The Oregon Wellness Program: Serving Healthcare Professionals in Distress from Burnout and COVID-19

Physicians experience substantial occupational stress but are often reluctant to reach out for mental health assistance.^1,2  Physicians and nurse practitioners often work when ill.³  Seeking mental health services for distress is perceived as a stigma.⁴  Healthcare professionals fear being reported to credentialing committees or medical licensing boards,^5,6,7,8  and risking loss of practice status and opportunities for advancement.⁵  Seeking help may also be perceived as labeling one as weak, not committed, and not meeting exacting historical professional bars.²  These perceptions are very likely learned as a precept of the culture from early training.⁹ 

In a 2020 survey from the National Physicians Foundation, 50% of physicians experienced emotional distress, 30% felt hopeless, 8% entertained self-harm, and 22% knew a physician who died by suicide. However, only a mere 13% sought help for a mental health problem.¹⁰ 

Burnout affects nearly half of all physicians, and even more in select specialties.¹¹  It is also prevalent in nurse practitioners,¹²  physician assistants,¹²  and registered nurses.¹³ 

The COVID-19 pandemic has emerged as an additional stressor,^{4,14,15,16,17}  resulting in anxiety and post-traumatic stress disorder (PTSD) especially for those working in critical care units and emergency rooms. For other specialties, providers may face furloughs, attenuation of work hours, decreased income, and idleness contributing to the psychological burdens of an already fragile healthcare workforce.^18,19  Burnout and the effects of COVID-19 are taking destructive tolls on relationships with patients,²⁰  careers,²¹  and personal lives.^17,22 

The acquisition of mental health services is an important cornerstone of mitigating these emotional consequences. This narrative serves as an expanded version of the Oregon Wellness Program (OWP) as reported by Divers.²³  Specifically, this article includes an evaluative component of both client-users and mental health professionals, adding important dimensions and offering insight to understand factors, some surprising to us, influencing client stress and the changes they made to better their situations.

We review its historical development, principles, and design, as well as utilization, feedback from clients, and perspectives from mental health providers. The OWP is the ultimate outcome of many years of effort among Oregon leaders, committed to the well-being of colleagues, from which the principles and design of the program were developed and implemented. It is our hope that this report may serve as a template of what is possible in bringing help to distressed and reluctant healthcare providers of all disciplines.

The Executive Director of the Oregon Medical Board created The Foundation for Medical Excellence (TFME) in response to an increase in physician suicides, bringing together leaders within the state to address issues of wellness and professionalism.

The Executive Director of Lane County Medical Society convened interested parties in her chapter to address the emotional fallout affecting individual physicians and the local medical community surrounding rising medical malpractice issues.

The Oregon Health & Science University (OHSU) established a confidential counseling program for resident and faculty physicians to address burnout and career concerns.^24,25 

The Oregon Medical Board revised application protocols to ensure that there were no questions about treatment for impairment. Only a single item asks about current impairment status.^7,26,27 

In the aftermath of several suicides, the Executive Director of the Lane County Medical Society formally established a physician wellness program, recruiting donors to underwrite costs. Services were both confidential and free, provided by a select group of mental health consultants and counselors.

Leaders of the Oregon Medical Board, concerned with the well-being of its licensees, initiated discussions with stakeholders regarding the feasibility of establishing a consolidated program.

The Medical Society of Metropolitan Portland (MSMP) introduced its wellness program, modeled on that of Lane County, and secured local funding.

Healthcare leaders established a consolidated statewide Oregon Wellness Program, which served as the central financial and policy resource for all individual programs, and a driver for creating new programs managed by the Central Oregon and Marion Polk County Medical Societies.

It was agreed that the Oregon Medical Board would have no formal role in any capacity with OWP.

1. Provide mental health services to a spectrum of the healthcare workforce, reflecting the reality that burnout, stress, and reluctance to seek help are universal.

2. Embrace the basic tenet of professionalism²⁸  where the emotional and physical well-being of patients, communities, and providers are equally valued.

3. Collaborate with professionals across healthcare disciplines, organizations, practices, credentialing bodies, academic institutions, disciplinary boards, and legislative entities.

1. All Oregon licensed physicians (17,216), physician assistants (2,224), acupuncturists (1,277), and podiatrists (215) became eligible for OWP in 2018.²⁹ 

2. Services are strictly confidential, completely voluntary, self-referral only, and cost-free.

3. Mental health consultants are vetted by local leaders and peers from regions where they practice, based on their reputations and experience in caring for healthcare professionals.

4. Appointments are easily accessed through a centralized call center and scheduled within 72 hours.

5. Visits, either in person or through telemedicine, are provided with up to eight free sessions per year.

6. Reporting to disciplinary and credentialing boards is prohibited.

An all-volunteer OWP Executive Committee is authorized to oversee the program. The Foundation for Medical Excellence (TFME), a 501c3 entity, is designated as the program’s fiduciary, focusing specifically on providing financial support to develop, maintain or expand services, and serving as the legal entity. To date, academic health centers, regional healthcare systems (RHS), private clinics (PCs), independent physician associations (IPAs), individual donors, and the Oregon Medical Board (OMB) have underwritten the costs, approximately $200 per visit.

To assure confidentiality, the Oregon Medical Board has no contact with or influence over OWP. However, OMB believes sufficiently in the value of the program to fully invest in providing funds in support. The Board far prefers that a licensee obtain help, rather than appear before it because of a disciplinary concern.

Calendar year 2019 utilization data are entirely pre-COVID and calendar year 2020 data are within the height of the first wave of COVID-19 (Table 1). Utilization increased from 228 clients to 349 clients (a 53% increase) and 405 visits to 625 visits (a 54% increase), from 2019 to 2020 respectively, coinciding with the first COVID-19 pandemic surge. There was considerable variation in the number of visits per client with 21% (n=16), 16% (n=12), 42% (n=32), 17% (n=13) of 77 responses reporting 1, 2, 3–5, or 6 or more visits respectively (Figure 1).

The Oregon Research & Education Foundation (OREF), a subsidiary of the Oregon Association of Hospitals & Health Systems provided $25,000 for the development and analysis of the patient (client) survey (Table 2) by the OHSU Department of Biostatistics. Survey completion by clients (patients) was optional. Between April 2019 and the end of August 2020, forty-one of 433 (9.5%) individuals, who were provided mental health services, returned 77 program evaluation surveys. Ninety-six percent of responses indicated satisfaction or high satisfaction with OWP and that it was helpful to them personally (97%). Clients reported changes in their personal lives (80% responses) and reallocated activities within their clinical practices. The latter was more prevalent with higher visit rates. The burnout rate fell from 75% for those with 1 visit to 64% for those with 3 or more visits.

Based on a validated questionnaire,³⁰  we surveyed 16 active OWP mental health professionals from July-September 2021. Fourteen surveys were returned (Table 3). The overwhelming majority of MHPs considered the COVID pandemic to be an important stimulus for their clients seeking services. The most pressing concerns of their clients were workload, anxiety, depression, challenges with personal relationships, exposing themselves and/or their families to COVID, and difficult professional relationships. Interestingly, concerns about childcare, loss of income, and reassignment to less positive practice settings were not considered important. Helpful strategies for coping included access to mental healthcare, support from family and friends, and making changes in their personal and professional lives.

Utilization is the best marker of OWP’s success, as evidenced by an increase of over 50% in both number of clients and visits between calendar years 2019–2020. The increase occurred in concert with the first peak of the COVID-19 pandemic, indicating the heavy mental health toll on front-line providers.

We believe attention to the program’s principles and design has facilitated its utilization. These data are particularly notable if one considers that marketing and advertising for OWP has been subtle and discreet out of respect for colleagues who traditionally perceive real barriers to seeking and obtaining mental health services. The availability of telemedicine has also offered easy access for clients.

