The Importance of Advocacy Increased during the Pandemic

Highlights

• Outlines the pandemic’s effect on health policy
• Describes legislative measures intended to curb burnout and lessen financial burden, including the CARES Act
• Summarizes the Dr. Lorna Breen Health Care Provider Protection Act, which is intended to reduce and prevent suicide, feelings of burnout, and other mental health conditions among providers of care

The American College of Surgeons (ACS) has long been involved in healthcare advocacy at the national and state level. The ACS supported front-line healthcare providers during the COVID-19 pandemic by advocating for improved access to personal protective equipment (PPE), pushing for financial support for surgical trainees and private practice clinicians, and promoting legislative and health policy support for wellness resources and initiatives.

COVID-19’s Effects

At the start of the COVID-19 pandemic, elective cases were halted, with some surgeons redeployed to other specialties to help fill the void in critical care.¹ With the extensive changes in healthcare delivery occurring daily, surgeon advocacy not only was important at a national level, but also within institutions and individualized surgical specialty programs.

The pandemic prompted changes in the health policy landscape, particularly with respect to the support of training physicians who bore the brunt of the pandemic workload. Assessment of trainee mental health noted there was an exceedingly high rate of new onset or worsened depression and burnout symptoms among residents and early career surgeons.²

The initial ACS Resident and Associate Society (RAS) survey of residents and early career surgeons demonstrated that inadequate PPE supplies correlated directly with those trainees and young surgeons who reported the highest rates of depressive and burnout symptoms.² These findings prompted the ACS to conduct qualitative studies to better understand the association between burnout and PPE shortages. Pilot studies to assess areas where residents were struggling with the lack of PPE ultimately led to an ACS statement on prioritizing PPE for residents.

The College advocated for several legislative measures to help combat burnout among surgeons and lessen the burden of the COVID-19 pandemic. With 73% of medical school graduates in 2019 holding some amount of educational debt, and with the median debt at $200,000, financial burden has a major impact on resident well-being.

Understanding the importance of wellness and burnout prevention, SurgeonsVoice, the ACS Professional Association’s nationwide, interactive advocacy program, was integral in endorsing the Coronavirus Aid, Relief, and Economic Security (CARES) Act. This law, introduced in March 2020, temporarily paused repayment of federal student aid, instituted a 0% interest rate for all active loans, and halted debt collection on defaulted loans. Monthly payments, even if zero dollars, would continue to count toward the 120 payments required for Public Service Loan Forgiveness (PSLF).³

These policies provided some financial relief as the effects of the pandemic worsened.⁴ Although these measures were automatically applied to most types of student loans, emergency assistance also was extended to traditionally ineligible loans such as Federal Perkins Loans and Federal Family Education Loans, as well as loans on previously ineligible repayment plans. Originally scheduled to end in September 2020, these policies were extended multiple times in response to the longevity of the pandemic. At present, repayment is scheduled to resume in September 2022.⁵ Along with temporary relief for federal student loan debt, the Biden Administration has discussed one-time limited loan forgiveness for all borrowers, with an amount and eligibility still being finalized.⁶

Dr. Lorna Breen Health Care Provider Protection Act

In March 2022, after the US Congress passed H.R. 1667/S. 610, President Biden signed into law the Dr. Lorna Breen Health Care Provider Protection Act. This act was named in memory of Dr. Breen, who was the medical director of New York Presbyterian Hospital’s emergency department starting in 2008 and into the COVID-19 pandemic, which severely affected New York City in the earliest days of the pandemic in the US. As a frontline physician, Dr. Breen treated a tremendous number of critically ill COVID-19 patients under austere conditions, including insufficient PPE and rationing of resources such as oxygen, ventilators, and extracorporeal membrane oxygenation circuits. The experience deeply affected Dr. Breen and, sadly, she died by suicide in April 2020.⁷ Her death highlighted the unprecedented mental health and wellness challenges faced by healthcare professionals during the pandemic.

