Dirty White Coat

Physician, Heal Thyself (Without Losing Your License)

• Mel Herbert for FoolyBoo Inc

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The Dr. Lorna Breen Heroes Foundation works to eliminate barriers to mental health access and improve work environments for healthcare workers, following the tragic suicide of Dr. Lorna Breen during the first COVID wave.

A interview with CEO Stephanie Simmons

Links:

ALL IN for Mental Health: https://drlornabreen.org/allinformentalhealth/

Specifically the ALL IN for Mental Health resource page: https://drlornabreen.org/allinformentalhealth/six-actions/accessible-affordable-mental-health-care/

ACEP wellbeing resource page: https://www.acep.org/life-as-a-physician/wellness

Dr. Lorna Breen Heroes' Foundation Licensing/Credentialing toolkit: https://drlornabreen.org/removebarriers/

Write your Representative to support Reauthorization of the Dr. Lorna Breen Healthcare Provider Protection act: https://drlornabreen.org/reauthorizelba/

Become an Ambassador: https://drlornabreen.org/become-an-ambassador/

Donate (and thank you!):  https://drlornabreen.org/donate/

Summary:
• Founded by Lorna's sister and brother-in-law after thousands of healthcare workers reached out following her death
• Three main areas of work: advocacy at federal and state levels, advanced collaboration, and accelerating solutions
• Successfully helped pass the Dr. Lorna Breen Health Care Provider Protection Act in 2022, establishing grants for healthcare provider mental health programs
• Working to remove stigmatizing questions about mental health from licensing and credentialing applications
• 35 state medical boards and over 600 hospitals have removed invasive mental health questions
• Many healthcare workers avoid seeking mental health care fearing professional consequences
• Anonymous resources available include the Emotional PPE Project and Physician Support Line
• Healthcare workers compartmentalize trauma like "putting it in a backpack" that eventually becomes too heavy
• The foundation is committed to being "completionist" in changing all state licensing boards
• Physicians and healthcare workers have unique power to advocate for these changes

Visit the All In for Mental Health website for resources and use the legislative call to action tool to support reauthorization of the Dr. Lorna Breen Healthcare Provider Protection Act.


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Speaker 2:

the Lorna Breen Foundation was founded after the death of Lorna Breen in April 2020, and Lorna was an ER doc. She was the chair of her department and, like many, she was called back. Actually, she was on vacation to care for patients in the first wave. She took care of her community and not just her community, but her team, working 16, 18 hour days, day after day. She was exhausted and she got COVID. She came back 24 hours after. She was fever free, like many people did, and it all caught up to her to the point where she was emotionally, intellectually and physically exhausted. Her family called on her friends from medical school and residency to drive her down to Virginia, which is where she grew up, and it was then that she had her first ever mental health care. She was admitted for three days to get her bearings, get some care, and when she was discharged to her family, she expressed to them that now that she had received this care, she was worried she was going to lose her license, her hospital credentialing and the respect of her colleague, and Lorna died by suicide on April 26, 2020.

Speaker 2:

The next day, the New York Times published an article about her colleague, and Lorna died by suicide on April 26, 2020. The next day, the New York Times published an article about her death, and her family received first dozens, and then hundreds, and ultimately thousands of messages from healthcare workers around the country, in the ER, out of the ER, saying Lorna's not alone. This is a problem for all of us. We're all worried about whether it's safe to get care, and this is a problem that didn't start with the pandemic. This is a problem that's been going on for decades and we need some change. So my name is Stephanie Simmons and I hail from Ann Arbor, michigan. Hail is chosen really mindfully. There. I am the chief medical officer for the Dr Lorna Brain Heroes Foundation and I am also an EM doc. So Lorna's sister and brother-in-law, jennifer and Corey Feist, started the foundation to help eliminate barriers to mental health access and also to help improve work environments for healthcare workers.

Speaker 3:

So, stephanie, tell us about the organization, how big you are, what's the scope of work that you're doing?

Speaker 2:

So we are national and we are small but mighty, so we have under 10 employees. We work in three verticals. The first is advocacy at the federal and state level. We help to get the first ever law specifically looking after the mental health of the health care workforce the Dr Lorna Breen Health Care Provider Protection Act passed. It's in reauthorization right now and we're working on getting the reauthorization passed.

