Advancing Health Podcast

00:00:01:06 - 00:00:23:23
Tom Haederle
Welcome to Advancing Health. Cyberattacks directed against hospitals continue to increase, and many cyber threats quickly escalate into a governance and patient safety issue. In today's podcast, we learn about how board members can educate themselves and prepare to help their organizations face these threats.

00:00:23:25 - 00:00:48:15
Sue Ellen Wagner
I am Sue Ellen Wagner, vice president of Trustee Engagement and Strategy at the American Hospital Association. I'm delighted to be with Ajay Gupta today. He is the board chair of Trinity Health Mid-Atlantic and Holy Cross Health, and he's also the co-founder and CEO of hsr.health. It's nice to have you with us, Ajay, today to talk about cybersecurity and what trustees need to know.

00:00:48:18 - 00:01:08:16
Sue Ellen Wagner
I am hoping this podcast will be a nice 101 for board members to educate them about [what] their role is in cybersecurity, and what they should know to prepare for a cyber incident should one occur at their hospital or health system. Ajay, you have both business experience in the cyber industry and you're also a board member.

00:01:08:19 - 00:01:38:14
Sue Ellen Wagner
So your insight will be very valuable to our members and our listeners. Cybersecurity vulnerable cities and intrusions really do pose significant risks to hospitals and health systems, and the threats continue to increase each year. It's important for trustees to be ready should an incident happen at their hospital or health system. So, Ajay, can you tell us what trustees should know to be prepared should an incident occur?

00:01:38:16 - 00:02:04:04
Ajay Gupta
Thank you, Sue Ellen. It's great to be here with you today. And thank you for this question. It's a great overall question for a 101. I wish there could be a short answer, right? You only need to know a couple of things for cybersecurity. It's unfortunately not quite like that. I think the first place to start is to recognize that cybersecurity is a technical issue, and it's always really been thought of as something that IT would handle.

00:02:04:06 - 00:02:31:12
Ajay Gupta
But today we need to know that given how much of our care delivery relies on IT systems, should those systems become unavailable, whether due to a cyberattack or any cause - it very quickly becomes a patient safety and governance issue. As such, trustees need to ensure hospitals are prepared. And for cyber, preparation means can our clinical teams continue to provide care if systems go offline?

00:02:31:15 - 00:02:53:12
Ajay Gupta
The board's role is to provide oversight and confirm the organization is ready, not just to defend against the cyber attack, but also to operate through one safely. But this starts by understanding what the nature of our IT infrastructure is and how stable is it? How secure is it? Are we comparing ourselves against benchmarks? What measures are we taking to ensure its security,

00:02:53:12 - 00:03:15:09
Ajay Gupta
and are those measures tested? Are our IT and cybersecurity departments aware of the trends the security of the industry is facing overall from a cyber threat landscape? Because that will depend and it will influence what kind of measures we take in the defense and in the resilience during the middle of the year of an incident. I hope that's a good starting point for discussion.

00:03:15:12 - 00:03:34:25
Sue Ellen Wagner
It's a great starting point and cyber security is very complicated. You had mentioned, you know, patient safety and quality, which are very important. How do trustees know if their hospital or health system is secure to continue to operate and provide that clinical care that's safe should a breach really occur?

00:03:34:27 - 00:04:11:00
Ajay Gupta
Well, if a breach has occurred, Suellen, by definition, the system is not secure at that moment, unfortunately. But to more broadly respond to your question, trustees need to ask about the resilience of the IT systems in the face of a possible cyberattack. That's really the question that we need to say. Unfortunately, we are operating in an environment where some level of cyberattack, whether an overt attack from a bad actor or even just the system's combination of users across the spectrum and anything else causes an IT issue that brings systems down.

00:04:11:06 - 00:04:32:29
Ajay Gupta
We need to know how resilient we are in any and all of those systems. And the only way to know if operations can continue during a breach is to experience continuing during a breach. Of course, we don't want that. So we have to do the next best thing: testing, preparation and practice. All of that is more and more important.

00:04:33:06 - 00:04:59:24
Ajay Gupta
That means having an incident response plan in place, which is not terribly unlike plans we may have - we likely have - in place for a natural disaster, or if there is a an expected surge in trauma. We have plans in place for surge and we need to have a cyber plan in place as well. This is a plan that lets everyone know what to do exactly during a cyber event, without any confusion or momentary disarray, because we know that can cause patient harm.

00:04:59:27 - 00:05:27:15
Ajay Gupta
Our critical care workflows like medication administration, lab orders, and surgical schedules operational without digital systems. Do clinicians know how to access key information when digital systems go down? And do clinicians remember how to treat patients when they don't have access to all of the digital sources of information, like lab reports or film that they do typically use in the course of patient care.

00:05:27:18 - 00:05:29:20
Ajay Gupta
That's a big, big issue as well.

