The fourteenth episode of MedCast features, Mr. Corey Feist, Chief Executive Officer and Co-Founder of the Dr. Lorna Breen Heroes' Foundation. In this episode, Mr. Feist talks about his sister-in-law's story and physician mental health.
Dr. Stephen Rockower (00:00):
Welcome to MedCast, the podcast from MedChi, the Maryland State Medical Society. Each episode we'll be doing a deep dive into medicine and taking an insider's view of facing Maryland's physicians and patients and healthcare more broadly. I'm your host, Dr. Stephen Rockower. Today, instead of interviewing a physician, we have the pleasure of sitting down with Corey Feist, a healthcare executive with over 20 years of experience. Corey is the co-founder of the Dr. Lorna Breen Heroes Foundation, and Corey recently served as Chief Executive Officer of the University of Virginia Physicians Group. He has a personal and compelling story to share about mental health and physicians, which changed your trajectory of his personal and professional life. Welcome Mr. Feist.
Mr. Corey Feist (00:54):
Thank you so much for having me.
Dr. Stephen Rockower (00:56):
So let's just start by giving some of the background into, you know, where Lorna was, where she was working, what happened to her, and her whole story.
Mr. Corey Feist (01:11):
Sure and, you know, thanks again for having me and thanks for highlighting this issue. So, Cory Feist here, president and co-founder of the Dr. Lorna Breen Heroes Foundation. We created the foundation following Lorna's passing, and I'll share with you a little bit about Lorna's passing. And I'll also kind of incorporate just a little bit about my background, because I was the Chief Executive Officer of the UVA Physicians Group down in Charlottesville, Virginia when this happened. Many of the issues that Lorna shared with us were not ones that were really top of mind for me as an executive overseeing a very large medical group. And had spent my entire career dedicated to supporting wellbeing of healthcare workers, and their administrative resources. So I just kind of put that at the top of the answer.
Lorna Breen was a 49 year old, incredibly accomplished, Ivy League trained, physician really practicing at the top of her game in New York City. She was the medical director of the New York City, New York Presbyterian Allen hospital. She was the medical director specifically of the emergency department there. And she was on faculty at Columbia where she was also obtaining her MBA at Cornell, just across the street, really trying to advance her career. Lorna was the the child of a physician and a nurse, the brother, sorry, the sister of another physician. And also the sister of my wife Jennifer. My wife Jennifer and I are both attorneys, and we met in law school. Jennifer, of course, was the outlier in the family, 'cause she was the non-clinician. But, Lorna was with us in at the annual ski trip that we always went on with her.
She had no children, and she always wanted my kids to learn how to ski. And so every spring break she took off our spring break to, to teach them to ski; it was her passion. She was incredibly passionate. She, in some ways, was the prototypical stereotype of an emergency medicine physician. Just out there, always traveling doing all sorts of really active, active things. She learned how to play the cello late in life. She was a salsa dancer. She was a snowboarder, a world traveler. And so she was doing just that, by taking care of the needs of her nieces and nephews on the side of a mountain, or at least in her mind, that. And that was really, that was the beginning of March, 2020. And Lorna had never had any prior mental health challenges in her career.
She was really thriving, a really thriving physician and really living at the top of her game. So Lorna, in the span of three weeks returned from that ski trip to treat confirmed covid patients, contract covid herself, and then come back to work too soon. Clearly she was very sick with Covid, but not sick enough to be admitted. During her waking hours when she was recovering at home, she was really trying to manage two very busy emergency departments in Manhattan at that peak of the pandemic. And then when she was afebrile for about 12 hours, she put herself back on the rotation and worked multiple 15 hour shifts in a row. To a point that about seven days into that she broke. Now, I want to just pause for a second, because Lorna's first day back was April 1st, 2020.
And she called us that day and she shared with us two important things for the story. The first was that what she was seeing was a volume of death and dying that she, as a seasoned physician, had never experienced before. And the second thing that she articulated to us was that for the first time in her career, she couldn't keep up with the volume. She couldn't keep up with what she was seeing, emotionally. She expressed to us concerns, that her colleagues could see her not being able to cope, and that that was going to be negatively impacting her professional reputation and her career. And instead of heeding our advice to go back home, because she was very sick, she just didn't have a fever. And remember this is like the beginning of the pandemic. So when the covid hit people, it hit 'em hard.