Speaker 3:

So let me read you what that act is. This is HR 1667, and it was passed in 2022. And this bill establishes grants and requires other activities to improve mental health and behavioral health amongst health care providers. Specifically, the Department of Health and Human Services must award grants to hospitals, medical professional associations and other health care entities to improve programs to promote mental health and resiliency among health care providers. In addition, hhs may award grants for relevant medical and behavioral training for health care students, residents or professionals. So you get the idea.

Speaker 2:

We also work at the state level on licensing and credentialing laws, prior authorization, workplace violence prevention and really anything where we feel it benefits the mental health of the health care workforce. The second vertical is in advanced collaboration. There are a lot of organizations who have a stake in the well-being of the healthcare workforce, but they're doing a lot of their work in a siloed way. So we have All In Well-Being First for Healthcare, which is over 30 organizations that come together to share their work and also advise us on what we do. That includes the AMA, the ANA, the AHA, asap, ena, ihi, schwartz Center for Compassionate Care, google Health, feminem. So these folks have been meeting every week to two weeks for five years to try to advance the work of removing barriers to mental health care and promoting healthy work environments.

Speaker 2:

We also have an ambassador group, which is 300 strong health care workers, family members who are survivors of suicide, health care leaders and mental health professionals who help carry this work forward. And we have a medical student coalition and they are spreading across the country and this is about awareness and also getting resource to those students. The third vertical and I think where we're really making some important impact is in accelerating solutions. This is removing stigmatizing and invasive language around mental health care from licensing and credentialing applications across the country, and last weekend I was at the Federation of State Medical Board meetings recognizing 35 state medical boards that have removed these questions from their licensing applications.

Speaker 3:

So, for those of you that may not be aware, when you apply for a job, you often have to state whether you've had a mental health issue, whether you've been admitted, whether you've sought care, and it really puts a dampener, a real dampener, on clinicians going to get care for their mental health, because it's not clear what happens with that information. Is that a ding against you? And in the past there was a lot of stigma against saying yes to any of these things. So, frankly, people just didn't disclose and, worst of all, worst of all, people didn't get care.

Speaker 2:

And we do this work with medical licensing, but also nursing, pharmacy and dentistry. We're doing this with credentialing at individual hospitals and health systems and we've been able to recognize over 600 hospitals where we can verify that they've removed these questions from their application, their repeat application and their peer reference forms. We're also working on a state basis to do this work as a cohort and then do leader education and form learning communities between the health systems in the state to tackle a workplace environment issue. In our first state, virginia, they chose EHR optimization and we're working with the HIMSS, the health informaticists in the state, to make sure that work is thorough and has longevity. We've added North Carolina, new Jersey and Wisconsin since we started and we're also working with a locum tenants company called Jackson Cooker.

Speaker 3:

So, Stephanie, give us a little bit of color about why are people so reticent to disclose? Is this concern that it's going to affect their income, basically that they are not going to get a job?

Speaker 2:

Yeah, it's an economic decision for a lot of people, and you've just dedicated 12 years of your life at half a million dollars of student debt and you're making a decision about whether it's safe to get care. We don't ask the same question about potentially impairing medical conditions and, to make matters worse, we ask the question right after have you ever committed a felony and are you a pedophile, right? And so really there's three ways to fix this. One is you just don't ask. In my household we call this a nunya question, like it's nunya business.

Speaker 3:

I will immediately immediately be adding that to my lexicon.

Speaker 2:

The second way is to ask are you impaired for any reason right now? And the third way is to say hey, we know you're a human being. Things can happen. Can you positively attest that you're going to take care of yourself and any issues that arise? So those three options are all acceptable and what we've done is we've said make the change, let us know, and then we're going to trust, but verify. So send us your applications. We'll review them and once we've seen that they are consistent with best practices, we will give you a badge to serve as a visible sign to the healthcare workforce that you're not going to be asked these questions here.

Speaker 3:

So my understanding is that all of the medical boards are independent the state medical boards and so are you having to go state by state by state to get some of these changes made.

Speaker 2:

Yes, the medical boards are state regulated, so there hasn't been a federal solution to this. We're going state by state. The good news is news is that the Federation of State Medical Boards and the Federation of State PHPs have been doing this work since the 20 teens, and so when we started the work, there were already 19 state medical boards that had made the change. Now there's 35. And we are committed to being completionist on this, so that people don't have to worry about this with their state license. And we are also working with hospital and health systems, with professional liability insurers and with payers, so that in any of the credentialing applications that healthcare workers have to fill out to do their job, they're also not getting asked this question.