00:05:29:22 - 00:05:55:10
Sue Ellen Wagner
Well, relying on the digital world that we live in today is something that we're all used to. You had mentioned that, you know, most trustees won't have an idea of what a cyber security incident is until it actually happens to them. So preparing is really difficult. And I think that's something none of us want as board members. Can you explain to trustees the impact that that breach will have and what their role specifically should be?

00:05:55:10 - 00:06:01:21
Sue Ellen Wagner
Because management leadership has one role, the board has another. So can you just kind of describe that?

00:06:01:24 - 00:06:26:06
Ajay Gupta
It's important to remember that a breach is more than a tech failure. It is a system failure. It's a failure of our system and ability to deliver care. As such, trustees will have a specific role. A breach can paralyze care delivery, right? Shutting down systems, delaying surgeries, leaving clinicians without access to medical records. This means patients may not receive the care they need, the care they trust us to provide.

00:06:26:09 - 00:06:53:14
Ajay Gupta
It's important for trustees to know and understand that while the fault is not ours, the fault resides entirely with cyber criminals who perform the attack. But patients don't see the hackers. They see us. And so they see us as unable to provide the care they need when they need it. And this is a stain on our reputation. That is a critical thing for the boards and trustees to recognize.

00:06:53:16 - 00:07:15:12
Ajay Gupta
Breaches trigger reputational damage as well as regulatory damage and a financial fallout. For instance, health systems may face fines, according to the breach. The average cost of a cyber breach was reported at just under 10,000,000 in 2024, as reported by IBM, which was less than 2023 when it was reported at 11 million. However, I don't think that we can plan for that trend to continue.

00:07:15:16 - 00:07:43:03
Ajay Gupta
Trustees have to lead from the front by ensuring the organization is prepared with strong cyber governance, risk management practices and a culture of preparedness in place. Our role is to ask strategic questions and ensure readiness, and that we are able to continue serving patients and to recover swiftly, regardless of the situation. We need to make sure that we have the experts ready to act on our behalf in a cyber attack.

00:07:43:10 - 00:07:57:12
Ajay Gupta
Technical experts who can respond to the technical details and dimensions of the attack, as well as legal and communication experts that can help us communicate and handle some of the regulatory and legal fallout that may follow a cyber attack.

00:07:57:14 - 00:08:17:22
Sue Ellen Wagner
So I hope our listeners never have to deal with a cyber incident. We obviously can't control whether that will happen or not. So I'm hoping that this is really helpful for folks. I think if they listen to it, they can actually start asking their leadership if they don't have a plan to develop a plan, or the board should know what the plan is and what their role is.

00:08:17:22 - 00:08:28:24
Sue Ellen Wagner
So Ajay, the last question, can you highlight some of the key takeaways for our listeners, some nuggets of information that they should just, you know, take away from this podcast to prepare themselves?

00:08:28:26 - 00:08:53:25
Ajay Gupta
Absolutely. One thing I want to mention, what you just said is that we can't control. That's true, we can't. We can't control the weather. Yet hospitals and health systems in a hurricane prone region certainly know to prepare for a hurricane, right? In that same sense, hospitals have to be prepared for this. Cybersecurity is a patient safety issue because, as I said, we use technology in everything we do in a hospital today almost,

00:08:53:28 - 00:09:14:19
Ajay Gupta
or it seems. If it's a patient safety issue, it's a governance issue and the trustees have to be involved. The impact is very real. Any event that can halt care and erode trust and cost millions of dollars has to be of great concern. Continuity demands preparation. Again, just like we practice our surge plans, we practice our hurricane plans.

00:09:14:25 - 00:09:35:06
Ajay Gupta
We have to develop and practice technical continuity plans from a cyber breach perspective. And trustees must lead. Our role is oversight, which means we have to ensure management has thought through all aspects from defense against attack, resilience in the face of attack and addressing the potential fallout after the attack.

00:09:35:09 - 00:09:55:29
Sue Ellen Wagner
So thank you, Ajay. In addition to this podcast, AHA Trustee Services does have a few resources to help boards prepare should a cyber incident occur. So trustees should visit trustees.aha.org to access the resources. Ajay, I want to thank you so much for sharing your expertise with us.

00:09:56:02 - 00:09:59:11
Ajay Gupta
Thank you, Sue Ellen. It's great to be here.

00:09:59:13 - 00:10:07:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:04 - 00:00:25:09
Tom Haederle
Welcome to Advancing Health. South Dakota-based Sanford Health is the largest rural health system in the United States. Yet even with its size and resources, there are many challenges to delivering the care that patients need, especially regarding behavioral health services and the threats to care posed by cutbacks to Medicaid.

