Once a year on March 30th, we celebrate National Doctors’ Day. As deaths from COVID-19 in the U.S. now far surpass the number suffered on 9/11, the impact of the novel coronavirus becomes more and more real. And for physicians and other healthcare professionals as well as first responders and all the other individuals who have been designated as essential workers, each day can bring exposure, emotional and physical exhaustion, grief, and sometimes conditions likened to a war zone.
Doctors are heroes in our midst
Just as firefighters ran up the stairs of the World Trade Center towers as everyone else was evacuating the building, so too do today’s heroes in the fight against COVID-19.
Undoubtedly, PTSD will be one of many residual impacts that will live long after the virus may be controlled by the development of natural immunity mounted by an antibody response, treatment with medication, and prevention by vaccines.
Recent studies indicate nearly one third of U.S. physicians are older than 60, placing them in a high-risk category for contracting COVID-19. Photos of doctors exhausted and insufficiently protected due to shortages of PPE (Personal Protective Equipment) while putting their lives on the line have moved a nation in a way that can be likened to images of soldiers on the battlefield.
A Clear and (Even More) Present Danger
COVID-19 has focused a bright light on a long-standing and growing danger – physician stress and burnout – in a way that makes it evident to all. The novel coronavirus is exposing many societal inequities and areas of vulnerability resulting from years of neglect and failures to effectively and proactively plan for the future.
Physician shortages, hospital closures, an aging population with an increasing chronic disease burden, massive medical school debt averaging more than $250,000, a shortage of residency positions in the face of rising medical school applications, changing care delivery and reimbursement models, and medical knowledge that doubles every 73 days all contribute to stress, which, if left unmanaged, may lead to burnout.
And now with COVID-19 in the picture, especially for those involved in direct patient care, there is yet another source of emotional distress further exacerbated by physical exhaustion.
Diagnosing physician burnout
A 2019 Medscape survey of more than 15,000 physicians revealed just under half (44%) of physicians feel burned out. An additional 11 percent feel down, blue, or sad, which, when prolonged, progresses to depression.
Some medical specialties see even higher rates of burnout, with urology, neurology, physical medicine, and rehabilitation all seeing burnout rates above 50 percent. It leads to serious consequences not just for affected physicians but the entire healthcare system.
When there’s a serious health crisis, like COVID-19, burnout and stress are real concerns for every medical professional.
A broad systematic review of 182 studies on the issue published in JAMA in 2018, found at least 58 ways to label burnout and 142 unique definitions of it. The definition of burnout varies depending on the diagnostic tool used.
To understand what burnout is, it’s helpful to understand ways it may be diagnosed. The Maslach Burnout InventoryTM (MBI) is a long-standing burnout diagnostic tool used across many industries. It’s been around since 1981 and evolved over the years, with the Areas of Worklife Survey (AWS) now part of the evaluation.
The MBI and AWS are combined in one toolkit which examines the interpersonal connection of burnout and perceptions of workplace settings, in addition to the emotions which fuel the condition.
Maslach defines burnout as a “psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job.”
There are three factors:
- Overwhelming exhaustion.
- Cynicism, depersonalization, and detachment from your job.
- Feeling that you’re ineffective or not accomplishing enough.
It’s not just about the medical professional, but also the relationship with professional work and with others. That’s why a feeling of exhaustion doesn’t necessarily mean a person suffers from burnout.
So, let’s take a look at all three factors and some of the symptoms experienced with each.
- With exhaustion, the individual may have less energy, feel worn out, fatigued, or debilitated.
- With the second factor, a person may have a negative or inappropriate attitude toward others, including patients. Also, irritability and withdrawing from certain work environments can occur.
- Finally, low morale, loss of productivity, and inability to cope are all symptoms of feeling ineffective.
During a crisis like this, the burnout threshold may be insignificant. Stress and anxiety over the shortage of N95 face masks, shields, and gowns and daily exposure to the virus only compound a problem with burnout that may have existed long before the pandemic changed our lives dramatically.
The Cost of Physician Burnout
The cost of physician burnout to the healthcare system as a whole is estimated to be $4.6 billion annually according to a 2019 study in the Annals of Internal Medicine. It’s not just a physician problem. It affects patients and the entire healthcare system. Everyone pays a price when physicians (and other healthcare workers) suffer from burnout.
Maslach points out physician burnout is an occupational hazard because it impacts the clinician’s ability to do his or her job. Being a physician requires many years of study and training and an intense level of commitment and stamina. It’s rewarding work, but also emotionally and physically demanding. When a physician is feeling burned out, medical errors become more likely.