Speaker 3:

So let me state it a bit more clearly. So your state medical board might ask you this every few years as you get sort of recertified and you have to pay them lots of money to keep your medical license. But also when you go to a hospital to apply for a job, they might ask you these questions. And so what do you do if you're still in a place where these questions are being asked? What do you suggest we do, Stephanie?

Speaker 2:

So what I would recommend that people do, if they are applying for a job at a system that's still asked with their credentialing, is have a prepared statement about what their mental health diagnosis and treatment has been and a judgment that they are not currently impaired, so that they are going in and don't have to think like on the fly. How am I going to answer this question? Because it is part of the credentialing application. Now that's increasingly changing and our goal is that this removed from credentialing applications as well as licensing. At some states, this has been done via legislation and is in statute. So we have 35 state medical boards that have made this change and because it's changing all the time as we add more states, we have a map, and so on our website and I can give you the link for the show notes we have a map for medical licensing, nurse licensing, dental and pharmacy licensing, and then we also have a map of the states and you can click on your state and see which hospitals have also changed their credentialing applications.

Speaker 2:

So part of the reason why these questions have been so harmful is that people assume the worst in the absence of information about what actually happens If you are not impaired by your mental health condition and you seek care, you can explain that as part of your licensing application and it is likely not going to cause any problems for you. If you do have a concern for impairment, like an impairing condition, the state physician health program or professional health program for PAs, NPs, nurses can provide an alternative to discipline way to get treatment where you have some insulation from the medical board and some privacy. Now there's a set of best practice about how that relationship works, but it's a little different state by state. So the Federation of State PHPs has been working to get those best practices out to the states and I would encourage someone first, if they think they need help, to get help. Second, to educate themselves about what the rules are in their state so they know what the likely procedure is going to be.

Speaker 3:

So in the past, one of the workarounds that we were always told and many of us did was if you need to get health care mental health care do it off the books, do it in cash, don't use your insurance. Do this workaround ask the provider not to report. Is that still a thing that is suggested or is done in these places where you still have to report?

Speaker 2:

I think that there have been people throughout the decades that have done exactly that or have gotten care, paid cash, used a pseudonym, done telemed, used an email address that they create for that purpose, and if that's truly the only way that you feel that you're safe to get care, you know I would want people to get care more than anything else and that I would encourage them to actually speak with their physician, speak with their counselor and their therapist about how to address that when they do the licensing and credentialing, because part of the stigma is in between our ears, right, it's. What does it mean about me that I'm this competent, tough ER doc, right? Or trauma surgeon or pediatrician who needs help, and so we need to work to get over the stigma that's internal, and then we can help our colleagues get over the stigma that's external and in the meantime, we can be advocates to change the institutional stigma that these questions represent.

Speaker 3:

So specifically about insurance, then if you use insurance for your mental health, is that reportable to the state medical board or some state medical boards?

Speaker 2:

There's a record and a paper trail and that could be discoverable, and so there are a lot of different options for healthcare workers who want to get help. Options for healthcare workers who want to get help First of all, I always encourage people to think about the level of help that they want or need, and a lot of people start with peer support or with coaching, which are not formal mental health care and don't need to be reported. Next, you can think about some of the anonymous care resources that are out there. Now we've been compiling these as part of our All In for Mental Health campaign and again I can give you the link for the show notes. But some of the best ones that I've found are the Emotional PPE Project, which will get you to a healthcare worker for mental health in your state who's culturally competent to care for healthcare workers and who will provide free care that's anonymous. There's also the physician support line, which is psychiatrists, who offer that free, anonymous support. Asap also has really great wellness resource and I encourage people to look at that website under the wellness resources and take advantage of those. So we've compiled these together on this All In for Mental Health website and we want people to visit this, learn about the rules right, learn about how the PHP works and also have access to these anonymous resources that will stay off of your insurance.

Speaker 2:

And you know, mel, this isn't just about life and death, right, there's a lot of healthcare workers who are out there who are suffering and carrying a lot of pain, and I liken it to like this big backpack that we all wear on our backs and it's like you have a bad case and you throw it in your backpack. Right, and this is the coping mechanism that we learn it's compartmentalize and move on. You got to see the next patient, but if you never unpack that backpack, you're going to end up on your back like a turtle with your arms and legs in the air, incapacitated by that pain and suffering, and that might mean depression, that might mean anxiety, ptsd. It also just might mean that you are not thriving in your life and your relationships in the way that you could.