00:00:25:12 - 00:00:51:27
Rebecca Chickey
Hello, I'm Rebecca Chickey. I'm the senior director of behavioral health at the American Hospital Association. And is my great honor to be here today with Dr. Jon Ulven, who is chair of psychology of Sanford Health, which is the largest rural health system in the country and covers North Dakota, South Dakota, Minnesota, and probably parts of the country that are very small and rural surrounding those states.

00:00:51:29 - 00:01:20:25
Rebecca Chickey
So, Dr. Ulven, thank you so much for joining us today for this very important topic: serving and meeting the mental health needs of rural Americans. And particularly the intersection of that with patients who are covered by Medicaid. So to set the stage, I'd love to have you share a little bit about Sanford Health, what it's like to really - I say rural - but you're in frontier states for the most part.

00:01:20:28 - 00:01:35:05
Rebecca Chickey
So the vastness of North and South Dakota and what that does to create challenges in terms of access and, the solutions that you've had to come up with but help the listeners understand the barriers.

00:01:35:07 - 00:02:01:07
Jon Ulven, Ph.D.
Yeah. So first of all, just thanks for having me. And I really appreciate the attention to this really important topic. You mentioned a few states, but  I'm just going to mention a few more states that we cover, Rebecca, because we're also in Wyoming, Iowa, Wisconsin and then the Upper Peninsula of Michigan. We have a very, very large footprint for our organization, and we serve about 2 million patients in that area.

00:02:01:09 - 00:02:26:05
Jon Ulven, Ph.D.
We do a lot of work with very rural areas, as you were mentioning, frontier type states. And North Dakota and South Dakota, most of those counties are known as behavioral health shortage areas. I practice primarily in Moorhead, Minnesota. And in the state of Minnesota about 80% - 80 to 85% - of our counties are known as a behavioral health shortage areas.

00:02:26:07 - 00:02:49:24
Jon Ulven, Ph.D.
So we have, just a very unique set of challenges when it comes to the trying to provide world class health care and behavioral health care to a footprint that size. And when we look at the rurality of the folks we serve. And so things that we often encounter, we counter pretty much persistent challenges with provider shortages.

00:02:50:01 - 00:03:14:10
Jon Ulven, Ph.D.
It's hard to recruit to this part of the country. We're in a perpetual state of recruitment. And we also know that a couple of unique things that happen with rural areas. We have people who can travel for literally some of...I've seen patients who travel across the state of North Dakota to come to an appointment on the eastern side of the state.

00:03:14:15 - 00:03:31:21
Jon Ulven, Ph.D.
So there are sometimes some very legitimate transportation challenges. And then, and then also, I think one of the things that is - when you are in a small rural community, and I know because I grew up in one, I actually grew up about 25 miles from where I am right here in Moorhead. I grew up on a farm.

00:03:31:24 - 00:03:50:22
Jon Ulven, Ph.D.
There's some nice opportunities for connectivity in a rural setting, but there's also you lose anonymity. So you have you have challenges with people who, might need behavioral health services. But, everybody knows everybody's business. So it makes it really hard to reach out and seek care.

00:03:50:24 - 00:04:10:09
Rebecca Chickey
I hear you, I grew up in rural Alabama. And it took 20 minutes to get to the closest gas station, and 20 more minutes from that to get to the closest hospital. So, perhaps not quite as rural as yours, but you got the fact and everyone in the little community I grew up in knew everyone else's business.

00:04:10:09 - 00:04:21:00
Rebecca Chickey
And with that comes the stigma of seeking care. It's incredible. That's one of the things we've been working on. So glad you're working on it, too. What about broadband? Can you speak to that for just a minute?

00:04:21:02 - 00:04:45:23
Jon Ulven, Ph.D.
Yeah. So to try to meet this behavioral health need, Sanford has invested a tremendous amount of infrastructure and time into a virtual care platform that we offer for this footprint, an area that I described a little bit earlier, where currently we have about 1 in 5 of our behavioral health visits are virtual at this time.

00:04:45:26 - 00:05:08:16
Jon Ulven, Ph.D.
So people can access this through their phones, through their computers at home. And we offer a confidential service where we are able to with the technology throughout that footprint, be able to deliver that type of care. And it's something that we are training our clinicians on a regular basis about, the effective ways to provide this modality of care.

00:05:08:21 - 00:05:17:06
Jon Ulven, Ph.D.
I think in all of our areas, this has just become a pretty common way of life for us to do care that we have a certain portion of it that's virtual.

00:05:17:08 - 00:05:20:23
Rebecca Chickey
And so you complement that with in-person visits, I assume.

00:05:21:00 - 00:05:46:17
Jon Ulven, Ph.D.
We do. Like I said, about 1 in 5 of our visits are virtual. I really have appreciated, some of the innovative minds that we've had here at Sanford to do some unique things. Like, for example, we have a very small community. The name of the town is Lidgerwood , North Dakota. And in Lidgerwood, North Dakota, which is like I said, I grew up around here, so I remember playing basketball in Lidgerwood, just a very, very small community.

