Healthcare Provider Wellness in the Time of COVID and Beyond

Physician well-being and the larger topic of healthcare provider well-being has taken on an increased sense of urgency during the current COVID-19 pandemic. To be sure there has been a unique set of challenges resulting from caring for patients with COVID-19 (Table 1). Early in the pandemic, based on multiple interviews, Shanafelt, et al. identified eight frequently cited sources of healthcare provider anxiety related to COVID-19.¹ The COVID-19 pandemic has mostly illuminated the problems that have been lurking within our healthcare system for quite some time. It would be misleading to focus solely on this pandemic crisis as a novel cause of physician and healthcare provider burnout and dis-satisfaction. The recognition of physician burnout and the quest to improve physician well-being predates COVID^2,3 and will outlast it.

Table 1.

Unique Wellness Challenges During the COVID-19 Pandemic

Fear of contracting the disease (inadequate PPE) Fear of giving the disease to family members Constantly dealing with overwhelming numbers of critically sick patients Lack of evidence-based and up-to-the-minute information regarding treatment Poor outcomes in people who presented walking and talking Difficulty admitting patients, particularly to high levels of care Inability to console family members or allow family closure Backfilling shifts due to sick or quarantined workers Frequent (often daily) changes in policy & procedures

It is impossible to divorce wellness in the workplace from the overall wellness experienced within a society. Over the past two decades much has been published regarding how to best define and measure societal well-being and quality of life, along with multiple efforts to develop validated tools to measure it.^4–7 These tools advanced beyond the previous simplistic model which equated wellness solely with national wealth and gross domestic product, to one that was complex and multidimensional. This model includes material living standards (income, wealth), health, education, personal activities (including work), political governance, social connections, environment, and insecurity (both economic and societal).

Physician Burnout

Within this larger framework, work or occupation can be a dominant positive factor in achieving and maintaining well-being in that it affects many of the other components, including wealth, health, education, social connections, and insecurity. The benefits of work in these other areas of well-being likely varies based on one’s exact role in the healthcare system (technician, nurse, advanced practice provider, or physician). Physicians might be expected to benefit in many, if not most, of the wellness measures based on their occupation; so why do physicians apparently score lower on well-being measurements than other professionals and even non-professional workers?⁸ Interestingly, it does not start out that way. At least one large study found that persons about to begin medical school suffer less from burnout and have higher quality of life scores across all tested domains when compared to age and education matched controls in the general population.⁹ These better than average quality of life scores among beginning medical students begin to fall below the average of their matched controls during medical school and residency and remain below population averages among physicians in practice.^8,10 This suggests that it is not an underlying lack of personal resiliency or psychological well-being which leads to excessive burnout among physicians, but rather the circumstances of their training and practice.^9,10

Physician burnout has been a hot topic in the international medical literature for at least a decade. It turns out that the United States is not alone when it comes to physician burn-out, and the same causes seem to be universally responsible, although the magnitude differs by country (and likely on a more granular scale by work location).¹¹ The factors which are most often cited by physicians as the major contributors to job dis-satisfaction and burn-out are: administrative burden, excessive bureaucratic tasks, insufficient time to complete tasks, spending too many hours at work, and lack of respect.^12–14 Although the electronic health record is a significant contributor to burnout, its relative importance is age-dependent, with only post-World War II “baby boomers” rating it in the top three causes.¹³ An overarching theme summarized by a paper from the Agency for Healthcare Research & Quality (AHRQ) is that chaotic environments, low control over work pace, and an unfavorable organizational culture were strongly associated with burnout and intent to leave practice (AHRQ).¹⁴

Hospitals and medical centers (whether academic, public, or private) have become increasingly aware of the problem of physician burnout. The answer many organizations initially embraced to this growing threat was to offer mindfulness and resiliency training.¹⁵ West et al. found that mean physician resiliency scores were significantly higher than those of the general population, and although higher resiliency scores were associated with less burnout, there were still high burnout rates even among those with high resiliency scores.¹⁶ We do not minimize the benefit of mindfulness and resiliency programs, as they can help to promote well-being. However, such individually initiated measures must be part of a larger effort to 1) improve work conditions, 2) allow more autonomy, 3) promote a culture of respect and cooperation, and 4) make employee satisfaction a measured quality indicator (AHRQ).^{1, 14, 15} Relying solely on resiliency training as a solution to burnout brings H.L. Mencken’s quote to mind: “For every complex problem there is an answer that is clear, simple, and wrong.”

