Article In Brief
Neurology practices, hospitals, and academic institutions across the country are experiencing severe workflow disruptions as a result of hiring and recruitment challenges post-COVID-19.
Over the past 20 months, many sectors of the health care workforce have suffered extraordinary levels of stress and exhaustion due to the COVID-19 pandemic. This has resulted in massive departures of physicians, advanced practice providers (APPs), nurses1, technicians, medical assistants (MAs), research assistants, administrative assistants, and other employees.
According to a survey by Morning Consult, which polled 1,000 U.S. health care workers in early September, nearly one in five had quit their jobs during the pandemic, and one in five of those remaining had considered leaving. The exodus has placed downstream pressure on the remaining staff, who are often asked to bear an increased workload, creating a domino effect on the outflow of employees.
The causes for these departures are complex and multifactorial. They have been attributed to the effect of vaccine mandates on those unwilling to get vaccinated, illness related to COVID-19 or its sequelae, and severe burnout and other psychological consequences triggered by the pandemic. More broadly, COVID-19 has caused health care professionals to reevaluate what they find meaningful in life, to examine whether they feel sufficiently valued in their workplaces, and to consider alternative positions or even professions. Many ultimately end up leaving for higher pay and better opportunities.
As a result, neurology practices, hospitals, and academic institutions across the country are experiencing severe workflow disruptions. So ubiquitous is this crisis that one might ask who in our profession has not been impacted, rather than who has.
Neurology Today spoke to several neurologists and business administrators who provided examples of how the employment shortages have affected their departments and practices across the country.
A Dearth of Medical Assistants
Randolph W. Evans, MD, FAAN, a solo practitioner in Houston, who has practiced general neurology and headache medicine for the past 39 years was unable to find an MA after two left in April 2021. Prior to the pandemic, a listing in Indeed by his practice would have elicited a robust response of qualified assistants, but in April he received responses from 73 unqualified applicants, despite posting a two-year experience requirement. (Candidates included a canine coach, bus driver, waitress, sales associate, babysitter, school volunteer, housekeeper, security officer, music school coordinator, and a preschool teacher.)
“Five people worked in the office for less than two weeks each and did not work out,” said Dr. Evans, who tried to do the best he could by hiring nursing students who proved to be unreliable or left the position for better pay. Another new hire resigned due to the vaccine mandate and one person never showed up at all.
“After I lost an MA due to illness and another due to a family relocation, it created big problems for me, but it was nothing compared to our regional hospitals, which have been very short-staffed and overwhelmed during waves of COVID over the last few months,” he added.
“Recruiting for nurses, APPs, and MAs is somewhat similar to the post-COVID housing market—a seller's market—with owners receiving multiple offers that end up increasing the selling price,” said Bryan Soronson, MPA, FACMPE, CRA, senior administrator in the department of neurology at the University of Maryland School of Medicine- in Baltimore, who has not previously witnessed such market forces in his 36 years of work in the department.
“These job searchers are offered additional salary, benefits and other goodies, and usually take the highest offer.”
“Recently we had two vacancies for MAs; on two consecutive occasions, candidates accepted the position, gave notice, and two to three days before the start date contacted our clinic director stating that they decided to take another position that paid a higher salary,” he said. “We then went to a temporary agency that was supposed to send two new MAs but only one showed up,” noting that the lack of consistent MA staffing is an ongoing challenge which is negatively impacting clinic operations and efficiency as well as patient satisfaction.
“Many large medical systems are behind in providing competitive salaries and this is becoming an ongoing spiral,” Soronson said. “Once a market adjustment is made, other medical groups further increase their salaries, a treadmill that continues to be pushed faster.”
Neurodiagnostic Technicians and Work Backlogs
“There have been workplace shortages throughout the pandemic and our clinic and hospital, like many others, have been working very hard to cope,” said neuromuscular specialist, Anne Louise Oaklander, MD, PhD, FAAN, director of the Massachusetts General Hospital Nerve Unit & Neuropathology Skin Biopsy Service in Boston, Massachusetts. “But I hadn't expected to lose one of two histotechnologists in my neurodiagnostic skin biopsy lab with two weeks' notice, particularly with the workload becoming so heavy in 2021,” explaining that the sudden resignation was a result of a hospital-wide vaccine mandate.