00:05:46:19 - 00:06:08:06
Jon Ulven, Ph.D.
And if you head to that town, what they have is they had a clinic setting there, but it was nearly impossible to keep that staffed. So now what we've done is we have some bare bones medical staff in that area. We have some imaging capabilities and we have people to check patients in as they come in, and then they can do virtual care from there.

00:06:08:08 - 00:06:31:16
Jon Ulven, Ph.D.
And so they can do all different types of virtual care. They could be there for a checkup with their primary care physician. They can be there for a specialty visit for one of our other departments, and they can do behavioral health care from there as well. So we're trying to have both kind of this, this nice opportunity for people to have where they can go to a location if they need, if they have some difficulties with their technology

00:06:31:16 - 00:06:56:19
Jon Ulven, Ph.D.
and so they can't do the virtual care themselves, that we offer that up to people. And in this building that I'm in right here in Moorhead, we have 17 psychologists and master's level therapists. We have psychiatry here, social workers, nursing staff. And then within our building we have family medicine, internal medicine, women's health, pediatrics. We have a lab here.

00:06:56:19 - 00:07:20:28
Jon Ulven, Ph.D.
We have a pharmacy here. So we have this nice opportunity to provide just a really well-rounded, amount of health care. To tie back into the, connecting with what we're all here for, it's talking about the, you know, our ability to do that type of care, to think that way and to provide this platform of care.

00:07:21:00 - 00:07:37:26
Jon Ulven, Ph.D.
A lot of it has to do with in our country the ways that we pay for health care. And that's where we get into what has been a mainstay for health systems, and especially when we think about rural health systems is the services that are allowable by Medicaid.

00:07:37:28 - 00:08:04:18
Rebecca Chickey
I want to get back to that point. But before we go further about the devastating cuts that are being discussed right now, help the listeners with a couple of stories, if you can. What has been - so your ability to provide these services, your ability to provide access to care virtually or in person by being creative around that clinic that was probably on the verge of maybe closing and not being there in that community.

00:08:04:20 - 00:08:09:18
Rebecca Chickey
What are some of the personal stories you've seen that have impacted the lives and how?

00:08:09:20 - 00:08:30:08
Jon Ulven, Ph.D.
Many stories that that I could share around this. I've been here with, Sanford for 21 years. I'm a licensed psychologist, and as you were saying, I'm the department chair of our adult psychology group. So I often feel like, jack of all trades and a master of none. But what I do is I do some hospital based coverage from time to time.

00:08:30:08 - 00:08:56:24
Jon Ulven, Ph.D.
And so we have an inpatient psychiatric unit that I will occasionally provide care for. So a very common course that we would see would be somebody who is uninsured or underinsured. And they end up coming through our emergency department for a mental health crisis. And while they're there, the team, with our emergency department determines that the patient needs hospitalization in our inpatient psychiatric unit.

00:08:56:26 - 00:09:23:18
Jon Ulven, Ph.D.
Patient is admitted there. While they're there, we might uncover, for example, a first episode psychosis. So if you take someone who is a young individual in one of our communities who is having an onset that might lead to schizophrenia diagnosis, they're having a first episode of psychosis. And so we have the opportunity to assess the person there, start the person on anti-psychotic medications.

00:09:23:18 - 00:09:42:21
Jon Ulven, Ph.D.
And then let's say that we also uncover that this person has a substance use disorder. Well, we have had the opportunity to enroll this person in Medicaid. Perhaps this person is unemployed, underemployed, has a position where they just don't have the benefits to have, that standard type of health care that a lot of us are able to have.

00:09:42:23 - 00:10:07:29
Jon Ulven, Ph.D.
And so we get this person on Medicaid, and what we're able to do from our inpatient unit is set this person up with a primary care provider, a psychiatrist, a therapist, and we're able to do things like get this person started on some medication that might help with cravings for substance use. And we can we can also work with some of our community partners to try to get this person engaged in that care.

00:10:08:02 - 00:10:27:16
Jon Ulven, Ph.D.
What I often think about is just that if that early intervention that we know that if we can help this person out at that point on an early basis, we are really and in some ways, we're bending the trajectory for their health throughout the course of that person's life. And it is such an important time.

00:10:27:18 - 00:10:50:10
Rebecca Chickey
That's phenomenal. For the listeners: Statistically, by the age of 14, probably about 50% of the population if you're going to show or have a psychiatric or substance use disorder, those symptoms are showing by the age of 14. And correct me if I'm wrong here, keep me honest. But then by the time you're 21 to 24, we're up to 75%.

00:10:50:12 - 00:11:13:05
Rebecca Chickey
So that early identification and intervention and treatment, there's so many opportunities to improve the long term health of the individual, the ability to have a joyful life, to engage and be productive and make the most of the resources around them. It's just critically important. And you're being there, is equally so.

