We Need To Fix The “Triple-demic” In The Healthcare Workforce Now

“The system is flawed. It’s grinding us. It’s grinding good docs and providers out of existence.”

Keith Corl, M.D, Assistant Professor of Medicine, Brown University
Image Credit: Shutterstock.com

Author’s note: This is not a post about technology. I’m deeply concerned about the current state of our healthcare workforce, and recent newsfeed articles only point out that the situation is getting worse. And it’s not just about burnout, which is covered extensively in the press, in research publications, and at conferences around the world. It’s broader than that. I’ve borrowed the term “triple-demic” to characterize the current situation to include moral injury and physical threats to healthcare workers as the key issues demanding immediate action.

Roughly 2.9% of healthcare workers quit their jobs in November 2022, equating to about 600,000 resignations, according to new data from the Bureau of Labor Statistics. That’s the second-highest quit rate in recent healthcare history, only behind the 3.1% rate in November 2021. Burnout from caring for Covid-19 patients, rigorous work schedules, and stagnant or low wages continue to push many hospital nurses, technicians, nursing home staff, and others to switch to other healthcare settings — or leave the profession entirely. Three major factors contribute to these resignations: burnout, moral injury, and physical threats. Burnout has received most of the attention throughout the pandemic. But the other two factors also need to be addressed to fix the problem. Some thoughts on each follow.


Burned-out healthcare professionals are more likely to leave practice, which reduces patients’ access to and continuity of care. Burnout can also threaten patient safety and care quality when depersonalization leads to poor patient interactions and when burned-out caregivers suffer from impaired attention, memory, and executive function. A survey conducted by an AHRQ-funded project, the MEMO—Minimizing Error, Maximizing Outcome—Study (AHRQ grant HS11955), found that more than half of primary care physicians report feeling stressed because of time pressures and other work conditions. Some of those work conditions are shown in the graphic below:

Image Credit: AHRQ

“The nation’s health care delivery systems are overwhelmed, and nurses are tired and frustrated as this persistent pandemic rages on with no end in sight. Nurses alone cannot solve this longstanding issue and it is not our burden to carry.”

Ernest Grant, PhD, RN, FAAN, President of the ANA

Moral Injury (MI)

Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical, and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care. Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.

That idea resonates with clinicians across the country. The response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, and endless clicking on electronic health records.

“We have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction.”

The Moral Injury Institute

Healthcare workers suffer an injury at the hands of each other: the medication error ignored at the nurse’s station, the doctor who orders unnecessary procedures, and the technician who is forced to carry out morally questionable orders. This regular violation of ethics, winking at incompetence, and hypocritical prosecution of employees ‘outside the clique’ drags down an organization’s culture. Healthcare workers are so blind to the effects of moral injury that they call their cognitive dissonance ‘professional detachment’ and label the effects they suffer ‘burnout and fatigue’ rather than guilt and anger. The impact on the healthcare worker of human trauma should not be downplayed: the opportunities to address trauma and suffering bring providers into the system. It is when the system itself inflicts suffering that the healthcare worker experiences MI.

A less discussed aspect of moral injury is shaming in the healthcare profession. The best discussion of the issue is this recent video from Dr. Zubin Damania. He interviews Dr. Emily Silverman, a UCSF hospital physician and host of the popular podcast The Nocturnists. They dive into shame and emotional repression in doctors, healthcare professionals, and beyond. It is a lengthy discussion but well worth the investment of your time. (And read the comments thread too. Interesting observations from healthcare professionals worldwide on the shaming issues they’ve faced.)

YouTube Video Credit: ZDoggMD

If you want to learn more about the topic, here are some additional resources to explore:

  • The Nocturnist Shame Series
  • More on Dr. Silverman
  • The Shame Space – An international network of professionals who use creative storytelling and research to advance shame awareness, shame resilience, and shame-sensitive practice in healthcare, with the overarching goal of creating more connected, authentic, and safe healthcare systems for all. The Shame Space was formed in 2022 by scholars studying shame at the University of Exeter, Duke University, and Duke-NUS Medical School.

Physical Threats

The seriousness of this issue was reinforced last week in an article written by Michael Dowling, President & CEO, Northwell Health, in Beckers Healthcare titled: The unthinkable priority now facing hospitals.

In his opinion piece, Dowling highlights this “additional and disturbing priority — one that, I would argue, we never imagined. We now must protect our hospital patients and employees from the growing threat of intimidation and violence. There has been a dramatic spike in staff assaults, with many leading to serious injury and some leading to death.” (How have we gone from nightly 7 pm balcony applause and cheering for healthcare workers during the pandemic to physical assaults in their workplace?)

“People are proud of their bitterness now.”