Clients indicated overwhelming satisfaction with OWP, reported making changes in their personal lives, and reallocated activities within their clinical practices. The burnout rate fell, but not nearly to the degree we expected.

The mental health providers assessed that COVID-19 was a significant factor in their clients seeking help, corroborating our hypothesis that COVID-19 was the reason for the increase in utilization in 2020. The concordance between the clients and mental health providers that making changes in both their personal lives and professional practices were significant factors in alleviating stress lends credibility to the client survey.

The client survey response rate of 9.5% represents the major limitation of this paper. This study lacks critical power to substantiate objective value to the clients’ feedback. In addition, the small numbers do not lend to comparing results of client feedback before (2019) and during (2020) the COVID pandemic. Further, we purposefully chose not to undertake incentivizing or requiring mental health professionals to remind clients to complete surveys. In our view, incentivizing could have biased the results in favor of our intervention and using reminders would do the opposite. No doubt our decision not to mandate completion of the survey or provide incentives to comply were factors in the low response rate, fearing clients would interpret such actions as a threat to confidentiality.

Confidentiality, a cornerstone of the OWP, does have its limits. All MHPs uphold the tenet that there may be occasions where risk of harm to self or others requires reporting to the appropriate authority. They review this exception to all clients at the first visit. To date, all clients have accepted the terms of the contract and there have been no complaints of breach in confidentiality. In addition, when impairment is evident, the MHPs make a firm recommendation for the client to take a leave from practice.

Insights regarding OWP should be of perennial interest to those bodies, locally, regionally, and nationally, overseeing healthcare professionals and those that certify, credential, license, and discipline them. We believe that it is better for individuals in need to voluntarily seek and receive help than be mandated to do so, long before they might ever come before a licensing board or credentialing committee. In a 2018 position paper, the Federation of State Medical Boards expressed its support for addressing healthcare professional distress, burnout, and well-being proactively.³¹ 

This is the first report summarizing two years of outcomes data from an evolving OWP. It is important for those interested in professional wellness to have data at each step. We anticipate and expect significant changes in demographic markers, client stressors, and research methodologies in the future. In an environment of increasing utilization from COVID-19 and expanded eligibility for OWP services that now includes advance practice nurses (4,735 in 2019), dentists (3,905 in 2021), and likely registered nurses (59,778 in 2022), we must broaden our financial base. We have obtained support from multiple healthcare systems, independent practice associations, individuals, the Oregon Medical Board, the Oregon Dental Association, and anticipate the same from the Oregon Nurses Association.

As OWP becomes more inclusionary of providers across the spectrum of healthcare, we need to develop strategies to ensure that all potential users are aware of the program and its value. COVID-19 has taught us that burnout and stress is a healthcare workforce problem, not one confined to physicians.

Finally, we must address the difficulties in conducting research to assess outcomes for clinicians in distress as our client survey returns were less than we had hoped. Our situation is not unique.³² 

The authors would like to thank the following for their contributions:

Design and principles of the Oregon Wellness Program: Candice J. Barr, Lane County Medical Society, Eugene, OR; Timothy Goldfarb, MHA, The Foundation for Medical Excellence, Portland, OR; Kathleen Haley JD Emerita Executive Director Oregon Medical Board; and Nicole Krishnaswami JD, Executive Director Oregon Medical Board

Research design, data Acquisition, and data analysis: School of Public Health, Department of Biostatistics, Oregon Health & Science University and Portland State University

Research concept, design, and data analysis: David H. Hickam, MD, MPH, Professor of Medicine, Oregon Health & Science University, VA Medical Center

Careful review of the manuscript: Diane N. Solomon, PhD, PMHNP-BC, CNM; Chair, Nurse Practitioners of Oregon; Board Member, Oregon Nursing Association General Scholarly Article