00:11:13:07 - 00:11:33:12
Jon Ulven, Ph.D.
Thank you for that. You know, as we're having this conversation that when we hear stories like this, sometimes the tendency as humans to just say, oh, that's nice. And it's important to hear about that. But we, it's a bit abstracted from us. If we don't have the ability to treat that type of individual, we see, as we see, diminishing services across the board.

00:11:33:14 - 00:12:02:13
Rebecca Chickey
Research shows that 50% of children and 18% of adults in rural communities are covered by Medicaid. Let that sink in, listeners. 50% of the kids in rural communities are covered by Medicaid and 18% of adults. Medicaid is also the largest payer for behavioral health. So speak a little bit more about the impact of these Medicaid cuts that are, currently being discussed in Congress and what that would mean for your community.

00:12:02:15 - 00:12:22:02
Jon Ulven, Ph.D.
Yeah, thank you for that. And just as you were saying that, just another I think another example just comes to mind for me, and that's the that's the example of that, something that I think a lot of people don't think about. And that's health care coverage for foster kids, for foster children. So, if you think about that for a moment, you're a family who's taking on a foster child.

00:12:22:05 - 00:12:46:25
Jon Ulven, Ph.D.
We  don't allow that those folks to go under the foster parents' insurance. There's a gap. There's a gap in care that is consistently filled by Medicaid. And if we think about some of the folks and even if our, you know, listeners can think about some situations where they think a foster child would come from a situation if they're obviously coming from a situation that is a distressing and challenging situation.

00:12:46:27 - 00:13:13:13
Jon Ulven, Ph.D.
Often there are there are lots of different health related issues, including mental health issues. Essentially, these folks would possibly be in a situation where they would have no care, no, no access to care. And we know some things about, looking at places, for example, where, Medicaid expansion has hit a certain area and we can we can take a look at some big numbers about like what's the impact of that?

00:13:13:13 - 00:13:39:27
Jon Ulven, Ph.D.
And we know, for example, that in one study they, looked at suicide rates, of the rate of suicide. And it was over the course of many years and found that folks who had access to Medicaid expansion that suicide rates go down. In the study that they looked at over a series of years, literally thousands of lives, they can see a reduction in completed suicides, which would suggest that there were thousands of lives saved.

00:13:40:04 - 00:14:08:14
Jon Ulven, Ph.D.
I'll also offer just a more pragmatic one. There was a study that was out of Montana that looked at a group of people who were participating in a tele-psychiatry practice. A large number of these folks were Medicaid recipients. And what they found was that, participating in this psychiatry practice, they had a 38% reduction in inpatient hospitalizations, 18% reduction in emergency department visits.

00:14:08:16 - 00:14:45:00
Jon Ulven, Ph.D.
So if you think about the higher cost elements of health care, when we can invest in ways that we know have evidence support, are effective, get the job done, we're actually preventing some of that higher cost care that that truly is. But I would much rather work on preventing something from getting worse than what ends up happening when people are at that level of distress, when they make it to our emergency department, or when I'm covering on our inpatient unit and I can see that I'm working with someone who has gone without care for a significant amount of time.

00:14:45:02 - 00:15:09:13
Rebecca Chickey
Again, going upstream, early intervention prevention, treatment, rather than waiting for the crisis, which might not only just impact the individual, but others as well, depending upon what the crisis is and how many people show up to the emergency room. So, as we draw this podcast to a close, is there a call to action that you would share with the listeners?

00:15:09:13 - 00:15:19:23
Rebecca Chickey
If there's something you would like to encourage them to do? Or, the last thing that you want to make sure that they that resonates as they click off to this podcast.

00:15:19:25 - 00:15:48:29
Jon Ulven, Ph.D.
My heart often goes to children. I only work with adults in my practice, but I but I mean, I'm a father myself. I think about that. Just that point you just made that earlier, we can intervene the better. And I think it's important that one study found that there children who have Medicaid coverage, they're four times more likely to have a regular visits with like, a pediatrician or get some of their health care needs met.

00:15:49:01 - 00:16:08:28
Jon Ulven, Ph.D.
And that that includes behavioral health and that they're 2 to 3 times more likely to receive preventative care. And then we think about when it comes to, adults who are enrolled in Medicaid, that they're five times more likely to have a regular source of health care and also receive preventative care. From the listening perspective

00:16:08:28 - 00:16:34:28
Jon Ulven, Ph.D.
I hope that what this has done is just increased an awareness to truly wide reaching effects that a change in Medicaid is going to it's going to have for the way that we deliver health. And I would say especially in rural health care. Rural health care systems are routinely much more impacted by non reimbursable care. And so you add to that, we're going to see some pretty significant reduction in services