“Clinical diagnostic labs still have specimens arriving even if the lab is short-staffed. My one remaining technologist has been working sometimes seven days a week and until midnight to try and catch up,” Dr. Oaklander said. “Clinical testing labs are disproportionately affected by loss of technologists as there isn't a pool of trained EEG, EMG, histotechnologists, and intra-operative monitoring techs looking for jobs.”.
Dr. Oaklander said the loss of their team members affected the remaining staff emotionally, herself included, because they worried about how departed staff members would support their families, given that mandated resignation makes employees ineligible for unemployment benefits.
Loss of Billers, Coders, and Reduced Revenue Flow
“We have not experienced this degree of personnel loss in any given year in my 14-year tenure,” said Vinny Kaur, MPH, senior clinical department administrator in the department of Neurology at the Texas Tech University Health Sciences Center in El Paso. “In Texas, no entity has allowed state-based institutions to mandate vaccines to date (although this may change on January 5) so we have not lost neurology personnel for this reason so far.”.
Kaur, who performed exit interviews on all departed staff, said, “After a campus-wide restructuring in January 2021, a new centralized billing department lost more than half its billers and coders within ten months, including five of six neurology personnel.”
One chose retirement, another with childcare issues decided to be a stay-at-home mother, and three changed their line of work and transferred to other departments. The clinic structure was also reorganized leading to the departures of a manager who decided to pursue an RN degree and a cashier and authorization personnel who left for jobs in the community. (MAs also left due to a variety of reasons.)
“We used a combination of strategies to fill the positions, including utilizing interns and temporary agencies, outsourcing coding and billing, and turning to internal hires and promotions,” said Kaur. “But we experienced no shows for interviews and also ended up reopening positions for a long period of time, since we did not have a robust pool of candidates applying.”
While staff had a multitude of other reasons for leaving, Kaur explained that the duration of unfilled positions has been compounded by a very lengthy hiring process at her institution.
“The range of staff issues, which have impacted clinic operations, has included burnout due to overtime requirements, human error due to fatigue, and a pervasive inability to catch up with daily operations,” she noted. “In addition to permanent staff loss, the department of neurology has been struck by temporary staff losses due to FMLA [Family and Medical Leave Act] issues and illnesses, which has made this an extraordinarily challenging time. This unfortunately has hampered the provision of effective service to our patients.”
Scientific Research Suffers
The scientific community has been hard hit over the past year due to serial obstacles serving as impediments to research which could cripple science for some time to come. A perfect storm of adversities has ensued from the pandemic, including the loss of clinical coordinators and related personnel, supply chain shortages, and barriers to patient enrollment, including prolonged travel fears and telemedicine regulatory roadblocks.
Neuro-oncologist Maciej M. Mrugala, MD, PhD, MPH, FAAN, professor of medicine and director of the Comprehensive Neuro-Oncology Program at Mayo Clinic in Phoenix, has been witnessing difficulties with retention of research coordinators. “It's hard to provide exact numbers, but we have been plagued by high turnover rate with departures from the clinical research core,” he said.
He suspects that many left for better opportunities within the institution or elsewhere, with improved work schedule and/or pay. “I think most feel overworked and underappreciated,” he said. “This is a high-stress work environment that calls for excellent navigation skills and an ability to multitask and meet tight deadlines.”
The departures have impacted day-to-day operations with periodic halts in enrollment into trials due short staffing. “This is concerning, particularly in my field, neuro-oncology, where clinical trials are a vital part of treatment strategy, and patients don't have time to wait as prognosis is poor and disease progresses rapidly,” he explained. “Situations like this can lead to potential problems providing appropriate follow up of study patients and may threaten protocol compliance and data integrity.”
Dr. Mrugala pointed out that this is a nationwide problem. “Clinical research specialists/coordinators are vital parts of the team and scientific progress can't be achieved without their involvement,” he said. “They must be recognized for their work and treated and compensated appropriately, so that their retention will improve.”
To compound the dearth of research assistants, the pandemic has led to a loss of study patients who are averse to travel. “Until now telemedicine filled the gap,” said Bruce Cohen, MD, FAAN, director of the NeuroDevelopmental Science Center at Akron Children's Hospital in Ohio. “But as states rescind the waiver for telemedicine licenses, it may no longer be legal for us to practice medicine across state lines without obtaining a license in that state,” Dr. Cohen explained.
“We went from a time prior to COVID-19 when patients got on a plane at the expense of a pharmaceutical sponsor to take part in a clinical trial to a pandemic when we learned how to conduct research safely by telehealth with the assistance of their local doctors, laboratories, and visiting nurses,” he said. “And although we have patients who are still reluctant to travel, state license waivers are being rescinded removing telemedicine as a viable alternative option.”