Dr. Stephen Rockower (05:46):
Nobody knew what was going to happen.
Mr. Corey Feist (05:46):
Nobody knew what was gonna happen, nobody. And so she pushed on, she pushed through, she worked 15 to 20 hour days, and she called us on a, I think it was the 7th or 8th of April, catatonic in her apartment and needed to be medically evacuated from New York City. Which was a challenge in and of itself because New York was shut down. So, we had a chain of friends and family that started to drive her south from New York. All the while, while my wife Jennifer was driving north from Central Virginia and actually picked Lorna up on the side of I695 outside of Baltimore, and turned around and immediately drove her to the emergency department at the University of Virginia. As I mentioned before, I was the CEO of the UVA physicians group. And so we had arranged for her to be admitted to the inpatient psych unit.
What I would just maybe wrap up by saying is that we thought Lorna was doing a lot better, but as she started to kind of come out of the fog during her inpatient stay, she began to articulate to us another concern, a concern that was not at all ever on my radar. And I mentioned before that I was an attorney, and I was the general counsel for the physician's group for many years. And I was an, a lawyer for the medical center for many years, the medical center at UVA. She started to say things like, now that I've obtained mental health treatment, now I'm gonna lose my license and my credentials to practice. And we thought that that can't be possible in today's age, but she continued to hold firm that was in fact the case. And on just a few days after she was discharged on the 26th of April, Lorna died by suicide.
And I'll end by saying that the family had really hoped in that horrible moment, that moment that you never think you will ever experience. We wanted to maintain our privacy. We were devastated, beyond devastated that this could have happened. And we didn't want anyone to know, because we too were so burdened by the stigma around mental health and suicide. But over our objection the New York Times published her cause of death 12 and a half hours after Lorna died, which then opened up a national conversation for our family. A conversation we were not prepared for, but a conversation that we decided to step into and engage with. Because what we heard then, days and days and days, actually for multiple years thereafter, was consistent feedback from the healthcare workforce about the state of affairs that had been hidden in plain sight from people like me who was a healthcare leader, but just not a practitioner. But really starting to express concerns around mental health as well as as burnout, which is an occupational syndrome. And so, just a few months after Lorna's passing in response to the outcry of enough is enough from the healthcare workforce, my wife and I gathered our witts and we created the first Dr. Lorna Breen Heroes Foundation with the exclusive focus of the wellbeing, the professional wellbeing, and mental health of healthcare professionals everywhere, envisioning this future state where it is a sign of strength to obtain mental health treatment if you are a clinician.
Dr. Stephen Rockower (09:25):
And with that foundation I know that Senator Tim Kaine got involved and you got things passed through Congress.
Mr. Corey Feist (09:37):
Yes, one of the many things that we've been able to accomplish in the three years that we've been in existence as a foundation is that in March of 2022, we were in the Oval Office with President Biden, watching him sign the first ever federal law creating programs to support the wellbeing of healthcare professionals named after Lorna, the Dr. Lorna Breen Healthcare Provider Protection Act. Which infuses over $140 million of new programmatic dollars into health systems across this country to support the wellbeing and mental health of healthcare professionals. And as I said, that's one of many things, but if you know anything about how long it takes to get new legislation passed and funded we did this in about 18 months. And it was in part because we were able to share with members of Congress Lorna's story. But more importantly, because we were able to share and shine a light to members of Congress on the stories of other healthcare professionals, the hundreds and hundreds of healthcare professionals who reached out to us to express their concerns about the state of the wellbeing of the workforce. And I'll just point out one other thing about the law, Dr. Rockower.
This was discussed with Senator Kaine at the beginning of the pandemic. And so we envisioned the Dr. Lorna Breen Healthcare Provider Protection Act as the first few steps of a full staircase of health policy that we're trying to help create, but recognize that it was not intended to address what now has been experienced by the healthcare workforce, all these shortages. It was really signaling and pointing back to a day that was really a pre-pandemic state of burnout and a state of depression around physicians and other healthcare professionals. So I just point that out, that it was really a first few steps and we continue to work with a bipartisan, and bicameral coalition of really dedicated members of Congress as well as professional associations to advance policy, to support professional wellbeing of healthcare workforce.