00:16:34:28 - 00:16:51:12
Jon Ulven, Ph.D.
would be I think a reasonable guess. The thing that like call to action? I think one of the things I'm so I feel so privileged about in, in that, in North Dakota. I'm a citizen of North Dakota, I practice in Minnesota, I'm right on the border. Because we're in a small state of North Dakota,

00:16:51:15 - 00:17:30:05
Jon Ulven, Ph.D.
I have been able to work with our government support people and been able to testify. The last two legislative sessions, we have had laws changed in the state of North Dakota. That's been a great opportunity through connections of - here's me as a psychologist, working with our legislators. We all are responsible in a health care setting or our elected officials to improve the lives of the patients and the citizens of our states. And in a bipartisan way, when we can find some nice opportunities to get some things done that are truly meaningful for people in the states we serve, it's a win for everybody.

00:17:30:08 - 00:17:49:16
Rebecca Chickey
That's phenomenal. Thank you. Your passion for this work, both for the patients that you serve, for the organization that you work for and with, and for having an impact work globally. It resonates throughout this entire podcast. So thank you for that passion, for bringing it to the work that you do. And thank you for sharing it with the rest of the field.

00:17:49:18 - 00:17:51:13
Jon Ulven, Ph.D.
Well, thank you very much.

00:17:51:16 - 00:17:59:27
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:01:02 - 00:00:23:19
Tom Haederle
Welcome to Advancing Health. Today's medical residents and fellows are tomorrow's doctors. In this podcast, we hear about Boston Medical Center's innovative program to provide mental and emotional support during the rigors of medical training, and to address the tendency of many medical trainees to deprioritize their own health.

00:00:23:21 - 00:00:53:21
Jordan Steiger
My name is Jordan Steiger, and I am the senior program manager for Clinical Affairs and Workforce at the AHA. I'm joined today by Simone Martell, who is the director of Boston Medical Center's Employee Resilience Program, and Dr. Jeff Schneider, the associate chief medical officer, designated institutional official and chair of the Graduate Medical Education Committee at Boston Medical Center, and the assistant dean for graduate medical education at BU Chobanian & Avedisian School of Medicine.

00:00:53:23 - 00:01:16:04
Jordan Steiger
So just to set the stage a little bit, in 2022 and 2023, the AHA received some funding from the CDC to identify the leading interventions for preventing suicide in the health care workforce. And we got to know the Boston Medical Center team through this learning collaborative that we hosted that focused on implementing these practices at hospitals and health systems across the country.

00:01:16:06 - 00:01:20:04
Jordan Steiger
So, Simone and Jeff, thank you so much for being here with us today.

00:01:20:06 - 00:01:21:18
Simone Martell
Thank you for having us.

00:01:21:20 - 00:01:22:22
Jeff Schneider, M.D.
Thank you.

00:01:22:24 - 00:01:35:03
Jordan Steiger
So to get us started, I'd love for the audience to just learn a little bit more about your roles at BMC, and how the two of you work together to support workforce well-being. So Jeff, let's start with you.

00:01:35:05 - 00:01:53:09
Jeff Schneider, M.D.
Sure. Thank you very much for having us. And, happy to share what we have done and also what we've made to do moving forward. By training, I am an emergency medicine physician, and I still work clinically in our emergency department. And then the other part of my job is I oversee all of our residency and fellowship training programs across the organization.

00:01:53:09 - 00:02:15:02
Jeff Schneider, M.D.
So it's more than 750 residents and fellows across roughly about 70 training programs. And I really oversee those residency and fellowship programs from a bunch of different perspectives, everything from operations, to finance to accreditation. Obviously, working very closely with our program directors and our program administrators, and the educators and teachers that we have here at BMC.

00:02:15:04 - 00:02:16:20
Jordan Steiger
Great, Simone?

00:02:16:23 - 00:02:44:06
Simone Martell
So I joined BMC in June of 2023. My background is I'm an LICSW, licensed independent clinical social worker in Massachusetts. And, the program here is to provide mental and emotional support and resources to all of our workforce, clinical and non-clinical, in the realm of mental health, emotional well-being, stressors around the workplace, occupational stress injuries.

00:02:44:08 - 00:03:04:10
Simone Martell
And we have a couple of initiatives that target residents and medical trainees in particular. One of the first I was also introduced to was this initiative that had started the year before I joined, which are these wellness chats for incoming trainees at the beginning of the academic year.

00:03:04:13 - 00:03:28:28
Jordan Steiger
That's great. So I know that health care workers overall can experience barriers to receiving mental health services, can experience challenges around well-being and taking care of themselves. I think everybody listening to this podcast probably knows that. But we also know there's a lot of research that shows that residents have some kind of special challenges and adjustments that they need to make as they're starting residency.

00:03:29:01 - 00:03:33:29
Jordan Steiger
But could you tell the audience about some of those maybe special challenges that face residents?