A study published in AJMC found burnout can lead to poorer patient outcomes and lower patient satisfaction. That’s just the patient side of things.
For clinicians themselves, it may lead to reduced work hours, leaving a job, depression, and even suicide, the rate of which in physicians is double that of the general population.
Medical Errors and Patient Safety
No doctor wants to make a medical mistake. However, the estimated number of deaths each year in the U.S. due to medical errors is 200,000. There are many causes.
A study led by researchers at the Stanford University School of Medicine found physician burnout is as much to blame for medical errors as unsafe medical workplaces.
In the Stanford study of nearly 6700 physicians, 10 percent reported a major medical error in the prior 3 months. The vast majority (77%) of those reporting an error were more likely to have burnout symptoms and thoughts of suicide.
It’s not just actual medical errors that are a problem but also perceived mistakes. Your perception of how well you’re doing your job changes when you’re stressed from long work hours and more time spent navigating electronic medical records than directly caring for patients.
Efforts to improve safety and quality of care measures often focus on systematic improvements within the workplace, but the study found they should focus on the people too.
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Doctors and Depression
The mental health of doctors is also concerning. Depression is a serious medical problem and can prove to be deadly. The 2019 Medscape survey found 14 percent of doctors thought about suicide but had not attempted it. Another 6 percent preferred not to answer the question.
Depression happens regardless of gender, but a survey of more than three thousand medical interns published in JAMA found depression more prevalent in female doctors.
The explanation proffered was that female doctors have more demands placed on them by their personal life than their male counterparts. While all working women face work-life balance issues, it can be more challenging as a physician because of the long training process that takes years to complete following graduation from college.
Male doctors are 1.41 times more likely to commit suicide than their counterparts in the general population. Female doctors are 2.27 times more likely to die this way.
Depression is not burnout, but one can lead to the other.
Physician Turnover Costs Healthcare Organizations
Physician burnout impacts healthcare organizations too. Doctors leave their job or cut back on hours when there’s a stressful work culture, increased workload, general concern about making medical mistakes, and a loss of confidence in one’s ability to do the job.
Physician burnout costs clinical healthcare organizations two to three times their salary to find a replacement when physicians leave their job (between $500,000 to more than $1 million per physician) There are also other costs like medical malpractice lawsuits and lower patient satisfaction.
Stanford Medicine calculated it would lose nearly 60 physicians in two years if it did nothing about burnout. The cost to the institution was forecast to be between $15.5 million to $55 million.
COVID-19 Impact
“Never let a good crisis go to waste.” ~ Winston Churchill
COVID-19 has impacted our lives, and the pandemic will be one of those “Where were you when it happened?” moments. The repercussions will be great, and some will be long-lasting due to the ripple effect of a shock to the system on a global scale.
Below is far from an exhaustive list of the many ways COVID-19 may deliver a blow to mind, body, and spirit to each one of us, much less to those on the frontlines risking their lives every day to provide care and healing to the rest of us. And remember, many of these healthcare professionals started at a baseline of stress, depression, and burnout.
Repercussions of the Novel Coronavirus:
- Feelings of fear, uncertainty, and insecurity about the future.
- Anxiety and depression.
- Loss – death of loved ones, colleagues, and patients.
- Loss of closure – death of loved ones and inability to visit and be with them at the time of their death, inability to gather in person for a funeral, memorial service, or celebration of life.
- Loss – loss of a job, loss of a business, loss of a home, loss of financial security.
- Loss – loss of life’s celebratory milestones due to social distancing and travel restrictions: graduations, weddings, proms, baby and wedding showers.
- PTSD – insufficient or no PPE → increased risk of infection, shortage of tests → inability to optimally assess the risk of exposure and spread; difficult decisions that may make the difference between who lives or dies; day after day of providing care to acutely ill patients, many of whom will die despite best efforts to save their lives; loss of job due to “whistleblowing” about work conditions and inability to adequately protect self and others.
- Domestic violence – stress + close quarters with others 24/7 + financial insecurity/unemployment, anger, self-medicating with alcohol, depression
- Increased health disparities – low-income populations, communities of color, and those living in rural areas.
- Exacerbation of stress, depression, and burnout.
- Onset of compassion fatigue.
The Silver Lining of COVID-19?
Silver lining? Really? Yes, really.
History tells us it is possible for humanity to survive crises that seem to create insurmountable challenges. We are still at the front end of the COVID-19 tsunami, but we have already observed so many actions that reflect the very best that crisis can bring out in us.