“Patients will be difficult to recruit for new trials if they continue to avoid getting on planes,” he said, adding that this may slow development of new therapies for some time to come.
“The worst-case scenario for patients currently enrolled in trials is that they will not be able to receive the drug/device and lose the opportunity entirely. To avoid that we are scurrying around trying to identify accredited visiting nurses in their communities who are research-qualified to assist us,” Dr. Cohen said. “Furthermore, if we are unable to complete trials, industry stands to lose years of work and millions of dollars of their investment, an especially dire situation for smaller pharma companies who may not be able to recover and for new treatments for serious illnesses.”
Finally, supply chain shortage has impacted not only consumer household goods but laboratory supplies. Research labs across the country are running low on plastic lab materials such as gloves, pipette tips, reagents, centrifuge tubes and other essential items for which they are waiting longer and paying more. Several neuroscientists cited shortages in cryotubes, commonly used for cryogenic storage of biological materials using liquid nitrogen, including the preservation of serum, blood, and cells.
“This six-month long shortage is impeding an NIH-sponsored multi-institutional trial at our institution,” said Dr. Cohen. “Two patients this week who wanted to participate in the trial were turned away due to shortages of these containers.”
Rescinded State License Waivers, Admin Departures Disrupt Care
Justin T. Jordan, MD, MPH, who serves as clinical director of the MGH Pappas Center for Neuro-Oncology and director of the MGH Family Center for Neurofibromatosis (NF) in Boston, said that his current administrative assistant is pulled in more directions than ever, working with more physicians and doing additional non-secretarial work to support hospital and patient needs. Indeed, she is the fourth secretary he has had this past two years due to multiple departures.
“During the pandemic, telemedicine opened a unique door to see NF patients during virtual visits,” he said. “But now that state license waivers have been rescinded, that door has been closed again.”
This regulatory roadblock acutely affects people with rare diseases, who typically must travel a significant distance for care, he explained, having studied aggregate data on patient access to care reported by patients and specialty NF clinics between 2008 and 2015.
He found that geographic access to care is particularly limited for adults, patients with rarer conditions, and patients in the Western U.S.2
Dr. Jordan is currently applying for a license in New Hampshire so that he may continue to care for patients who reside there. The process has been laborious and disruptive and even with the available secretarial assistance he has, there were many things only he could do.
“For example, I had to go out to get ink fingerprinted this week,” he said. “The administrative burden of completing an application for a new license is so high that it leaves me with little desire to accumulate licenses from other states,” he said.
Neurology Today reached out to Paul B. Ginsburg, PhD, professor of health policy at the Sol Price School of Public Policy at the University of Southern California in Los Angeles, California, who also serves as vice chair of the Medicare Payment Advisory Commission, to understand what is happening to the labor market and to ask how long the current workforce departures may last.
Dr. Ginsburg, who has spent his career studying changes in the financing and delivery of health care and the evolution of health care markets is particularly intrigued by a behavioral economics explanation for the workforce resignations, particularly those in low-wage jobs.
“It suggests that that the pandemic caused many employees, typically comfortable with the status quo, to look into alternative positions,” he explained.
This gets reinforced when they see others changing jobs to get higher pay and possibly more satisfying work, he added.
“People often have little information about employment alternatives, but the pandemic motivated them to look more,” he said. “The pandemic has also caused people to do serious rethinking about where they are in their lives, often triggering a move to make a change.”
Dr. Ginsburg expects that as COVID-19 gets under control and the infection rates go down, some of the precipitants of departures will recede as people get used to a new status quo. A winding down of the pandemic will also allow more individuals to work; for example, when more children get vaccinated and schools are open more consistently, some parents will be able to return to work.
Medical facilities are responding to labor shortages by reducing services delivered and likely some will affect patient health, while others will not.
“It is said that about a third of medical care does not produce value, so with pressure to do less due to workforce constraints, wasteful services may be abandoned,” Dr. Ginsburg explained. “Over time, this will lead to even faster consolidation in health care delivery.”
Many economists believe that much of the economy-wide inflation is temporary—caused by large shifts in spending away from services towards goods.
“People are already starting to shift back; they are rejoining gyms and acquiring less home exercise equipment,” said Dr. Ginsburg.
But the higher wages that came from greater willingness of workers to look at alternatives will stay with us—and this may be a good thing, he concluded.