00:03:34:01 - 00:03:55:21
Jeff Schneider, M.D.
The genesis of our program really actually goes back probably 6 or 7 years now, when we realized that our residents and fellows really deprioritized their own health on many occasions, given the choice between learning something clinical, or learning how to do something or gaining experience and taking care of their own health. Residents across the country tend to deprioritize throughout health.

00:03:55:24 - 00:04:13:08
Jeff Schneider, M.D.
So one of the things that we did very early on was trying to understand what are the barriers for our residents taking care of themselves? If they're not taking care of themselves, how can we expect them to take care of patients, to learn and to grow? So we had an idea that we would introduce primary care appointments during intern orientation.

00:04:13:08 - 00:04:37:11
Jeff Schneider, M.D.
Again, this is probably 6 or 7 years ago now. And we set up a process, a mechanism really carved out an afternoon that was protected for residents and fellows, where those that wanted to get primary care appointments could have them here at Boston Medical Center. Our goal again really, just a little bit around reducing stigma, reducing barriers and normalizing the conversation around taking care of your own health is very, very important.

00:04:37:14 - 00:04:56:23
Jeff Schneider, M.D.
I will admit that when we started this I had no idea if anyone was going to show up. We put a lot of time and effort, operations and planning into organizing this, but not really knowing frankly how well it would land. And we were pleased to see that even after year one, the majority of our residents and fellows were very interested in participating in this.

00:04:56:23 - 00:05:22:18
Jeff Schneider, M.D.
And we continued to grow the program a little bit, to learn, to iterate. And a few years later we said, well, if we're introducing primary care, maybe we should do the same thing with behavioral health or mental health to really, really try to accomplish three things. The first was we really wanted to normalize the conversation. It is totally normal for residents and fellows who need any behavioral health support, any behavioral health or mental health contexts.

00:05:22:20 - 00:05:42:28
Jeff Schneider, M.D.
How can we help them do that? To really normalize the conversation? It's as normal as in anything else that we do. And then really trying to reduce the stigma around it. Talking about it in the wide open, not behind closed doors or at hush voices. It was something we talked about very early on, when these new residents and fellows were coming and really tried to make the conversation part of what we do.

00:05:42:29 - 00:06:01:14
Jeff Schneider, M.D.
It's an expected part of what we do. And then really trying to figure out how we decrease the barriers, how do we make it as easy as possible for residents and fellows to take advantage of the wonderful resources we've had here? And Simone and her team have really taken an idea and grown it so that it's flourished. I'll let Simone talk a little bit more about some of the details of how she's actually executed.

00:06:01:15 - 00:06:32:27
Simone Martell
Yeah, yeah. Thank you. So I do also want to give credit to the team that preceded me as well, because I inherited this. And so the first year that the behavioral health component was launched was in 2022. So now we're going into our fourth year doing it. I think the whole framework, at least as how I view it in our approach, is like this philosophy of preventative care, which I think, you know, as trainees who are going to be, fully practicing doctors would preach to their patients.

00:06:32:27 - 00:07:06:14
Simone Martell
We want them to be able to and have it, or embody that themselves as well. The way that it's been structured right now through a couple of key learning points over the past couple of years is that we use different tools for signups. So in the welcome letter that gets sent out by, Dr. Schneider's office in April, welcoming folks, there is a portion of the letter that talks about the PCP visits and a portion of the letter that talks about signing up for these wellness resource chats. And they're 15 minute chat sessions.

00:07:06:20 - 00:07:32:06
Simone Martell
They're not therapy, but they are really focused on an opportunity to talk about any concerns somebody might have, letting them know about the resources that are available to them, helping them kind of highlight what are some anticipated stressors or things that they can do ahead of time again, from a preventative standpoint. So oftentimes we'll talk about what are some coping skills that got me through medical school.

00:07:32:08 - 00:07:56:09
Simone Martell
What are some things and ways we can augment that knowing that you're going to be in a new situation, a new territory now, maybe away from the support community that you'd established and been a part of and need to kind of configure here. So sometimes, you know, it might come up where somebody and I think, generationally there's a stigma which has been really lovely to see and kind of capitalizing on that.

00:07:56:09 - 00:08:22:05
Simone Martell
So some folks might come in and they've had, experiences with mental health supports before, but they might not realize, oh, that person doesn't have a license to practice in Massachusetts. So I need to be able to keep that going and find the resources locally and work within my insurance, because now my insurance plan is moving from what I had previously to BMC is now their employer and putting on the network that that's here.

00:08:22:07 - 00:08:47:15
Simone Martell
And so we want to set it up so that it can be something where again, coming from how do we anticipate what some of those barriers might be? What are those challenges going to potentially be? And a big piece is about access point because it might be early on, there's a lot of excitement. They're still riding the wave of having just graduated, you know, and starting out their new program. Which is a stressor in itself.

00:08:47:15 - 00:09:06:06
Simone Martell
You know, sometimes there are positive stressors and this is a positive stressor. But at the time when, you know, mental health challenges potentially do arise or distress does arise, we don't want it to be, oh, now I'm having to start from scratch at the time where I'm already struggling. We want the groundwork to already be laid for them.

00:09:06:06 - 00:09:10:24
Simone Martell
So that's really sort of the framework, by which we're trying to approach this.

00:09:10:26 - 00:09:35:24
Jordan Steiger
You both hit on so many important things that I feel like we could dig into forever on this podcast, but I think, you know, addressing that stigma piece, I think is so important. Bringing that to the front of the table, the front of the room, the second a resident starts at BMC and saying, this is okay, we expect that you're going to be stressed because residency is hard and you're learning and there's a lot of things going on for you.

00:09:35:26 - 00:09:56:19
Jordan Steiger
I think just getting out in front of it is so important. I think one thing you mentioned, Simone as well, is that, it's not therapy. You know and I wonder sometimes if people kind of shy away from these programs or thinking about mental health because it's they don't want to be providing those therapy services, but it really sounds like it's just more connecting people to those services.

00:09:56:21 - 00:10:22:00
Simone Martell
Yeah, it has a lot to do with the awareness and the access piece. So what we've done with the chats is that, in addition to myself, some of my colleagues who are, you know, doctors level will be able to join in and hold the discussions. Also, they won't have to have the pressure of going into to anything that's outside of their territory.

00:10:22:00 - 00:10:58:12
Simone Martell
We also don't want to give a false impression to the residents for this session, either. I'll say residents or fellows, because we do this for fellows as well. But it's more about here are the different resources that you are eligible for and have access to, and here's the route with which to do it. And here's at least, you know, through our internet source, our fliers, our point of contact, so that you have an easy way of - you don't have to remember all of this - but there's just, a streamlined way to think about how do I set up what I might need.

00:10:58:15 - 00:11:19:17
Simone Martell
And then again, for, you know, folks that maybe have had experiences before or are just saying, like, you know, coming into this, I know that this is something that was difficult for me in med school or something that I've found challenges with. So I want to kind of be thinking ahead. We can roughly just touch upon what are some coping strategies that have been helpful for you.

00:11:19:17 - 00:11:39:24
Simone Martell
Again, this being a new territory, a new framework, what do you think that you might need in anticipation and have you think through ahead of that without it being anything that would delve into the territory of therapy per se? That said, trainees are able to schedule confidential appointments with a licensed clinician in the resilience program at any point through their tenure.

00:11:39:27 - 00:11:47:18
Simone Martell
And we also help them navigate how to get connected to a therapist through their behavioral health benefits, if that's something they'd like to pursue.

00:11:47:21 - 00:12:10:09
Jeff Schneider, M.D.
I think another really important piece of this is getting the residents and fellows to normalize a conversation amongst themselves. So for every resident or fellow that Simone or her team meets with who goes through or has their eyes open to some of the resources that we have here, my hope, my deep hope is that even if you know, maybe it's not applicable to them today or tomorrow or the next day...

00:12:10:12 - 00:12:26:24
Jeff Schneider, M.D.
but if they see a colleague, if they see a friend, if they see someone, a resident or fellow who maybe they don't even know all that well and they just look at them and say, I'm worried about you. Are you okay? Like, that's always the right currence. It's always the right question to ask. It's never the wrong question to ask.

00:12:26:26 - 00:12:41:21
Jeff Schneider, M.D.
And then also so they can start arming themselves and say you know what, at the very beginning I went to this talk and I had this resilience chat, I learned a little bit about some of the resources we have at Boston Medical Center. I don't remember all the details, but I know that there's help out there. And I remember here's how you can help access it.

00:12:41:21 - 00:12:53:16
Jeff Schneider, M.D.
So again, the more we can start normalizing these conversations, I think for every resident fellow that Simone touches, the hope is that that spreads almost virally so that they can help themselves but also help their colleagues.

00:12:53:19 - 00:13:19:24
Jordan Steiger
Absolutely. I think the program and the work that you are doing at Boston Medical Center is setting such an incredible example for our membership, and we're so happy that we get to share your story with everybody today. Simone and Jeff, thank you so much for being here with us today. I think the work that you have shared and the work that you're doing and continue to do to support your teams is really setting such a strong, incredible example for our membership.

00:13:19:24 - 00:13:30:03
Jordan Steiger
And I'm just so happy that we get to share your story and hopefully others will get to learn from it and start to maybe, implement some of the things that you shared today.

00:13:30:06 - 00:13:31:00
Jeff Schneider, M.D.
Thank you.

00:13:31:02 - 00:13:33:03
Simone Martell
Thank you so much.

00:13:33:06 - 00:13:41:17
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.