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“Even if Omicron is mild, it will create a large denominator of cases, some number of which will need to be hospitalized,” says Gigi Norris, Managing Director at Marsh where she leads the US healthcare practice. “That's happening at the same time as other COVID cases and influenza, which always creates an uptick in hospitals in the wintertime. There is a potential deluge of patients.”

In this episode with interviewer ľ��ӰԺ Chief Public Affairs Officer Erick Gustafson, Norris brings her expertise in public health and pandemics to describe the unfolding of events of a disease with many unknowns, the issues around information and communication, and the effects on the critical labor force needed to treat millions of patients.

TRANSCRIPT:

Gigi Norris:

This is about a nurse who wanted to give the family a little bit more time with the patient. The patient was in the process of dying. The nurse was using a manual ventilator called an "Ambu bag." You pump it with your hand, essentially, to inflate the patient's lungs. She pumped that with her hand for an hour, an hour-and-a-half or so. Her hand's cramping, I mean, difficult experience all around, mentally and physically. The patient, of course, does expire, eventually. The next week, she comes back, and her employer calls her into the office and says, "The family of that patient called and they just wanted to make sure that everything was done that could be done." That was so demoralizing to this particular healthcare worker who had very selflessly put herself into this situation, and in her mind, had absolutely done everything that could be done. You get into a situation where you feel as if there's never enough that you can do, even though you're making these sacrifices and sacrificing not only your own mental and physical health, but a health of your family a lot of times because folks are dealing with an infectious disease and healthcare workers can bring that home.

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Erick Gustafson:

Gigi Norris is the healthcare practice leader at Marsh. In this podcast she talks about a crisis in healthcare that was actually happening before the pandemic began, which was a shortage in nursing and support staff. Now, with hospitals scrambling to treat COVID patients, it's even more uncertain. Not only are nurses and support staff quitting, but according to a recent report by the recruiting firm, Nursing Solutions, a third of hospitals can't fill all their positions and it's getting worse. In addition there's not enough faculty to fill the teaching positions at schools to train the next generation of nurses we need. This is the podcast ľ��ӰԺ Matters. I'm Erick Gustafson. Gigi Norris knows something about pandemics. She's an epidemiologist, trained at UC Berkeley where she earned a doctorate in public health. And in her career she led a pandemic task force. We started the discussion by stepping back to ask a general question, what's the root cause of the nurse and staff shortage at hospitals?

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Gigi Norris:

That's really the $64,000 question, right, because hospitals are dealing with this and they are dealing with trying to manage all these patients and they're struggling with the financial implications of this. It is just a really difficult moment for healthcare all over the world, of course, but in the US, and as a result, one in five physicians and two in five nurses say that they intend to leave practice within two years. Many hospitals are really doing their best to ensure that healthcare workers have good support through mental-health-type interventions. A lot of them are reacting as well by trying to incentivize healthcare workers through other means, wages, et cetera. However, this is something that is a bit more existential than we're used to dealing with.

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Erick Gustafson:

Whether it's in the US, or elsewhere, have you seen any innovative solutions to address the educational bottleneck? I know in the past, the US has recruited from other countries, but that's a little bit of like robbing Peter to pay Paul because, of course, the global nature of this crisis.

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Gigi Norris:

Yeah. No, I think you're absolutely right.

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Erick Gustafson:

Where's the solution? I think, too, there are ER-related nursing, but then there is also long-term care nursing and you combine big risks, right? I mean, the one that's in our grill right now with the aging population needing more long-term care facilities, you really do see a shortage of skilled medical professionals and nursing staff and those who support the nursing staff.

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Gigi Norris:

Yeah, I think you're absolutely right there. Yeah, in the past, we were able to recruit from a number of other countries, and you're right, that's more difficult now, of course. People need their nurses because this is happening everywhere at the same time. It's also difficult to bring people in from other countries because we've got different kinds of restrictions due to COVID. I think with respect to going forward, one of the things we're seeing from the government, certainly, is an increase in support for things like hospital at home and healthcare at home, so beginning to structure some care delivery so that family members and other caregivers can actually receive some compensation, or otherwise be supported to take care of family members at home, for example, in your long-term care scenario, so that may be helpful with respect to the aging population going forward.

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Erick Gustafson:

Yeah. At some point, the pandemic's going to end. I'm an optimist. I think in every crisis there is a bit of a silver lining. Do you share that optimism? How, when the pandemic finally ends, does the nursing and other medical professional shortages right itself? What do you see in the future, if you can look that far out?

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Gigi Norris:

Yeah. There are a couple of different things happening here. First of all, we definitely are going to be in a spot where we have an ongoing shortage of workers. In August, for example, just one month, about half a million people left their jobs. According to the Bureau of Labor Statistics, more people are rethinking their career choices, particularly in the nursing profession and in the other tiers that support the nurses. We were facing a shortage of healthcare workers in 2019 and we've had shortages before and we've had different ways to respond to some of those shortages. We're facing a bigger issue now. I'm an optimist in that I do also agree with you, the pandemic definitely will end at some point. However, we're at a point where three in 10 healthcare workers today say they're considering leaving the profession. But we've actually seen a big uptick in medical school enrollment. If there's any good news here, that's probably the good news, I think about 17.8% uptick of enrollment, and usually…

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Erick Gustafson:

That's encouraging.

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Gigi Norris:

... Yeah, it really is. That usually fluctuates by two to 3% up and down each year in medical school enrollment. One of the other bright lights there is that the enrollment to medical school is characterized by previously underrepresented populations, so that's kind of exciting. Nurses, on the other hand, one of the big issues with nursing schools is there is now also a shortage of nursing school professors, so we've got this bottleneck with even being able to get people trained up to be able to act as nurses, and we are going to face an uptick in expense relative to this issue going forward.

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Erick Gustafson:

Maybe changing tack just a little bit now, what can we do? What should society and medical professionals be doing to encourage greater public compliance with, obviously, first, getting vaccinated, but then second, following whatever is needed regarding social distancing or limits on access to certain kinds of restaurants or non-essential facilities? I hesitate to call them "lockdowns" because, of course, not quite that in the US, elsewhere, it is, but whether it's mask mandates or other limitations.

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Gigi Norris:

Yeah. Yeah, I think that if people really did have a better sense maybe of what was happening with healthcare workers, that might inform some of our actions and some of our willingness to comply with some of these. I think you're right. I don't think they are lockdowns, but I think they are some different kinds of compliance regimens that may need to be put into place. I think that what these healthcare workers are going through, it's kind of multifactorial. A lot of people were burned out before, so we did have an impending, a looming crisis with healthcare workers before the pandemic ever happened. Then this occurred, and what it means is that every day, these people are dealing with excess death, the likes of which they've never seen before, a lack of public participation in the process because most of the people in those hospitals are people who are not vaccinated, for COVID, anyway, and the fact they're also being frequently put into morally difficult situations. Another story that I found compelling and sad was a story of, it was another nurse who worked in a hospital, and he said that every day for a series of days running, he got a new COVID patient, and every day, that patient died before noon. Imagine that every single day, for some period of days, having that experience, going to work, getting a patient, doing everything you can to help that patient survive, and every day, that patient expiring within a number of hours. What we're seeing now is poor healthcare workers are, Omicron, there's not a bed available in some places, and now, we're potentially awaiting a new wave of cases, and even if Omicron is mild, if it's as infectious as people seem to think that it is, it will create a large denominator of cases, some number of which will need to be hospitalized, and that's happening at the same time as other COVID cases and influenza, which always creates an uptick in hospitals in the wintertime, so yeah, there is a potential deluge of patients.

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Gigi Norris:

I do think that lockdowns the way that we had them in the beginning of the pandemic probably will no longer be effective, I don't think people will comply with them, but I do think that if people understand the importance of their actions, many of which are pretty simple, with respect to their every day congregate activities, going into settings, where they can become infected and infect others and potentially create some hospitalizations, even if those hospitalizations are not among anyone that they know, this thing travels. I think just that awareness may be something that is useful informing people's actions.

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Erick Gustafson:

In encouraging individuals to follow proper etiquette, get vaccinated, we're seeing, obviously, individuals that choose not to, and many instances, unfortunately, the clash occurs at a point where medical professionals are involved. How are hospitals, whether it's nursing staff, or doctors, or even just the executives that are managing the hospitals, dealing with that as that new aspect of their job, which is effectively some physical violence, enforcement-facility-type structure? What are you see seeing in hospitals? How are they managing that risk?