How COVID Has Contributed to Burnout

Our struggle with identifying and fixing the underlying causes of burnout and dissatisfaction in the clinical practice of medicine may be at least partially informed by the ongoing COVID-19 pandemic. However, there is a unique factor which has emerged with COVID-19. That factor is fear; fear of contracting the disease and fear of spreading it to loved ones.^{1, 17} Those of us in healthcare have seen unique changes in practice during this pandemic, from decreasing availability of consultations to segregating admissions by COVID-19 testing. We have also seen alterations in off-work behavior, with many healthcare workers isolating in basements, garages, or trailers rather than going home and exposing their family to possible infection.¹⁸ Although physicians in general recognize that they can contract disease from their patients, this pandemic has been vastly different. The response of healthcare administrators and managers regarding the very real fear factor during this pandemic is one of the universal lessons regarding clinician burnout we can learn from COVID-19. We have seen how expressions of appreciation from patients, the public, and health administrators can inoculate to some extent against the overwhelming fatigue of caring for a continuous wave of sick patients, often with insufficient personal protection, and constantly having to fill shifts for those that have been taken from our ranks by disease or quarantine. A recent Canadian survey of emergency physicians showed that physician burnout remained stable during the first 10 weeks of the pandemic and acknowledged that expressions of patient gratitude and renewed purpose were important factors for maintaining physician wellness.¹⁹ But we have also seen that expressions of appreciation are hard to sustain. We have seen how lack of commitment, if not resistance, by many to undertake the steps required to control the pandemic²⁰ and the reluctance of healthcare administrators to maintain their workforce in the face of financial losses have demoralized our frontline caregivers.²¹ Initially there was a concerted St. Louis metropolitan-wide effort to streamline processes and to provide space and resources to care for COVID-19 patients. This was given the highest priority. There was also an unprecedented cooperation among various departments and services to meet this once-in-a-lifetime challenge, but as overall patient volumes and revenues decreased, and it appeared that the wave of illness was waning, these efforts and attitudes were not sustained. When the third (and by far most devastating) wave hit, it felt as though there was little appetite to redouble the efforts that had been put in place to suppress the first wave. As a tsunami of patients inundated our emergency departments and hospitals, a familiar feeling of chaos, time pressure, and lack of control over our workplace descended. These of course, are well known to be associated with dissatisfaction and burnout,¹⁴ but many have begun postulating that the real underlying cause of physician burnout, particularly in the time of COVID-19, is something more egregious: “moral injury.” This relatively recent idea has been elevated to the fore by the ongoing pandemic. The term “moral injury” was first used in 1981 by Friedman to describe a psychological condition found in post-Vietnam war veterans.²² It was further explored in a wider array of war veterans by Litz, et al. in 2009.²³ Litz described moral injury in the veterans he was seeing as “a wound that can occur when troops participate in, witness or fall victim to actions that transgress their most deeply held moral beliefs.” Diane Silver, in a 2015 article describing the epidemic of posttraumatic stress disorder that Litz and others were treating among Afghanistan and Iraqi veterans, wrote that moral injury is “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”²⁴ The first reference I could find regarding moral injury in healthcare workers was in an opinion piece by Talbot and Dean in 2018.²⁵ In this piece they attempt to explain the difference between the source of moral injury in war veterans and those in healthcare workers. They suggest that the root cause of moral injury among physicians (and I dare say among other healthcare providers as well) is “being unable to provide high-quality care and healing in the context of health care.” They go on to say that the failure “to consistently meet patients’ needs has a profound impact on physician well-being — this is the crux of consequent moral injury.”

