Conditions are ripe for a shadow epidemic in medicine. How physician employers, and the doctors themselves, choose to respond will have major implications for the health of these vital healthcare providers, and the American healthcare system in general.
We’re talking about physician mental health, a topic doesn’t get the attention it deserves. Consider this: The most recent presidential debate, held at the Cleveland Clinic amid a pandemic. You might think the setting would bring healthcare workers to the forefront of either candidate’s thinking. Instead, they debated mask-wearing. We weren’t aware that the subject was still up for debate.
Unfortunately, many are taking the contributions of physicians and other healthcare workers for granted. Our healthcare system is far from perfect, and the pandemic certainly revealed room for improvement, but it did not break down. Doctors, nurses, and other frontline healthcare workers held and continue to hold the line. But at what cost?
The strain, explained
The ongoing struggle with COVID-19 will likely keep us from knowing the full impact on physician mental health for years to come. However, we do know that physician burnout was a serious issue prior to the pandemic, and that early research has raised some alarms. Coronavirus may prove to be an accelerant.
The novel virus created massive amounts of fear and uncertainty among physicians, tasked with keeping others, and themselves, alive. A recent WHO report found that of all viral cases globally, healthcare providers represent 1 in 7. The figure hits 1 in 3 in some countries. Not only do doctors worry about falling ill, many must also grapple with the fear of infecting the people they love when they go home.
Researchers documented this fear in a UC San Francisco study of emergency medicine physicians during the early days of the pandemic. Among the surveyed physicians from 7 cities, male doctors reported stress levels at 5 on a scale of 1-7. Women put their stress levels at 6. Both said burnout increased from a pre-pandemic level of 3 to 4 out of 7 after the onset of the pandemic.
Researchers documented similar results in China among healthcare workers. A JAMA Network Open study found that among more than 1,200 healthcare workers in 34 hospitals, 50.4% reported symptoms of depression, 44.6% reported anxiety symptoms, 34% said they had insomnia, and 71.5% said they felt distressed.
“Protecting health care workers is an important component of public health measures for addressing the COVID-19 epidemic,” researchers wrote. “Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented.”
What’s causing the strain
The existential risk of being a physician during a pandemic is one thing. But exposing one’s loved ones is another. COVID-19 has added a new layer of complexity to the burnout crisis. Not only do physicians worry about harming their families, but they also don’t have access to their usual social outlets.
“Prior to the pandemic, physicians were able to seek solace from the psychological weight of their profession with familial and social lives,” reads a July report in the American Journal of Emergency Medicine. “Physicians worrying about infecting their families and contaminating their homes may choose to self-isolate or face the guilt of potentially infecting a family member.
“The emotional trauma endured by physicians is intensifying as they witness high volumes of death, including infection and deterioration of coworkers,” the report reads.
What to do about it
Stopping this silent epidemic in its tracks will be difficult, but not impossible. Eileen Barrett, MD, a veteran of the ebola outbreak in Sierra Leone offered some specifics in a recent JAMA Medical News and Perspectives interview.
Doctors must make self-care a priority, according to Barrett. That means doing all that they can to sleep sufficiently and soundly, implement strategic caffeine use as well as nutritious eating habits, and yes, even get some exercise. This may seem like a luxury, but her experience with Ebola says otherwise.
“I often repeat the story about what we learned when I was in the Ebola treatment unit. If you aren’t eating and you aren’t drinking, you put your peers at risk,” she said. “If you end up collapsing while you’re at work, then everybody else will have to do the work that will put them at risk to take care of you.”
Barrett stresses that your life can’t be all COVID-19 all the time. Physicians need to spend time outdoors and make and maintain whatever social connections that they safely can. And when you’re on the job, Barrett says it’s important to go easy on yourself.
“Another thing that we need to do is to cultivate a sense of self-compassion so that we aren’t too critical of ourselves,” Barrett said. “Sometimes we do everything right and the patient has a bad outcome. And it has nothing to do with what we did. So how do we give ourselves permission to be people? By talking with peers and staying connected to our lives outside of being practicing physicians. And possibly also seeking mental health care if we need to.”
Physician employers also have a vital role to play. The American Journal of Emergency Medicine report suggests “establishing a modern day hierarchy of needs for our physicians,” noting that a similar approach was effective in a Chinese hospital during the height of the pandemic. Foundational in the hierarchy is protecting physical wellbeing. That means adequate PPE. According to the nonprofit Get Us PPE, the data indicate that the shortage persists, even now, among smaller facilities.
Next, physician employers must tend to the psychological needs of their employees, followed by supporting and addressing the communities and families of physicians. While protecting physician physical wellbeing is pretty straightforward, what should be done about the more amorphous recommendations?
Employee-sponsored childcare and mental health services are a great place to start, Barrett said.
“I think that every leader has a duty to create systems for people to have peer support, in addition to having access to telemedicine for mental health services,” she told JAMA.
Even seemingly simple gestures from employers make a big difference, she said. They might include providing adequate, socially-distanced spaces for doctors to perform telemedicine appointments, free meals, or simply saying thank you. Clear, direct communication is invaluable.
“Communication with transparency about why decisions are being made and avoidance of overly normalizing or overly catastrophizing what’s going on. Being factual,” Barrett said.
At this stage in the pandemic, healthcare organizations also have a rough idea of what surge staffing demands may look like. Physician employers, such as hospitals, should use momentary lulls in case volumes to create backup forces of healthcare workers, according to the American Journal of Emergency Medicine report. These might include retired workers, students near graduation, and past or current members of the armed services.
Unfortunately, asking for help isn’t a part of physician training and conditioning, and many often worry about the career implications of mental illness. This needs to stop, according to the American Journal of Emergency Medicinereport. Psychological support cannot be “one-size-fits-all,” and doctors must have access to choose the approach that works best. That might include telemedicine, video chats, online forums, or in-person visits with psychologists and psychiatrists.