine is replacing in-person face to face care. I'm sure there are a variety of reasons for why it's a supplement and not a replacement. But I wondered if you could talk maybe about what licensees identified as some of the challenges related to practicing telemedicine.
CS: Right. So there certainly are challenges. They fall sort of in two buckets, the first bucket is inpatient care. So, there are limitations in your ability to conduct a thorough exam of a patient that's mentioned by 43% of licenses. And it's also a little bit harder to establish that rapport. About a quarter say that they have less fulfilling interactions with their patients through telemedicine. And as someone who has sought telemedicine, I certainly see that from the patient side as well. And then the other bucket is access to technology. So, whether patients have the appropriate systems or access to broadband So, 37% generally say access to technology and a quarter say access to reliable broadband. And I mean, how many pockets of North Carolina do not have reliable access to broadband internet, that certainly is a consideration for telemedicine.
JFB: Absolutely. Yeah, that makes complete sense. I mean, North Carolina's had so much rapid growth that people forget it's still largely a rural state and we just don't have the infrastructure everywhere we need it. So final topic or final special topic that I wanted to ask you about in the survey, the opioid epidemic. We've talked with licensees about this. This may even be the third time we've surveyed licensees about the ongoing opioid overdose epidemic, but it's important it's still going on. Unfortunately, opioid overdose deaths are still rising in the state of North Carolina. One thing that I thought was really interesting about the findings related to the impact of the opioid epidemic on licensees is that a large majority of the survey respondents said that their practice has been impacted by the epidemic. Tell me a little bit more about that. What we found.
CS: Sure. Yeah. So about three quarters say that they have made specific changes to their practice as a result of the opioid epidemic. Those who have made changes really have taken a variety of steps to address this issue. Most have increased their use of the opioid prescription database. So, 59% have increased their use of that database. Many have also changed their prescribing behavior. So, it's not just accessing information, but really changing their prescribing behavior, whether that's through referring patients out to pain management clinics, reducing their frequency of prescribing opioids, or reducing the dosages of the opioid that they’re prescribing.
JFB: Mm hmm. In recent years, the focus on intervention in the opioid overdose epidemic has really shifted from excessive and inappropriate prescribing to addressing substance use disorder addiction, which is, of course, the leading cause of overdose deaths. Our survey found that most respondents have actually completed training that touches on opioid dependance and opioid addiction. But there's a little more to that story. How ready did our licensees report feeling to tackle the issue of opioid dependance and addiction?
CS: Yeah. So, 87% of licensees have received training on recognizing opioid dependance, which is great. And that audience who has received that training is far more well equipped than those who have not received training in recognizing the difference between dependance and addiction. But even among those who have received that training, only 10% say that they're extremely confident in their ability to distinguish between dependance and addiction. So, they definitely still need some support and possibly some ongoing training to better equip them moving forward as this continues to be an issue.
JFB: Mm hmm. And the findings really couldn't be more timely because, as we've discussed on the podcast very recently, the federal government and others are in the process of trying to expand that number of providers who can treat opioid dependent and opioid addicted patients, specifically by requiring all DEA registrants to complete 8 hours of training in treating opioid use disorders. So clearly there has been recognition at the federal and state level that this is needed, that we need to get our medical providers more comfortable, more knowledgeable about treating opioid dependance and opioid addiction. When you talk about support it, I immediately thought of the fact that our state is fortunate to have some of the leading academic centers where addiction medicine specialists practice. They're actually building a support network, a hub and spoke model where community physicians can call on specialists in these academic centers to provide that support. So that community clinicians who are just starting out have someone to call and say, help me talk through this difficult case, or this just happened with a patient and I'm not sure what to do, what's the right thing. So I think there's a lot going on in this area. There is support available. The medical board recently collaborated on a series of CME modules that address this, and we'll link to those in our show page, but very timely findings indeed. It's good to see that people are changing their behavior. They're using the tools, they're getting the knowledge. But obviously this is not something that people learn how to do overnight. Treating opioid use disorder.
CS: Well, and I'm sure every interaction with a patient is different, right? You can't just learn it through a class or a book. You really have to live it and experience it, right. And so having that support network will be really great for clinicians to sort of talk through those real-life scenarios.
JFB: Absolutely. I mean, that is, in fact, exactly what some of the addiction medicine specialists we've talked to have said. It is completely unsurprising that people who have just taken a CME course, that alone does not prepare you to go out and provide patient care to a really difficult population. It takes some experience to develop the confidence to know what it is that you need to do and to get really comfortable meeting the needs of this particular population of patients. Well, Claire, thank you so very much for taking the time to talk through the licensee survey findings with me. Do you have any parting thoughts that you wanted to leave our listeners with about the survey findings?
CS: I think it's just really exciting to continue this research every few years so we can start to see the upward and downward swings in the data and see the progress that the Board has made in addressing some of these topics. So, thank you.
JFB: Same here. We agree. The Board members really do value this information. And I just wanted to take a moment to thank all of the licensees who took the time to complete the survey. I know they're extremely busy people. I don't think it was terribly long, but it still probably took 15, 20 minutes of their time to go through and do a detailed survey like this. So, I again, just wanted to say how much the Board appreciates people who did participate and let them know that the Board members really do value and use the information. It drives discussion that's really important at the medical board and it can affect policy and help the Board identify things that they need to learn more about, things that they need to focus on, policies that they need to review. So, we definitely feel that this is a valuable undertaking and I look forward to seeing what more we learn in future with this.
CS: Thank you. I do have one fun fact if you'd like to hear it about…about the licensees who took the survey. So, there was about a 12% response rate on the invitations that we sent out. We had over 2000 licenses complete the survey, which was about 15 minutes long, which is not insignificant. Generally, with a client database, which is what this was, I see about a 1.5 to 2% response rate and that that is sometimes even with an incentive. So, thank you to the licensees who participated. That is huge. And there were a few open-ended questions in the survey, which is a bit more difficult. You have to actually provide that and type in your response. And the open-ended responses were incredibly thoughtful. There weren't responses that were throwaway answers. So truly, I do think that the licensees deserve a big round of applause for participating as well. To your point.
JFB: Most definitely. Thank you so much for mentioning that. I have to say, I saw the response rate and I just wasn't sure not doing research on a regular basis of this nature if that was a good response rate or not. But it sounds like it was exponentially higher than what you see in other sectors. So again, thank you very much. That's incredible. All right. Well, that's a nice note to end on. Again, appreciate your time and your expertise.
CS: Yeah. Thank you very much.
Episode closing: 32:06
You guessed it. You’ve reached the end of another episode of MedBoard Matters. I hope you found NCMB’s 2023 Licensee Survey findings as illuminating as I do. If you would like to take a closer look at the survey, we have posted detailed findings on our show page, which you can find at www.ncmedboard.org/podcast. You will also find links to the MATE Act CME series I mentioned during my conversation with Clare. If you found this episode interesting, informative, and just plain worth listening to, please share it with your friends and colleagues. And remember you can send thoughts, questions, and constructive criticism by email to podcast@ncmedboard.org. Thanks again for listening. I hope you will join me again.