Dr. Stephen Rockower (11:52):
You said that she had never had any previous mental health challenges. Was there anything, you know, when she got sick and started coming back that gave you any indication that something like this might happen?
Mr. Corey Feist (12:10):
None whatsoever. I mean, this is one of the pieces about this that is so illustrative to the family is that clearly covid impacted her cognition, there's no question. And now there's a myriad of examples of that, but this was the first weeks of covid. It clearly was impacting her judgment and her cognition. She she definitely had had issues there. But what I would say that was just so illustrative to the family was how quickly something like this can come on and how, while there are a myriad of things that we need to do to address and support mental health and wellbeing of healthcare workers being courageous enough to use that new nine eight, eight phone number or raise your hand and speak about these issues, is really a lifesaving exercise. And this is not something that anyone who has a family member or loved one or themselves is concerned about, should wait on at all. If Lorna's story is any indication of how quickly something like this can happen, this was three weeks start to finish, now we can't do anything about it, because she's gone.
Dr. Stephen Rockower (13:27):
Wow. Three weeks is just mind blowing to me. Y ou said that there are new numbers being done and, and things about stigma. Can you talk more about the stigma that physicians feel to bring out any other problems and what kind of licensing problems physicians have?
Mr. Corey Feist (13:56):
For sure. so I, I like to think about the conversation around wellbeing as a Venn diagram with one side of the Venn diagram addressing burnout, which is an occupational syndrome, not a mental health syndrome. And on the right side of that, thinking about things like depression and substance use disorders and anxiety, because those are true mental health conditions. So I think we have to address this in kind of at least both of those domains. And then in the middle, we'll talk about the middle. But, you know from the burnout perspective, I think first and foremost, we need to recognize that burnout is not what is creating suicide in healthcare workers, particularly physicians. Burnout is an occupational syndrome, it is a reaction to a stressful work environment. And thus far, the response that I would call the well-intended response to support physicians and other healthcare workers has really been to provide individual support to those healthcare workers.
It's tantamount to holding pressure on a bleeding wound when a patient comes into the emergency room, but that's only part of what needs to happen. We need to go beyond individual support in that case, and we need to get to systems change, those underlying root causes of the bleeding, if you will. And there are a myriad of contributing factors there. But when I look at the data, and I'll point back to January of 2023, Medscape continues to publish a survey around that time of the year and ask physicians, what is the number one driver of your burnout? And by double digits, the number one driver continues to be the administrative burden. That was the case before the pandemic, during the pandemic, and after the pandemic. In fact, during the pandemic and after the pandemic, when you looked at the laundry list of issues that were contributing to the burnout of the workforce, your eyes had to drop all the way to the bottom of the page to see the words covid appear.
So that's kinda the burnout side, and that's what really needs to happen, is we need to double down on removing the administrative burden from the healthcare professionals, particularly physicians.
Dr. Stephen Rockower (16:01):
The dreaded EMR.
Mr. Corey Feist (16:03):
The dreaded EMR. But these are all things that can be done. That's why I say it's kinda the roadmap, right? So when I think about the mental health side of that Venn diagram, what we see on the right side, or that's always the way I show it on a side. The mental health side. What we need to make sure that we understand first is that there are these barriers to mental health access that uniquely appear apply to licensed healthcare professionals, physicians, nurses, pharmacists, et cetera. Beyond that, we also need to train healthcare professionals and how to diagnose and treat suicide.
