VA’s Women’s Health Services (WHS) provides a Women’s Health Mini-Residency for Primary Care Rural Providers and Nurses. In this photo, a nurse instructor shows VA nurses at the Murfreesboro, Tenn., VA Medical Center contraceptive options available to women veterans. Photo from May 26, 2020, VAntage Point blog.
PALO ALTO, CA — The delta variant’s march across America brought a crisis long in the making to the blazing front of the news—and made research coming out of the VA potentially beneficial for the wider health care industry.
As cases of COVID-19 surged, many hospitals that had converted cafeterias and offices, expanded into garages and popped up tents in previous surges made no attempt to expand into additional space despite having patients waiting for hours in the emergency department and in parked ambulances. There was no point in adding beds when they lacked the staff to care for more patients.
That staffing shortage, building for years as nurses and physicians decried a lack of support from hospital administrators, chronic under-staffing and mandatory overtime, became a staffing crisis as health care workers left their jobs in droves throughout the pandemic. In 2017, 418,000 nurses quit the profession. A survey conducted last March showed that 30% of all health care workers (nurses, doctors, technicians, hygienists, and staff) considered their profession within a year because of the pandemic. If those surveys accurately indicate the sentiment of America’s nearly four million nurses, more than 10 times the usual number of nurses could be leaving the profession in 2021 and 2022.
Physician-specific studies indicate that four times the average number of doctors left practice in the last 18 months. Some left to care for family members. Some died. Many burned out as the community support of the first months of the pandemic faded into apathy and, in some cases, descended into violence.
Lessons from the VA
“When an experienced provider opts to leave a healthcare workforce (attrition), there are significant costs, both direct and indirect,” VA researchers led by Rachel Schwartz of the VA Palo Alto Health Care System wrote in a recent article in the Journal of General Internal Medicine. “Turnover of healthcare providers is underreported and understudied, despite evidence that it negatively impacts care delivery and negatively impacts working conditions for remaining providers.”1
The team of researchers focused specifically on the loss of women’s health primary care providers (WH-PCPs) in the VA, but their findings likely have implications for other specialties and health systems. “Exploring potential mechanisms [for retention]—e.g., shared mission, appropriate support to meet patients’ needs, or a cohesive team environment—may inform broader efforts to retain front-line workers,” the authors noted.
The demands on WH-PCPs are significant: they must remain current on primary care topics along with women’s health content and provide care for women veterans, who tend to be patients with complex needs. These providers practice in one or more of three different clinical settings. They may be in a general primary care clinic that serves both women and men or in a limited women’s health clinic, typically adjacent to or in an isolated part of a general care clinic. Alternatively, they could practice in a comprehensive women’s health center, which offers a range of specialties within a center that serves women exclusively from the front door and waiting area to the exam rooms and counseling spaces.
Typically, the comprehensive women’s health centers include specialists in gynecology, mental health, social work, and clinical pharmacy under one roof. The general and limited clinics co-locate primary care and mental health and offer referrals to other specialties.
To determine whether practice setting, ready access to specialty support services, workload or other factors influenced attrition, the researchers compared data from the Designated Women’s Health Provider Assessment of Workforce Capacity (DAWC) and Women’s Assessment Tool for Comprehensive Health (WATCH) from September 30, 2016, and 2017 to determine the rate of attrition. They verified that the providers (physicians, nurse practitioners, and physician assistants) had an active patient panel and extracted information on clinic environment, workload and co-location of services.
Of the 2,259 in the final cohort in 2016, 7% worked in a comprehensive women’s health clinic exclusively and 4.2% worked only in a limited women’s health clinic. Five percent worked in multiple settings, and 83.8% worked entirely in a general primary care setting. Seventy percent of the WH-PCPs in general primary care clinics were women, while 95% to 98% of those who worked in limited or comprehensive women’s health clinics (CWHC) were women.
After attrition of 307 providers, 1,952 continued as a WH-PCP in the VA a year later.
“We found that only clinic environment—specifically, working exclusively in a comprehensive women’s health center—was associated with significantly lower odds of WH-PCP attrition,” the authors said. “While recent research emphasizes the need to address team-based elements of primary care delivery to improve job satisfaction and reduce intent to leave, our findings address an important gap: the dearth of literature on clinic-level drivers of PCP attrition.” They observed that others have previously called for a systems approach to reducing burnout among providers.
Providers working in CWHCs had a 60% lower odds of attrition, even after consideration of col-located specialty support services, degree type, gender, and patient volume. The difference in retention rates between settings was most pronounced in VAMCs. WH-PCPs had three-fold lower odds of leaving their role if they worked in a CWHC than in a general primary care clinic.
“Given the structure and function of the CWHC model, it is plausible that this clinic environment may facilitate providers’ ability to deliver care that they feel meets their patients’ needs,” the team observed, or “that CWHCs provide greater workplace ‘match’ between care delivery processes and individual WH-PCPs’ values.” CWHCs may have a greater sense of shared mission, which could reduce workplace chaos, increase provider satisfaction, build a more cohesive team, and support professional identity better.
Alternatively, as CWHCs are staffed almost entirely by women, it could be that a predominantly female clinic environment changes clinic interactions in ways that provide more support to women providers, perhaps by reducing sexual harassment and other negative interactions with male peers or that as sex-specific exams require extended visits, based on VA policy, providers have more time with patients.
On the other hand, the researchers suggested that the higher attrition in general primary clinics could be a result of seeing fewer women, typically just 10% of the case load, and not maintaining confidence in the skills needed for women’s health care or not seeing the need to keep up to date with the extra medical education requirements.
- Schwartz R, Frayne SM, Friedman S, Romodan Y, Berg E, Haskell SG, Shaw JG. Retaining VA Women’s Health Primary Care Providers: Work Setting Matters. J Gen Intern Med. 2021 Mar;36(3):614-621. doi: 10.1007/s11606-020-06285-0. Epub 2020 Oct 15. PMID: 33063204; PMCID: PMC7947068.