The Dr. Lorna Breen Health Care Provider Protection Act was introduced in Congress in March 2021 to “reduce and prevent suicide, burnout, and mental health conditions among healthcare professionals.”⁷ The law establishes grants from the US Department of Health and Human Services (HHS) for healthcare professionals to create programs that improve mental health and resilience among healthcare providers, requires HHS to develop a national educational campaign, requires HHS to disseminate best practices for dealing with mental health issues, and provides grants for educational activities and peer-support programs.⁸

It is anticipated that the funding allocated for grants will allow for comprehensive research to develop programs that best address the mental health crisis among healthcare professionals, which has been present for decades but worsened and was brought to the public’s attention during the pandemic. This legislation will allow multiple projects to be conducted simultaneously to determine which mental health and wellness programs can provide the most benefit to healthcare professionals.

The ACS endorsed the legislation, and it was highlighted as a legislative priority at the 2021 ACS Leadership & Advocacy Summit. Surgeons and surgical trainees across the US participated in dozens of virtual congressional meetings to discuss the impact of the COVID-19 pandemic at their hospitals and clinics and to advocate for their colleagues’ mental well-being.

By sharing Dr. Breen’s story and their own experiences with moral injury and burnout, RAS members focused legislators’ attention on the ongoing impact of the pandemic on healthcare professionals’ mental well-being. The bipartisan bill gained dozens of new cosponsors following the summit, and by the time of passage the bill had 166 cosponsors in the House and 29 in the Senate—a testament to the purposeful and sustained advocacy of surgeons.

During the second year of the pandemic, individual hospital systems and national physician organizations attempted to combat depression and burnout through various means. Data from the RAS-ACS COVID-19 survey indicate that 37% of the respondents reported new formal mechanisms to support resident wellness and promote resilience at their individual programs, and approximately 30% of respondents were aware of the wellness and resiliency resources available to them via the ACS or other professional societies.

Although these numbers are low, they are a first step toward supporting healthcare providers in the effort to improve wellness, reduce burnout, and decrease the stigma of mental illness. As previously described, the ACS led prodigious advocacy efforts over the past 2 years, and these efforts could not have been undertaken without the strong support of ACS members. Residents and early career surgeons are encouraged to get involved with advocacy efforts by joining the Advocacy and Issues Committee of the RAS-ACS.

Voice Your Views

At a local level, SurgeonsVoice provides a way for any physician to contact their elected officials with the click of a button. This resource allows surgeons to engage and build valuable relationships with lawmakers, advance pro-surgery policy and legislation, and help foster champions for surgery in Congress.

References

1. Crowe CS, Lopez J, Morrison SD, et al. The effects of the COVID-19 pandemic on resident education and wellness: A national survey of plastic surgery residents. Plast Reconstr Surg. 2021;148(3):462e-474e.
2. Abdelsattar JM, Coleman JR, Nagler A, et al. Lived experiences of surgical residents during the COVID-19 pandemic: A qualitative assessment. J Surg Educ. 2021;78(6):1851-1862.
3. US Department of Education. Federal Student Aid. COVID-19 emergency relief and federal student aid. 2022. Available at: https://studentaid.gov/announcements-events/covid-19. Accessed June 22, 2022.
4. Association of American Medical Colleges. Physician education debt and the cost to attend medical school: 2020 update. October 2020. Available at: https://store.aamc.org/downloadable/download/sample/sample_id/368/. Accessed June 22, 2022.
5. Lustig M. Coronavirus student loan relief: Borrower update. US News & World Report. April 8, 2022. Available at: https://www.usnews.com/education/blogs/student-loan-ranger/articles/update-on-coronavirus-relief-for-student-loan-borrowers. Accessed June 22, 2022.
6. Pager T, Douglas-Gabriel D, Stein J. Latest White House plan would forgive $10,000 in student debt per borrower. Washington Post. May 27, 2022. Available at: https://www.washingtonpost.com/us-policy/2022/05/27/biden-student-debt-borrower. Accessed June 22, 2022.
7. Dr. Lorna Breen Heroes Foundation. The Dr. Lorna Breen Health Care Provider Protection Act. 2022. Available at: https://drlornabreen.org/about-the-legislation. Accessed June 22, 2022.
8. Library of Congress. H.R. 1667—Dr. Lorna Breen Health Care Provider Protection Act. Available at: https://www.congress.gov/bill/117th-congress/house-bill/1667. Accessed June 22, 2022.

Dr. Navin Vigneshwar is a postgraduate year-6 general surgery resident, University of Colorado School of Medicine, Denver.