Because what we have seen repeatedly is that when healthcare professionals are trained on what the symptoms of suicide are and what to do when they see those symptoms exhibited. We are seeing them intervene with each other when they see a peer exhibit those symptoms. And then finally, we need to make it abundantly clear where the confidential pathways to mental health treatment are. So I'll go back up kind of that top of that third list, because this is where we spent a tremendous amount of time, and we have made incredible progress. So from, from the barrier perspective, in the fall of 21, we published an article in US News and World Report where we identified six barriers to mental health access. Four of the six are exactly the same issue, which are overly invasive questions, which appear on applications that physicians, nurses, pharmacists, et cetera, have to complete, in licensing, hospital credentialing, insurance credentialing, malpractice credentialing, and the list goes on and on. So those are the first four. Beyond that, there are certain states, and I'm not sure if Maryland is one, there are certain states where any healthcare professional's mental health medical record can be subpoenaed if that healthcare professional is being sued and a civil action for a malpractice or whatever that might be. So HIPAA, in other words, doesn't protect I, again, I'm not sure of Maryland's laws,
Dr. Stephen Rockower (18:16):
I believe we're protected, but I'm not a hundred percent sure
Mr. Corey Feist (18:19):
Perfect. We'll wanna make sure and we'll need to circle back and let the audience know. And then finally, this is one that speaking with the widow of Dr. Scott Jolly in Utah. She explained to us that when physicians and other healthcare professionals are on the health insurance of their health system, the health system often decides which services can be used. In other words, which facilities can be used and accessed. Well, we need to make sure that when health plans are created by health systems, that those health systems are giving their workforce an alternative pathway outside of their health system to obtain mental health care. Because if you talk to Scott's wife, Jackie, Jackie will tell you that his health system in Utah limited his access to his own facility. And it was the stigma that he felt associated with that. That really impacted his decision to die by suicide. It was a few months after Lorna died.
Dr. Stephen Rockower (19:23):
So he wouldn't go to the doctors in his facility because he didn't want it necessarily to be known that he was having troubles.
Mr. Corey Feist (19:31):
Actually, I should have explained it. He did, he was admitted, but the only facility that he could get insurance coverage for, because it was, you know, the only facility that his insurance would pay for. Because, it was the plan that was designed by his health system, was his health system. So he was admitted to his health system, wheeled by his colleagues after discharge died by suicide because he was so burdened by the stigma. So those are the six main barriers. As I said to you, the first four are these overly invasive questions. And so one of the things that we've done is we've published a toolkit on our website, which allows organizations, whether you're a licensing board, a hospital system, an insurance company, a malpractice insurance company, to take three simple steps to audit, change, and then communicate the changes of these questions to the workforce.
Now, why is this important, other than the fact that we've kind of stumbled on it? Well, in October of 2022, the American Hospital Association published its first ever suicide prevention guideline that was funded by the CDC. And in that guideline, they identified three key drivers of suicide of healthcare professionals. This is the number one driver of suicide stigma and concerns of loss of license. So we knew that this was an issue, and now it has been documented as the number one driver of why healthcare professionals are dying by suicide in this country. And so what we've done as a result is take this toolkit, and scale it across the country. It is being used all over the place. In May of 2023, we published a joint statement with NIOSH, as an example, pushing out the toolkit to all hospital systems in the country saying: make these changes.
We conducted an audit of physician licensing in the fall of 2022. We published that in US News and World Report. And at that time, there were 21 states that were compliant with the Americans with Disabilities Act and really asked, what I would say is, appropriate questions. Since that time, we are now pushing the country or helping the country achieve a state where the vast majority of the states are changing their questions. And we've developed a badge recognition program for anyone who wants to apply to us, and we will help them change their questions using the toolkit using our free legal services that we've been donated to help them change these questions and make the environment one where physicians, nurses, and other healthcare professionals can obtain mental health treatment without fear of professional repercussions.
Dr. Stephen Rockower (22:24):
Let's take a quick break. We're speaking with Mr. Corey Feist, the Director of the Dr. Lorna Breen Heroes Foundation, speaking about physician mental health and suicide.
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Welcome back to Med, the podcast for MedChi, the Maryland State Medical Society. We're continuing our discussion with Mr. Corey Feist, as he discusses physician mental health and suicide. Tell me more about the licensing concerns that you've been having and, and what you're dealing with in states and specifically in Maryland so that physicians don't feel the stigma.
Mr. Corey Feist (23:42):
Absolutely. As I mentioned before, our toolkit is really scaling the country. And what's exciting about it is when we share our toolkit with organizations, usually the first response is, I have not looked at these questions, or, we as an organization have not looked at these questions for a very long time. We had no idea that these questions were really enhancing this stigma, reinforcing the stigma, and serving as a barrier and a concern. And wow, this was easy to change when they do it. The record in terms of speed to change right now is 48 hours. We had a health system that also owned an insurance plan, by the way, changed their questions on a Friday afternoon after we had a conversation with them, and published those changes on Monday morning very, very fast.
But basically what we're asking organizations to do is to take a look at their, if they're a licensing board or a hospital with credentialing application, take a look at your initial and renewal applications, take a look at your peer reference forms, and don't just look at the one question that might might be clearly asking about prior mental health. But there's a lot of little sneaky questions in there. we can help with that. But basically what we want them to do is we, we give everyone three choices. One is to eliminate all those questions altogether. Don't ask any questions, because the reality is as we know, a physical condition can be just as impairing as a mental health condition. And I should say an untreated physical condition can be just as impairing to someone's abilities as a mental health condition.
So why are we differentiating? I think that's antiquated thinking, and the data would support that. So option one, don't ask any questions. Option two, ask a question that focuses exclusively on current impairment. The Federation of State Medical Boards, the American Medical Association, and our foundation, have supported a statement which basically limits questions to current impairment. The third choice would be to go to the model that has been adopted by states like North Carolina and Mississippi, which asks for an affirmation from the applicant that they're taking care of their wellbeing. In those states, they clearly recognize the connection between self-care and patient care. In order to do your job and be a clinician at the top of your game and deliver the highest quality, you gotta be taking care of yourself.
Those two states are saying, attest to us that you're doing that. I think we need 48 more of those to happen in this country. But so those are the three criteria. And basically what happens is organizations take a look at our toolkit. It says, pull out all your forms and your peer reference forms. Take a look at this, change them if necessary, submit the forms to our foundation through our portal, have us verify to you that you're doing that. We find often the fine print is where where we help organizations make changes. I will tell you every single organization, and we've worked with dozens and dozens who come to us to submit their questions, who say, hey, I think, I think we're good, but will you take a look?
Every one that we've said, "Hey, here's one more. Here's one more little sneaky one that we found". They said, "oh, great". And they change it. We give a badge of recognition, this all in wellbeing first challenge badge which is dated for an organization. And then we give them a communications toolkit so that they can tell their workforce what is current state. And I'll tell you we're working with Maryland right now actively on changing their questions because they were not in that initial cohort of 21 states. But I wanna point to another state for just a brief moment because just to show you the impact. So I was recently working with Oregon, and Oregon changed their medical licensing questions over the course of a week that we worked with them.
And then they used our toolkit, and they sent a blast email to all physicians in the state. And the very top of it said, "we want you to take care of your wellbeing. Here's what we've done. Here's a link to the badge so you can see that we are a safe state". And I heard the next day from a physician, and she reached out to me, forwarding me that email from the medical board saying, "thank you, thank you, thank you. I was just about to apply for my renewal, and I have been terrified about how to answer these questions". And so you know, like I've said, this has been an issue that's been hidden in plain sight for so long. And it's an issue that that impacts people selectively, you know, in a time where they are just so vulnerable. They're so burdened by the stigma. They don't wanna ask the questions at the time of someone else: "Is this gonna be okay?" So what we find, by and large, is that physicians and other licensed healthcare professionals don't get help because they're fearful of the professional consequences of doing so. We've gotta change that dynamic.
Dr. Stephen Rockower (29:11):
What does organized medicine, both on the state and national level, do to help you in all this?
Mr. Corey Feist (29:20):
Oh, I thought you'd never ask. Yeah. yeah, great question. We have got to lock arms as a healthcare industry on the issue of supporting the professional wellbeing and mental health of our healthcare workforce. We have seen turnover at all levels across healthcare, physicians, nurses, and others. What I think is important here is that while there are an ocean of issues to boil, the data can be our roadmap. One of the things that we created was a national initiative called ALL IN: WellBeing First For Healthcare. And in that we brought together hospital associations and medical societies and pharmacy associations and other parties across organized medicine to lock arms and to scale wellbeing solutions at a policy level, at a practical and local level, as well as to remove these barriers to mental health access.