From Chef José Andrés World Central Kitchen and the ongoing efforts of the non-profit Bread for the City to provide medical care, social and legal services, and food to their clients; to the pursuit of PPE for healthcare professionals by the Wharton Healthcare Alumni Association through a market exchange; to actions by volunteers in Poland to provide coffee, energy drinks, water and packed lunches to paramedics and doctors working overtime as well as running necessary errands for those who are isolated and unable to manage on their own.
And there are the 6000 behavioral health specialists who have volunteered their services in NYC to help New Yorkers cope and manage emotional distress and mental health disorders during an unprecedented event which triggers fear, anxiety, and potential worsening of mental health disorders.
Despite the xenophobic behavior of some against the Asian community, especially against those who are Chinese, many people are more civil to each other and seem more willing to show their vulnerability, to ask for help, and to practice acts of kindness, both large and small.
If you want or need a moment of inspiration, read the stories of CNN Heroes on the front lines.
It seems, ironically, that social distancing may be bringing us closer together. And stay-at-home orders and the move of millions of workers to home as the workplace means families may be together in ways they never have before.
COVID-19 has also served as a catalyst to pre-existing services and repurposing existing assets to meet acute needs, like the Gap using its factories to fashion face masks, gowns, and scrubs for healthcare workers instead of clothes as well as more unfettered collaboration, like the mobilization of scientists, pharmaceutical companies and government officials to launch tests of > 50 different compounds as possible vaccines against the virus.
Additional examples of changing patterns of care delivery include:
- Deployment of remote monitoring to increase hospital capacity.
- Telebehavioral health services to provide ongoing treatment as well as to provide support to populations suffering from the emotional distress resulting from fear, uncertainty, stress, grief.
- Use of telehealth to deliver care and reduce risk of exposure, infection, and spread.
- A Clearlink survey of 2000 people distributed across geographies in the U.S. indicated:
- 19% had used telehealth in the past.
- 66% of those who have already had a telehealth visit had more than one.
- 38% liked the idea of being able to get a potential diagnosis without being exposed to others who are sick in a waiting room.
- 36% preferred the potential of an appointment without having to commute to a clinic or physician’s office.
- 12% found the ability to schedule same-day care appealing.
- 66% said that COVID-19 increased willingness to try telehealth in the future.
- 25% had not considered telehealth as an option before COVID-19.
- A Clearlink survey of 2000 people distributed across geographies in the U.S. indicated:
Many physicians and employers are encouraging use of telehealth as a way to reduce the risk of exposure and spread. And many of the major health insurers are covering the cost of COVID-related care, including telehealth consultations.
And the FCC “developed and approved a $200 million program to fund telehealth services and devices for medical providers. Hospitals and other health centers will be able to apply for up to $1 million to cover the cost of new devices, services and personnel.”
Crisis can also serve as an accelerant of innovation like:
- autonomous robot vehicles to deliver food, medicine and other supplies in Wuhan.
- wearable temperature monitoring.
- 3D printers to help address containment and supply chain challenges.
- lung ultrasound.
Rejuvenation from a Reawakened Sense of Purpose
Although physicians are under a new level of stress, compassion fatigue, and personal sacrifice that most cannot imagine, some have found a new sense of purpose and buoyed by a degree of recognition and public appreciation that many may not have previously experienced depending on the stage of their career.
And some medical students are even graduating early to begin internship and bring extra manpower to the fight against the virus.
The pandemic is driving what could be transformational change and new ways of thinking and living. The medical professional is now high-profile and more respected than ever before. Will the goodwill and empathy of a nation be enough to take decisive action?
Once the novel coronavirus has been conquered, the economy rebounds, and life returns to a post-COVID world, will there be the real investment required to both address the stress and burnout we know existed long before the advent of COVID-19 and to proactively help prevent their development in those not yet suffering the potential “side effects” of the career they have chosen?
As a physician, healthcare executive at a Fortune 100 company, and integrative health practitioner, Z. Colette Edwards, MD, MBA knows the unique value of a holistic, whole-person approach to health and well-being. She also understands the challenges health inequities can present. Known as “The Insight Doctor,” she offers guidance and powerful tools that prepare your body, mind, and spirit for menopause, stress, and inflammatory bowel disease. Lastly, Dr. Edwards coaches individuals in the development of self-advocacy and health system navigation skills.
(Personal Insight MD, LLC, PeopleTweaker, and Insight MD does not provide medical advice, diagnosis, or treatment. If you are feeling extreme anger with thoughts and actions harmful to yourself or others such as physical/verbal abuse or acts of violence, find yourself self-medicating with alcohol, illicit drugs, etc., expressing your anger in such a way that threaten relationships or your job, etc. seek professional help immediately and call 911 if necessary if you find yourself in an out-of-control situation or have the urge to hurt yourself or others.)
