Heal the System
Feb 18, 2020 Cassie Tomlin
How can physicians improve access to healthcare? Can a policy change help address unmet health needs? New doctors and nurses are seeking solutions to the frustrating problems that can arise from well-intentioned layers of bureaucracy.
For the past three years, Cedars-Sinai has partnered with UCLA on the National Clinician Scholars Program, a nationwide consortium based at six higher-learning institutions. The program trains early-career physicians and PhD nurses to navigate, evaluate and sometimes redesign the healthcare system to better serve doctors and patients. That includes recognizing systemic shortcomings as well as proposing and evaluating solutions to positively influence public health policy. The scholars treat patients at Cedars-Sinai and earn a master's degree at UCLA while performing health services research under the guidance of expert mentors at both institutions.
Teryl Nuckols, MD, vice chair of Clinical Research, who oversees the program, says, "Fellows have the opportunity to devise answers to big questions, such as, 'What does it cost to improve quality of care?'"
Meet the Fellows
CARL BERDAHL, MD, Emergency Medicine
THE PROBLEM: Even though paperwork is now mostly digital, primary care physicians almost universally express frustration with its increased burden. One study found that 70% of physicians report IT-related stress. Increasingly stringent requirements to document visit details and update electronic health records squeeze them for time—often at the expense of patients.
THE STUDY: Recent rules from the Centers for Medicare & Medicaid Services (CMS) aim to incentivize physicians to focus on quality care but require even more documentation. Berdahl studied physician reactions to one "pay for performance" policy implemented by CMS in 2015.
THE OUTCOME: Most physicians agreed the policy's crushing administrative burdens cost them time with patients, for a net negative effect. Berdahl says his work demonstrates that CMS should simplify requirements and provide more technical assistance to doctors who struggle to find enough time in their workdays for administrative demands.
THE TAKEAWAY: "What we want and what patients want is to be face to face addressing each other, but a lot of things need to go on behind the scenes to ensure we're doing our jobs well," he says. "However, it's hard to make meaningful change when you're spending so much time in front of a computer screen."
PARALLEL PROJECT: Berdahl, who trained at Yale and the University of Southern California, also spent a month in Washington, D.C., analyzing health policies at the U.S. Department of Health and Human Services during the transition between presidential administrations.
"In federal government, you have two types of people: the political appointees and career civil servants—the lifers," he says. "Despite varying political beliefs, a lot of federal employees are trying to do great things on the inside."
ISH BHALLA, MD, Psychiatry
THE PROBLEM: Patients suffering from mental illness are often admitted to emergency departments (EDs) in hospitals that don’t have inpatient psychiatric departments. In Los Angeles County, about 57 times a day a patient is transferred out of an ED to a more appropriate facility.
THE STUDY: Bhalla, who subspecializes in forensic psychiatry, evaluated a pilot program implemented by L.A. County at 10 EDs—including the Cedars-Sinai Ruth and Harry Roman Emergency Department—designed to streamline the transfer process. The program allowed physicians to facilitate transfers immediately, instead of waiting hours or days for county-designated representatives.
THE OUTCOME: "This change had ripple effects throughout the entire array of services, everything from outpatient to the ED to inpatient," says Bhalla, who also found that the program helped avoid treatment delays and alleviate backups in EDs.
"Patients who come into the ED are in crisis—they may have used drugs or are suicidal or thinking about becoming violent," he says. "This change has helped them more quickly get to the inpatient hospital so they don’t have to sit in the ED, which is a loud and busy place. You can’t heal in that environment."
THE TAKEAWAY: "It's not just what medications we put them on when they’re here," he says. "When they’re released, how do they get their prescriptions filled by a pharmacy? How does the patient manage to actually put pills in their mouth? What about housing, employment, transportation and therapy?"
PARALLEL PROJECT: Bhalla also studies how the criminal justice system handles mental health services, how inmates are evaluated to stand trial and how they receive services behind bars. Additionally, he seeks solutions to poor coordination of care for mental health patients that often results in higher hospital readmissions.
MOLLY EASTERLIN, MD, Pediatrics
THE PROBLEM: Pediatricians are trained to recognize when family stress affects a child's health, Easterlin says, but they often struggle to find opportunities to intervene.
THE STUDY: In a 2019 study published in JAMA Pediatrics, Easterlin found that among children who experienced neglect, abuse, divorce, parental incarceration or other hardships, those playing team sports in adolescence were less likely to be diagnosed with anxiety or depression during young adulthood.
THE OUTCOME: Easterlin says her findings indicate that pediatricians should consider recommending team sports to foster resiliency, and also that public health policies should expand access to team sports in lower-socioeconomic schools and neighborhoods.
"Families often have to pay thousands of dollars for children to participate," she says. "Sports programs should be accessible to everyone."
THE TAKEAWAY: "We need to find ways that the healthcare profession can support families," she says. "There's not always a medicine for these things."
PARALLEL PROJECT: After graduating from the National Clinician Scholars Program, Easterlin began a fellowship at the neonatal intensive care units at Los Angeles County+USC Medical Center and Children's Hospital Los Angeles. With Cedars-Sinai researchers, she is also studying whether virtual reality can alleviate stress and anxiety for children with chronic diseases, like those with inflammatory bowel disease who receive frequent infusions and blood draws.