And so, what organized medicine can do to support is to follow our roadmap with ALL IN: WellBeing First For Healthcare. Within that, we've created actually our own program called Caring for Caregivers, which has three steps to it. Organized medicine can absolutely jump on board with these three steps. There's nothing radical about 'em, they're just organized, frankly. The first is to make sure that we eliminate every single one of those six barriers to mental health access to together. That's step one. Step two is to create a common vocabulary of understanding and bridge the gap that we're observing between healthcare professionals and healthcare leaders around what's needed. Because what we've seen is this heavy focus on individual resiliency and individual support, which is critical, but we've gotta go beyond that. So making it clear between organized medicine, different segments that we understand what these drivers of burnout are, and we're gonna go after them, and that they are achievable to go after together in a very methodical way.
And what we've done to attack that is working on learning collaboratives across the country focused on operational improvements, which tie to wellbeing, whether those be quadruple aim quality initiatives. We're attaching to every quality initiative in an institution, the view on professional wellbeing of the workforce, or the impact of that quality initiative on the professional wellbeing, or taking on focused initiatives. You mentioned before, electronic medical record making sure that that top 10 list that's been published by the EMR vendors around these are the top 10 things you should do. That gets to the front line and they're actually being done. It's not just a one-time conversation, it's an iterative and ongoing conversation.
So there's, there's a roadmap here. These are all very achievable, but organized medicine we have already included and we want to include in spades. And I would maybe go beyond that just to say that in January of 2023, I had a chance to host a panel at the AMA State Advocacy Conference in Tucson, Arizona. And in that moment, what we did was we took that Venn diagram that I just explained to you before, and we mapped policy solutions at a state level to it. What we found is that there are organizations and states across the country that are really developing best practices in each one of those domains, whether that be working on things like prior authorization or other administrative burdens, whether that be making sure that there are no barriers to mental health access, or making sure that there's confidential pathways to mental health care, et cetera, et cetera. But we would love the assistance of organized medicine and making sure that on every single state that we are really adopting the best practices at a policy and a practice level.
Dr. Stephen Rockower (33:27):
We are, and we are trying to help us as much as possible. But I gotta ask, you know, in these days of so much anti-scientific literature out there, have you gotten any pushback from the anti-vaxxers or the anti-science people that think this is all a hogwash?
Mr. Corey Feist (33:51):
No. In fact, I would say to you, what is remarkable for me, and I spent multiple decades inside the house of medicine, is how little resistance there's been. The resistance has only come in the form of organizations being so saturated with priorities that this is a hard one to take on. When you explain to them something like the licensing and credentialing toolkit is so easy to do. If you think about it, the two by two matrix you see on change initiatives where you have on one access, the effort, and on the other access, you see the impact. This is in the quadrant everyone wants to be in, which is in the high impact, low effort quadrant. When you show organizations that these are achievable, they're practical, they move the needle, organizations move quickly.
And so we've had almost no resistance to this at all. As I said, really the resistance has only been one of capacity to take it on. I would just share with you that when you think about the massive amount of turnover that we've had from healthcare professionals, physicians and nurses, and then you think about how long it takes to create more pipeline it's many, many, many years. 70% of a physician's time on average and 50% of a nurse's time on average is spent in administrative processes. You can immediately create more clinical workforce by reducing and eliminating that administrative burden. These are all very practical things. They take focus, but they are achievable. We are just honored, frankly, to be a part of this conversation now and working together with state and federal organizations like to really stay focused, laser focused on what are the root causes and what are the practical solutions. So that we can save this patient. Right now the healthcare workforce and the healthcare industry is really struggling, it is on life support. We need to look at why it's on life support and really take care of it, or it won't be here for much longer.
Dr. Stephen Rockower (36:18):
Well, this has been a fascinating conversation. I want to thank Mr. Corey Feist, who's been our guest on MedCast, the podcast from MedChi, the Maryland State Medical Society. If anyone listening has any type of mental health concerns, please call the nine eight eight hotline or call the Physician Health Line of MedChi at 800-992-7010 or email firstname.lastname@example.org. Thank you again, Mr. Feist.
Mr. Corey Feist (36:58):
It's been a pleasure. Thank you so much
Dr. Stephen Rockower (37:01):
For all of us here at MedCast. I'm Dr. Stephen Rockower. Thank you. And goodbye.