The National Academy of Medicine has recently put out a statement entitled “Strategies to Support the Health and Well-Being of Clinicians During the COVID-19 Outbreak” recognizing the role that “moral dilemmas” are playing in exacerbating physician burnout during this pandemic.²⁶ They provide several recommendations for managers and healthcare leaders which almost all of us would agree would be helpful, but which are woefully underutilized currently. The statement begins with a simple directive: “Provide clear messages that clinicians are valued.” The need for this is further emphasized in the opinion piece by Shanafelt et al.¹ Based on interviews with 69 healthcare workers, they conclude that “simple and genuine expressions of gratitude for the commitment of health care professionals and their willingness to put themselves in harm’s way for patients and colleagues cannot be overstated.” But statements without tangible signs of support and care “ring hollow.” The most important way to send a clear message that front-line healthcare workers are valued is by supporting them in real actions and in real time. Asking “everyday heroes” to care for COVID-19 patients without adequate PPE is not a show of support or respect. If the procurement of adequate PPE is impossible, then all energy must be focused on developing and implementing the best evidence-based alternatives with honesty and transparency.²⁷ It is not just managers and healthcare leaders that must step up. The need for real actions to lower physician burnout during this critical time is required by the general population as well. A recent survey of more than 2,300 physicians found that 80% identified lack of population compliance with masking and social distancing protocols as the single greatest cause of frustration to them.²⁸

We have entered what we hope is the final phase of this pandemic, with the approval of highly effective vaccines for general use. However, even with this promising news, the implementation of vaccination policies has appeared haphazard and problematic. The best strategy regarding vaccination priority can be debated, but the debate should include representatives from the most impacted groups and should be transparent. If vaccination access across the healthcare workforce will take a month or more, and our frontline workers are seeing a peak in COVID-19 patients right now, then putting younger frontline workers (whether they be nurses, technicians, therapists, environmental services, security, transportation, trainees, or physicians) at the back of the queue, allowing older providers earlier access, even if they have an extremely low exposure risk does not seem equitable. A more equitable approach may be to vaccinate frontline healthcare workers who are exposed daily to known or suspected COVID-19 patients, and within this group to stratify by risk factors for severe disease, such as age. There are clearly reasons for vaccinating our older population as quickly as possible, but it makes little sense to delay frontline workers, not because they are at high risk of dying, although there are estimates that there have been nearly 3,000 deaths among healthcare workers as of November of 2020.²⁸ But rather because when they get sick or need to quarantine, the loss can decimate the workforce we are relying on for our care.²⁹

The National Academy of Medicine and the Agency for Healthcare Research and Quality also have some wellness recommendations for clinicians, which are likely to be helpful if they can be implemented.^14,26 Self-care, taking breaks, staying connected, and performing self-check-ins are among these, but it may be the final recommendation that is most important to heed: Take the time to “Honor your service: remind yourself and others of the important and noble work you are doing. Recognize colleagues for their service whenever possible.” This has been even more challenging in the time of COVID-19. As an example, our Medical Staff Association has had to cancel several traditional annual events in which they honor their extraordinary clinicians and scientists for their service.

Conclusion

Ours is a noble profession, but we must be allowed the time and resources to fulfill our obligation to our patients or we take home the guilt of a job poorly done. That job has always been to help those we can and to comfort those we cannot. In the time of COVID-19, there is often insufficient time to do either. This is not an insolvable problem, but it will take determination and grit and the reimagining of a healthcare delivery system that is truly driven by patient-centric outcomes rather than production parameters. As Dean & Talbot conclude: “Physicians must be treated with respect, autonomy, and [given] the authority to make rational, safe, evidence-based, and financially responsible decisions.”²⁵ For those interested, one way to help healthcare families who need it is the Frontline Families Fund. Led by the Saint Paul & Minnesota Foundation in partnership with Dr. Michael Osterholm, the Director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota.