Donald E. Pathman

Creating a psychologically safe and supportive environment is important for everyone who works and learns within an academic health center (AHC) as well as important to AHC overall success. Recognizing a need to better understand the strengths and areas for improvement in an AHC’s environment, we developed and fielded an environment survey tailored to our many student, resident, postdoctoral researcher, staff, and faculty constituencies. This paper outlines the methodological and practical considerations and outcomes in developing and deploying the survey, including information on how it was received and the activities it subsequently stimulated. Three elements were central to our efforts: (a) analyzing and reporting findings at the individual department, center, and learner group level, where individuals directly experience the environment day-to-day, (b) characterizing the environment through three core dimensions of people’s experiences, which were perceiving that the department strives to be supportive; feeling embraced, appreciated, and supported within the environment; and feeling accepted in one’s beliefs, and (c) prioritizing the dissemination of findings to all members of the community. We provide our questionnaire and outline the findings report design, a document received favorably by departments and their leaders. All of these documents can be adapted by other AHCs aiming to assess their environments, learn where to target interventions, while also monitoring progress.

Purpose: Physician turnover within Health Professional Shortage Areas (HPSAs), as in all settings, frequently occurs when physicians are dissatisfied with aspects of their work and employment. This study evaluates how physicians’ assessments of 6 aspects of their work and jobs relate to whether they anticipate remaining in their urban and rural HPSA practices for more than 2 years, and assesses differences for physicians in urban and rural HPSAs. Methods: Survey data on physicians’ assessments of 6 facets of their work and jobs were obtained from 747 physicians working in urban HPSAs and 355 in rural HPSAs across 33 states (54.9% response rate). Separate hierarchical logistic regression models identified work and job factors independently associated with anticipated retention beyond 2 years for each group. Z ‐tests assessed differences between the urban and rural models in odds ratios for each work and job factor. Findings: Anticipated retention was more likely in both urban and rural HPSAs when physicians felt they had good administration, they felt connected and supported at work, and work felt meaningful, and likely also if they provided their desired range of services, but in neither setting if they felt adequately compensated or not. Anticipated retention in rural but not urban HPSAs was more likely when physicians had a good work‐life balance. Conclusions: Physicians’ anticipated retention within HPSAs is associated with how they feel about various aspects of their work and jobs. These aspects of work and jobs are generally but not exactly the same in urban and rural HPSAs.

A shortage of behavioral health clinicians impedes access to mental health services nationwide in the U.S., with shortages most acute in federally designated Mental Health Professional Shortage Areas (mHPSAs). Retaining behavioral health clinicians currently working in mHPSAs is thus critical. This study sought to identify behavioral health clinicians’ assessments of various aspects of their work and jobs that are associated with their anticipated retention within mHPSA practices. Data for this cross-sectional study were drawn from an annual feedback survey of clinicians when they complete federal education loan repayment support contracts for their work within mHPSAs, from 2016 to 2023. Clinicians’ assessments of various aspects of their work and jobs were measured with validated survey items with Likert-scaled response options, with most combined into scales for analyses. Bivariate and then adjusted associations with 5-year anticipated retention were assessed for clinicians’ assessments of various aspects of their work and jobs controlling for demographic, professional, and community characteristics. The 2,587 respondent behavioral health clinicians (67.5% response rate) included 42% licensed clinical social workers, 39% licensed professional counselors, 12% psychologists, and 7% licensed marriage and family therapists. Two-thirds of these clinicians worked in either community mental health centers or federally qualified health centers. 42% anticipated they would remain in their practices at least another five years. Five-year anticipated retention rates were nearly three times higher for clinicians who indicated satisfaction on global work and practice assessment measures than for clinicians neutral or dissatisfied on these measures. Five-year anticipated retention rates were also higher for clinicians who reported they had an effective and supportive administration, felt well and fairly compensated, had jobs that permitted a good work-life balance, and had jobs that allowed them to practice the full range of services they desired. How behavioral health clinicians view their jobs within U.S. mHPSAs is important to their anticipated retention. Based on study findings, to promote their retention practice administrators should provide fair and adequate compensation, foster work-life balance, permit them to deliver the services they wish to provide, and value them and their input and maintain good relationships with them.

Purpose: This study assesses how, among behavioral health clinicians working in rural safety net practices, the amount of exposure to care in rural underserved communities received during training relates to confidence in skills important in their work settings, successes in jobs and communities, and anticipated retention. Methods: This study uses survey data from Licensed Clinical Social Workers, Licensed Professional Counselors, and Psychologists working in rural safety net practices in 21 states while receiving educational loan repayment support from the National Health Service Corps, from 2015 to April 2022. Findings: Of the 778 survey respondents working in rural counties, 486 (62.5%) reported they had formal education experiences with medically underserved populations during their professional training, for a median of 47 weeks. In analyses adjusting for potential confounders, the estimated amount of rural training exposure was positively associated with a variety of indicators of clinicians' integration and fit with their communities as well as with longer anticipated retention within their rural safety net practices. The amount of training in care for rural underserved populations was not associated with clinicians' confidence levels in various professional skills or successes in their work, including connection with patients and work satisfaction. Conclusions: Formal training in care for underserved populations is a large part of the education of behavioral health clinicians who later work in rural safety net practices. More training in rural underserved care for these clinicians is associated with greater integration and fit in their communities and longer anticipated retention in their practices, but not with skills confidence or practice outcomes.

Background: Nearly every state offers loan repayment (LRP) and some offer loan forgiveness to clinicians who commit to work in safety net practices. The effectiveness of these programs from the perspective of safety net practices is largely unknown.Objectives: To assess safety net practice administrators' assessments of key outcomes for the 3 principal types of state service programs: LRPs funded by states, LRPs funded jointly by states and National Health Service Corps, and loan forgiveness programs.Subjects: Administrators of safety net sites where primary care, behavioral health and dental health clinicians began serving in 26 state service programs in 14 states from 2011 to 2018. Survey responses were received from 455 administrators reporting on 754 of 1380 clinicians (54.6%).Outcome Measures: Administrators' ratings of their sites' difficulty recruiting clinicians; relative ease, quickness and cost of recruiting the participating (index) clinician with the service program; program expected effects on participants' retention; participants' job performance.Results: Most administrators (66.1%) reported that recruiting clinicians of the index clinician's discipline is generally difficult but made easier (81.7%) and quicker (65.4%) with the service program, but only sometimes less expensive (34.8%). 78.8% of administrators anticipate that the clinicians will remain longer because of program participation. Participants are perceived to practice good quality care (96.9%) and be positive contributors (92.4%). Administrators' assessments are generally similar for the 3 types of programs.Conclusions: Administrators of safety net practices generally perceive states' loan repayment and loan forgiveness programs succeed in helping them recruit and retain good clinicians. ( J Am Board Fam Med 2022;35:1015-1025.)

Objective To explore the causes and levels of moral distress experienced by clinicians caring for the low-income patients of safety net practices in the USA during the COVID-19 pandemic. Design Cross-sectional survey in late 2020, employing quantitative and qualitative analyses. Setting Safety net practices in 20 US states. Participants 2073 survey respondents (45.8% response rate) in primary care, dental and behavioural health disciplines working in safety net practices and participating in state and national education loan repayment programmes. Measures Ordinally scaled degree of moral distress experienced during the pandemic, and open-ended response descriptions of issues that caused most moral distress. Results Weighted to reflect all surveyed clinicians, 28.4% reported no moral distress related to work during the pandemic, 44.8% reported ‘mild’ or ‘uncomfortable’ levels and 26.8% characterised their moral distress as ‘distressing’, ‘intense’ or ‘worst possible’. The most frequently described types of morally distressing issues encountered were patients not being able to receive the best or needed care, and patients and staff risking infection in the office. Abuse of clinic staff, suffering of patients, suffering of staff and inequities for patients were also morally distressing, as were politics, inequities and injustices within the community. Clinicians who reported instances of inequities for patients and communities and the abuse of staff were more likely to report higher levels of moral distress. Conclusions During the pandemic’s first 9 months, moral distress was common among these clinicians working in US safety net practices. But for only one-quarter was this significantly distressing. As reported for hospital-based clinicians during the pandemic, this study’s clinicians in safety net practices were often morally distressed by being unable to provide optimal care to patients. New to the literature is clinicians’ moral distress from witnessing inequities and other injustices for their patients and communities.

Background: There have been no studies to date of moral distress during the COVID-19 pandemic in national samples of U.S. health workers. The purpose of this study was to determine, in a national sample of internal medicine physicians (internists) in the U.S.: 1) the intensity of moral distress; 2) the predictors of moral distress; 3) the outcomes of moral distress. Methods: We conducted a national survey with an online panel of internists, representative of the membership of the American College of Physicians, the largest specialty organization of physicians in the United States, between September 21 and October 8, 2020. Moral distress was measured with the Moral Distress Thermometer, a one-item scale with a range of 0 (“none”) to 10 (“worst possible”). Outcomes were measured with short screening scales. Results: The response rate was 37.8% (N = 810). Moral distress intensity was low (mean score = 2.4, 95% CI, 2.2–2.6); however, 13.3% (95% CI, 12.1% - 14.5%) had a moral distress score greater than or equal to 6 (“distressing”). In multiple linear regression models, perceived risk of death if infected with COVID-19 was the strongest predictor of higher moral distress (β (standardized regression coefficient) = 0.26, p < .001), and higher perceived organizational support (respondent belief that their health organization valued them) was most strongly associated with lower moral distress (β = -0.22, p < .001). Controlling for other factors, high levels of moral distress, but not low levels, were strongly associated (adjusted odds ratios 3.0 to 11.5) with screening positive for anxiety, depression, posttraumatic stress disorder, burnout, and intention to leave patient care. Conclusions: The intensity of moral distress among U.S. internists was low overall. However, the 13% with high levels of moral distress had very high odds of adverse mental health outcomes. Organizational support may lower moral distress and thereby prevent adverse mental health outcomes.

Objectives: The impact of the COVID-19 pandemic has been particularly harsh for low-income and racial and ethnic minority communities. It is not known how the pandemic has affected clinicians who provide care to these communities through safety-net practices, including clinicians participating in the National Health Service Corps (NHSC). Methods: In late 2020, we surveyed clinicians who were serving in the NHSC as of July 1, 2020, in 20 states. Clinicians reported on work and job changes and their current well-being, among other measures. Analyses adjusted for differences in subgroup response rates and clustering of clinicians within practices. Results: Of 4263 surveyed clinicians, 1890 (44.3%) responded. Work for most NHSC clinicians was affected by the pandemic, including 64.5% whose office visit numbers fell by half and 62.5% for whom most visits occurred virtually. Fewer experienced changes in their jobs; for example, only 14.9% had been furloughed. Three-quarters (76.6%) of these NHSC clinicians scored in at-risk levels for their well-being. Compared with primary care and behavioral health clinicians, dental clinicians much more often had been furloughed and had their practices close temporarily. Conclusions: The pandemic has disrupted the work, jobs, and mental health of NHSC clinicians in ways similar to its reported effects on outpatient clinicians generally. Because clinicians’ mental health worsens after a pandemic, which leads to patient disengagement and job turnover, national programs and policies should help safety-net practices build cultures that support and give greater priority to clinicians’ work, job, and mental health needs now and before the next pandemic.