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Gigi Norris:

Well, workplace violence in healthcare is definitely a big theme now, much bigger than... It was a big theme before, but this has really exploded a bit. The majority of physicians and nurses say that they have experienced some kind of workplace violence at some point during their careers. Some of that has to do with factors like substance abuse and the intense emotions that patients may have when they're being treated. People are not at their best in the healthcare environment a lot of the times. Then, of course, now we have got a situation where, yes, we've got a divide around how people feel about some of these interventions, and we also have lower staffing levels. Some violence is thought right now to being committed as a way of getting a healthcare worker's attention, right? If there's nobody there, people are getting frustrated and they're becoming violent with respect to the fact that they can't get anybody's attention because the staffing levels are so low. With respect to pandemic-related violence being targeted against healthcare workers, we're seeing that as well. Some of the things that, I mean, certainly, there's security in hospitals and that has been increased, but there are also simpler and maybe a bit sadder interventions where, for example, healthcare workers are being told not to wear their scrubs outside of the workplace, so make sure that you are not identifiable as a healthcare worker when you are going from work to home, for example, and stopping at the gas station because people are vulnerable to other people's opinions and potentially violent acts as a means of expressing those opinions.

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Erick Gustafson:

I mean, that strikes me as ludicrous, in all candor, but unfortunately necessary. I think if I was to see someone in scrubs, I might react as a means of saying "Thank you," or, "I hope you're keeping well," rather than that alternative.

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Gigi Norris:

Certainly, at the beginning of the pandemic, there was all this outpouring of gratitude for healthcare workers. As it wore on, they have become targets, in some ways, which is incredibly difficult because, of course, that's happening as they're sustaining these new waves. All of us are like, "Oh, my goodness. Omicron? How can we have another thing like this happen at a time like this, during the holidays, even worse than another time?" Healthcare workers have that in spades. They keep thinking that we're nearing the end and then they get something new to deal with.

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Erick Gustafson:

How should society properly acknowledge the efforts of these medical professionals who have carried us through, no different than soldiers at a time of war, or first responders during a natural catastrophe, in some ways harder than all of those things because of a lack of uncertainty and seeming un-end to the crisis?

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Gigi Norris:

Yeah. Well, I think probably the first and most important thing is just honoring those people by showing them the respect of being vaccinated and wearing masks and following protocols, right? If we want to make their jobs easier, that's what we need to do, so that's the fundamental.

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Erick Gustafson:

Yeah. Mask up, pal. Get the shot, yeah.

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Gigi Norris:

Yeah. I'm sure that people are also happy to be compensated well and be respected and work in cultures that are respectful and have patients who are just culturally respectful to them or respectful in a more human way as well. I think some of this is simple. I mean, it's a little bit of the golden rule, right? We want to treat them in a way that we want to be treated. People, obviously, aren't thrilled to have their families health compromised by doing their job, so I think that that's one of the simple answers.

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Erick Gustafson:

Yeah.

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Gigi Norris:

All of the CEOs of all the hospitals in Minnesota got together and they took out an ad in all of the local news outlets, which was a plea to the public to please wear masks and get vaccinated because they had no ICU beds left in the state of Minnesota. In it, the healthcare workers themselves are actually making that plea. They say that "We're tired. We're burned out. We can't do this for long and we have no place to take care of you if you happen to come in because you have a car accident or a heart attack or any other kind of an emergency health condition," so that is also a pretty powerful statement, I think, given that a whole state got together to deliver that message.

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Erick Gustafson:

Gigi, you've got an impressive 25 years of experience in this field, a doctorate in public health. Tell us a little bit about how you came to Marsh and what led you to this area and drove your passion.

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Gigi Norris:

Yeah, so I've always been involved in public health in one way or another, even though I've worked as a broker for many years. I've always been involved in... Honestly, I initiated a global pandemic task force, I think, in the year 2000, because pandemic has always been a major risk issue in my mind. There was no question it was going to happen, it was just when. At the time, we weren't even thinking about what because we always assumed it would be an influenza pandemic because they happen about three times a century, historically, so I think the thing that has thrown everybody for a loop with this particular pandemic is it's not flu, which, of course, doesn't mean another flu pandemic couldn't happen at any time, so I see it as, obviously, a major risk area, something that we need to be thinking about and planning for all the time, mostly with relationship to business interruption in all areas of the economy, just as we saw during this pandemic, so I've always been very connected to these kinds of issues and helping think about how different types of businesses, including healthcare organizations, can plan.

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Erick Gustafson:

As I think about this issue, I always look for historical examples in most everything, like, "The world's gone through something like this in the past," but I don't know that that is applicable here. Certainly, the world has been through pandemics, but not that, in my understanding, have been as well recorded and attended as this one. How do medical workforces even contend with this?