Speaker 3:

I love this message. We need to move past this life and death decision making about whether we're going to get care and also talk about we just need to be happier in our work if we're going to do it a long time, because the world needs us to do this work. Now, my bias has always been that I believe every single ER, doc and nurse should be in care and that should be systematized. It should be at the residency level, it should be at the nursing school level. Everybody should get it, because if everybody gets it, there goes the stigma.

Speaker 2:

There are some training programs that have opt-out therapy for their trainees. As an employer, we are not at the point yet where employers say this is going to be opt-out in the medical profession. I think it's a great idea. I don't think that there's a single healthcare worker who would not benefit from some of the tools of cognitive behavioral therapy, who would not benefit from coaching and sort of having that external voice to help us as a thinking partner but also call us out when we start to spiral a little bit and think that the whole world operates on the rules of the emergency department, including what you're going to experience with relationships and in daily life. I think it's a great idea. And one way to de-stigmatize the question on licensing and credentialing applications is if everyone's answering yes.

Speaker 3:

So is this getting better? Are we making some progress here? Are you making progress here?

Speaker 2:

Well, mel, if you had asked me five years ago if I was going to be in the office of legislators or talking to regulators at a state level about how to change licensing, or talking to the CEO of a health system about how they need to change their policies or procedures, I would have told you no way, and what I've learned in the last five years is that physicians have a unique voice and a unique ability to get this stuff changed, and so what I would encourage everyone listening as a clinician is that you not only have a unique ability to care for yourself and your colleagues, but to make change in the whole country about how this works.

Speaker 2:

You can lead the credentialing work at your organization, and we have had a medical student do this in their organization. We have had multiple single attendings and we've had multiple sort of chief of staff med staff leaders take this on all by themselves. So, first and foremost, I'd want them to know that you can have a thriving, rich life, and that all of us need to have the help and the tools to do that with the work that we do.

Speaker 3:

So right now, how can we help the Lorna Breen Foundation?

Speaker 2:

Well, we are working on getting the Dr Lorna Breen Healthcare Provider Protection Act reauthorized and we're using a grassroots, grass tops approach, and so the foundation, through our all-in coalition, is doing a lot of legislative visits, but we also have a legislative call to action tool. I'd love to include that in the show notes for MRAP and encourage all of your listeners to write their representative. Asap has been key to moving this forward and has been a proponent of the legislation, and there's also a lot of ways that the foundation gets in front of healthcare workers and talks about mental health. So the pit has really driven a national conversation around mental health with healthcare workers.

Speaker 3:

And I want to express my gratitude, and those messages have been passed on to the incredible people that put together that amazing show. So what's the longer term goal of the foundation? Where do you see it going in the next five or 10 years?

Speaker 2:

We've got time and we're not going anywhere. We are working with the states longitudinally over three to five years, because we know that culture change doesn't happen overnight and we really want to see things get better for healthcare workers. We also, as I said and sometimes I joke as an ER doc, we're not always known for being completionist on things. As an ER doc, we're not always known for being completionist on things, but we're committed to being completionist on the licensing work and we want every doctor, nurse, pharmacist and dentist to know that they're not going to be asked this question on their licensing. You know the Department of Justice has actually weighed in and say that it violates the ADA, so there's no reason why all of these licensing applications shouldn't be changed.

Speaker 3:

And, as we wrap up here, what's your source of funding and is there some opportunities to help here as well?

Speaker 2:

It's a great question. A lot of people think that the Dr Lorna Breen Healthcare Provider Protection Act funds the Dr Lorna Breen Heroes Foundation, and it does not. So we are fully philanthropically funded and we have a mix of earned income, like the work that we do with our states, and we have a mix of sort of directed philanthropy to the foundation. This comes from institutions, it comes from individuals, and so we do rely on philanthropic support to do this work. We do not charge anything for the licensing and credentialing work that we do, and we never charge a healthcare worker for access to our resources. So we would also love support and I could certainly include the donation link in our materials that I sent to you, because that's an important way to move the work forward.

Speaker 3:

And we have all of those links in the show notes, thanks to Stephanie Simmons. Thank you to the Lauren Breen Foundation. This is really important work. These are good people trying to change the way we disclose so that we can stop being worried about the stigma and the ramifications and get the help that everybody in this profession needs. Thank you, stephanie, and your team.

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Mel Herbert, MD

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