Peggy Noonan, Wall Street Journal, 2019

The number of injuries from violent attacks against medical professionals was already on the rise pre-pandemic, increasing 86 percent from 2011 to 2018, according to the Bureau of Labor Statistics. In a spring 2022 survey by National Nurses United, nearly half of the hospital nurses (48 percent) reported rising workplace violence, more than double the 21.9 percent who responded as such a year prior.

Dowling has already taken action to address the problem. At Northwell, they call this new priority “The Safe Place Initiative.” It includes the following actions, investments, and measures:

  • An investment in educating visitors, patients, and team members on proper behavior and how to promote dignity, respect, and understanding. Thousands of pieces of informational signage and posters are prominently displayed, emphasizing that harassment and verbal or physical assault will not be tolerated. Signs are also on display that reminds all visitors that this healing place — the hospital and ambulatory facility are weapon-free zones.
  • A comprehensive investment in training employees on what to do in a potential active shooter situation, on how to de-escalate a potentially violent situation, and on how to “stop the bleed” in the case of such a circumstance. Over 50,000 of our employees have already received this training.
  • The enhancement of security in all locations by increasing the presence of security personnel, as well as increasing video surveillance and alarm systems.
  • The installation of weapon detection technology at the entrance of our facilities.
  • Education for staff on how to recognize signs of domestic and partner violence and enhanced support offerings to team members impacted by such violence.

“Now is the time to champion kindness, respect and compassion. Times like this call for even greater generosity of spirit, the “better angels” of our nature. Positive leadership unites, promotes mutual trust, builds confidence and is optimistic.”

Michael Dowling, President & CEO, Northwell Health

I have tremendous respect for the work that Mr. Dowling is doing at Northwell. Action, not just words. Leadership, not just platitudes. We need more of this.

I’m not sure that I have good answers to these critical issues. I suspect that there is not one solution that will fit every situation. But my hope in writing this post is to raise awareness of the seriousness of these issues, put a different frame around the various elements, and drive a deeper conversation around how we can solve these challenges before we lose more dedicated professionals because of frustration, exhaustion, and intimidation. These good people deserve nothing less.

Some Straight Talk About Technologies That Support Aging In Place

“The Decade of Healthy Aging: A global collaboration, aligned with the last ten years of the Sustainable Development Goals, that brings together governments, civil society, international agencies, professionals, academia, the media, and the private sector to improve the lives of older people, their families, and the communities in which they live”

World Health Organization, 2021
Image Credit: Shutterstock.com

Recently I received a book recommendation from a longtime reader of this blog who pointed out that they’ve enjoyed the “Straight Talk” series of posts but thought that I’d missed a big trend around an important topic that doesn’t get enough attention – age tech.

The book they recommended was The Age Tech Revolution: A Book About the Intersection of Technology and Aging by Keren Etkin. I immediately purchased and downloaded the book and couldn’t put it down. If you are interested in the intersection between demographic trends, global economies, and technology, this is a great read, helping understand the changes we are facing as a society and what role technology plays in all of this. A glimpse into our future from a passionate expert that has devoted her life to researching this topic but incorporating real-world experience as well, with a strong understanding of how technology is developed and scaled.

The book and her website, The Gerontechnologist, are the most comprehensive resources on age tech, the market, and the companies working in that space that I’ve found to date. If you are interested in this topic, do yourself a favor and buy the book, and bookmark her website. You won’t be disappointed.

Here’s my take on where we stand today, the challenges and opportunities in the market, and the technologies that support the ability to allow an individual to age in place.

The challenges – By 2050, we’ll have two billion people over the age of sixty living on this planet—that’s twice what we had in 2017. In the Organization for Economic Co-operation and Development (OECD) member countries, people over sixty-five are expected to be about 28 percent by 2050. On the other side of the equation, the “caregiver support ratio,” which is the number of potential caregivers aged forty-five to sixty-four for each person aged eighty and older—is declining. In 2010, every American over the age of eighty who needed care had seven potential family caregivers. By 2030, they will only have three (AARP Public Policy Institute, 2013). The US will face “a shortfall of over hundreds of thousands of direct care workers and several million unpaid family caregivers. This has real consequences for families, not only in America but also worldwide.

Image Credit: AARP The Longevity Economy® Outlook
Image Credit: AARP The Longevity Economy® Outlook

Costs are going up too. Genworth, who conducts and publishes an annual Cost of Care Survey, estimated in 2020 that the monthly median price for in-home care is expected to increase by approximately 30 percent by 2030. There will be a similar increase in the cost of assisted living and nursing homes, which are higher, to begin with. Currently, the cost of just two years of in-home care or assisted living could easily surpass $100,000, and many people require care for much longer than that.

Another challenge for the future is “the longevity factor.” Scientific breakthroughs will extend our lives by more than a year, for every year we are alive. This is called longevity escape velocity, and some experts think it’s only 12 to 15 years away. Of course, getting to that point is multidimensional. It means addressing health from all angles, with personal lifestyle choices, technology, and more.