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Gigi Norris:

Yeah. I think that that's so interesting, because, of course, we had 1918, right, which was a horrific flu pandemic, but we didn't really have science, right, in 1918. We didn't have a lot of evidence. We couldn't even really count what was happening to people in a very accurate way, so I think now that we have a lot of information, but still not enough information, I mean, you think about how this unfolded, and really, with a novel virus, what that means is you know nothing about it when it begins. We're a public who, at least a lot of us, we're really are waiting for the facts to come out so we can know how to respond and we didn't have a clear set of facts to start with and it was a really a learning process, so I think that was a big difference. From a healthcare provision standpoint, what that meant is there was no standard of care for healthcare workers to follow. As this began to unfold, no one knew what right way to treat a COVID patient was, so that was very, very trying in and of itself, and of course that evolved over time, and unfortunately, I think the situation we're in today is we've got all these tools to prevent people from ever being hospitalized and they're not being used to the extent that they can be.

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Erick Gustafson:

Oh, well, I was just going to ask, I mean, are there technology-oriented solutions, or perhaps even public-policy-oriented solutions that could ameliorate the problem to a degree?

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Gigi Norris:

Yeah, certainly, from a public policy standpoint, certainly, making sure that people have incentives to get trained and making sure that there are sufficient and professors to do that training is a big deal. I think really elevating the status of nurses in society is actually something that nurses and other healthcare workers, I think, that is something that we've got to somehow make it attractive for people to go into this profession, both in terms of compensation and in terms of identity. Technology is a double-edged sword, so a lot of physicians, for example, like 50% of physicians say the primary cause of their own burnout is technology, and it's because of the administrative requirements associated with complying with the medical records, so it can be a curse, but it can also be an extender. We're definitely seeing a lot of development in the area of things like artificial intelligence that can assist with various functions. We've seen a lot of telehealth. That, of course, also can be an extender and can shorten the amount of time for both patient and provider, so that can be a useful intervention in some cases, so there's a lot of different technology emerging. We live in the United States, so any technology that emerges also, it's going to take a while to get that appropriately vetted and regulated and allowable in the case of things like artificial intelligence, for example.

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Erick Gustafson:

It strikes me as if doctors and nurses are stretched and one of the things that's causing them great stress is paperwork. There needs to be a technological solution in the offing for that in the short order, notwithstanding the need for privacy and accuracy and all the things that we want in our medical record-keeping, but it seems as though public policy could help to ease the transition to a more digital or AI-oriented solution in that area, perhaps with some benefits, too, about accuracy and maybe even legibility.

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Gigi Norris:

I think that's absolutely right. I mean, I do think that there's a lot of hope for AI in a lot of different areas of healthcare to really reduce the number of tasks that are currently performed by healthcare workers and a lot of those more repetitive tasks that don't really require the professional education and the health sciences education that we need our healthcare workers to have. What physicians say is, and I'm sure this the same is true for other healthcare workers, as we were talking about before, they get into this profession because they want to be working with patients, they want to be directly interacting with patients, so every minute that you take away of that part of the job decreases job satisfaction, to some extent.

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Erick Gustafson:

Yeah. Is it possible? This is a weighty topic, so I'm reticent to get into this. What does Marsh do? I feel like we haven't really touched on that.

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Gigi Norris:

Right. In terms of what Marsh does, our colleagues at Mercer, they do a lot of workforce planning, so not only can they do a lot of measurement around, they get down to the metropolitan statistical area around the potential supply of healthcare workers in a given geography so they can look at the external labor market and help you figure out how to recruit from it and whether you can recruit locally or you need to recruit from a different part of the country because these shortages do vary by geography, but they also do a lot of internal labor management, so they can actually help healthcare clients, so healthcare institutions look inside their hospital, for example, and figure out how to deploy their resources potentially more efficiently or in different ways to meet different needs, so they have a lot of good consulting capabilities in that regard. We're interested in it at Marsh because what we're seeing is this decline in workforce. It has the potential to and it is proven to really affect patient safety, and so at Marsh, we help our clients with hedging for things like healthcare professional liability risk. This is important to us, this staffing issue on this side of the fence because we're potentially seeing it come around in claims, claims of medical error or medical negligence, so there's been a lot of research in the last couple of years around how staffing shortages result in higher medical errors, medication errors, for example, and the CDC came out with something just a couple of months ago about how the incidents of healthcare-acquired infections ticked up very significantly during 2020. Part of that was due to the chaos of the pandemic, of course, but part of it was due to low staffing levels, so you see how these low staffing levels, they affect everything that happens in a hospital.

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Erick Gustafson:

Gigi Norris is a managing director at Marsh where she leads the US healthcare practice. ľ��ӰԺ Matters is produced by ľ��ӰԺ with Connected Social Media. I'm Erick Gustafson. Thanks for listening.