The opportunities – AARP, the nonprofit, estimates there’s a $9 trillion economy all around us. It’s ripe for innovation. We have a unique opportunity within the next ten years to build better technology that will serve the needs and wants of the aging population and ultimately make us a more age-inclusive society. And, the 50-plus population has money to spend on products and services that make their lives easier, safer, and more productive. The 50-plus population is an economic engine in its own right, which helps drive the overall economy. Almost two-thirds of spending on financial services and insurance is attributable to the 50-plus age demographic for whom retirement and other financial planning needs are immediate and pressing. This spending provides an opportunity for industry leaders to make their companies more universally relevant by targeting the 50-plus cohort while simultaneously benefiting other generations.

Image Credit: AARP The Longevity Economy® Outlook

Foundational technologies that support aging-in-place – Few misconceptions are more pervasive than the notion that older adults are unenthusiastic about technology. The opposite is true. Numerous studies have shown that older Americans are embracing technology. Indeed, one survey in 2018 found that of the 50-plus population, more than 90% own a computer or laptop, 70% have a smartphone, and over 40% own a tablet. Moreover, older adults’ demand for technology goes beyond smartphones and apps. Their enthusiastic adoption of smart home assistants, strong interest in automobiles with computerized driving assistance, and enrollment in computer-based distance education suggests that business leaders in technology would do well to pay them greater attention. The problem lies not in an unwillingness to adopt but in being overlooked by the industry.

Image Credit: University of Michigan, Institute for Health Policy and Innovation, 2/9/2022

“AARP’s research has found a sharp increase in older adults purchasing and using technology during the pandemic, and many are interested in using technology to track health measures.”

Indira Venkat, Vice President, Consumer Insights, AARP

I believe that several “foundational” technologies will support the development of products and services to allow individuals to age in place. Remember that these will not be standalone use cases but will be combined with other technologies to create an exponential benefit for the user. Here they are in no particular order:

Voice technology – I’ve written here before on voice-enabled technology in health care. But I genuinely believe that this is one of the key foundational technologies that will support aging-in-place. Not only does the technology eliminate the need for complex user interfaces, but it can also be used in combination with AI and Machine Learning to determine a person’s state of mind, assess cognitive function and emotional health. Applications like Google’s Duplex allows Google Assistant to make calls for you and schedule appointments with local businesses and is currently being rolled out to select geographies and devices.

Robot assistance and companions – This is another technology I’ve covered before. Now that I’m older, I fully expect to have a live-in robot to help me with my ADLs (Activities of Daily Living) and household maintenance if I should require assistance. We could build home robots to handle household maintenance and help with ADLs.

Ambient technology solutions – We can develop ambient technology that’s embedded in our homes, able to anticipate our needs, and provide us with instant solutions. The idea of the “smart home” for seniors has been around for some time now. The phrase “Smart Home” means different things to different people. Any time a home gets some “intelligence” incorporated into some aspect of it, it gets a “smart home feature.” A smart home feature is any aspect of a home — usually involving some type of gadget or appliance — that incorporates some level of automation or programmable behavior. Smart home features also often include some aspect of “connectivity” — either to the outside world or other elements in the house.

An excellent way to think about smart home features is this. Various smart home features are suitable for the population at large. These include thermostats, automation of appliances, security systems (burglar alarms, video doorbells), and air quality. Then some specific smart home features might seem especially useful for subgroups of the population — including some who are “older adults.” These include things like a “smart device” which can connect wirelessly to a hearing aid, or some other type of personalized hearing gadget (e.g., headphone); a smart fridge that automatically reorders staples for you when they go low, and knows when you need to throw out old food; or a smart home gadget that replaces a conventional front door lock with a similar lock that can be opened either by a key or by a code entered into a set of buttons.

Since the smart home concept involves multiple technologies that need to be integrated, serviced, and supported, this creates an opportunity to create a business model around “The Smart Home as a Service.” This service would: help you pick the smart home features you need; teach you how to install the equipment or do it for you; provide ongoing monitoring and maintenance. And it would be easy to add a layer of extra services “enabled” by the smart home data, such as regular changing smoke alarm batteries and other routine preventative maintenance tasks. Over the last few years, we have seen several companies attempt to offer services like this.

Here’s a link to a recent Fast Company article on how Canadian communities are redesigning senior living.

Companies working in the AgeTech market space – As I mentioned earlier, the most comprehensive resource I’ve found is Keren Etkin’s website. She’s posted a terrific infographic with a list of companies developing technology solutions by market segment. I’ve included a copy below:

Image Credit: Karen Etkin, The Gerontechnologist website, accessed 2/9/2022

We have a unique, once-in-a-lifetime opportunity to impact the experience of living as an older adult in this world using technology. It’s a market that’s not getting the attention that it demands. But there’s hope on the horizon as more tech incubators focus their efforts on developing startups working in the space. Time to get moving, folks! I’m not getting any younger 😏