Since March 2020, when the COVID-19 pandemic was first officially declared, doctors, nurses and other clinicians have stepped up and shouldered burdens they never anticipated. They rose to the challenge magnificently, caring for the ill while protecting themselves and their families.
But their commitment to helping others has come, in many cases, at no small cost to themselves. Even many of those who didn't contract the coronavirus have changed forever.
For those who continue to treat patients with ever more virulent strains of the virus, the deluge of need seems unrelenting. And that constant pressure to provide care is giving rise to a new crisis, as providers grapple with the trauma they've witnessed and the close calls they and their loved ones have endured.
Burnout among doctors was a problem long before the pandemic dominated every conversation. But COVID-19 has made being a health care provider much more difficult. According to an April 2021 survey conducted by Kaiser Family Foundation and the Washington Post, frontline health care workers' mental health has taken a hit. Of the respondents, 62% said that worry or stress related to the coronavirus has had a negative impact on their mental health, and 55% say they feel burned out when going to work.
But the term burnout doesn't seem big enough to encompass all the trauma and heartache caregivers have witnessed, or the challenges it could create for the health care system moving forward. That's why various organizations and institutions have developed programs and support mechanisms that can help frontline workers now and well into the future.
Hospital-based programming
Some hospitals have launched innovative support programs. Dr. Deborah Marin, a professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York, now directs the Mount Sinai Center for Stress, Resilience and Personal Growth. The initiative launched in April 2020 to address the coronavirus's impact on frontline providers' mental health in New York City—one of the areas hardest hit in the early days of the pandemic. Other programs nationwide are now using it as a model for their own efforts.
"We were fortunate that our dean is a psychiatrist" who immediately recognized that the caregivers were going to need care themselves, Marin says. The center has offered more than 115 resilience workshops attended by hundreds of caregivers, in addition to one-on-one support and educational resources.
The Mount Sinai team created a smartphone app with a simple self-assessment tool that offers staffers feedback on their current state of anxiety, depression, PTSD and overall wellness. "That was built in a month," Marin says. Resilience training and other educational resources soon followed.
The center has strived to ensure its support resources are available in multiple languages, so that they're accessible for all the hospital's workers. "I always highlight that our center is for everyone at Mount Sinai, not just doctors and nurses," says Jonathan DePierro, an assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai and the center's clinical director. The pandemic has had an impact on security personnel, janitorial staff, clinicians and hospital employees in every imaginable role.
Gemma Tillinghast, a labor and delivery nurse at Mount Sinai, says she's benefited from these services. What she learned in the resiliency workshops helped her "make it during the difficult times," she says. "It's been very helpful to be able to express our experiences."
Participating in the center's workshops with her colleagues has been particularly meaningful. "We feel like there's a team, and like we're not alone," she says.
Read more: Doctors and Nurses Talk About Burnout
Doctors supporting doctors
In Boston—another early pandemic hot spot—long-standing efforts to support struggling health care providers saw an uptick in demand.
Dr. Jo Shapiro, an otolaryngologist who founded a peer-support program at the city's Brigham and Women's Hospital in 2008, was inundated by requests from health care organizations seeking assistance setting up similar programs. The peer-to-peer support program she developed aims to provide respectful ways to improve clinician well-being.
"What's really great about peer support, or just the whole idea of working toward providing emotional support for clinicians, is you get almost no pushback," Shapiro says. Many doctors want to speak with a physician colleague after a challenging event, such as a medical error, she's learned. "I think people want to talk to someone who's been there and knows what it feels like."
But there are "significant cultural and structural barriers" for doctors to seek that kind of support on their own. Shapiro says that when she first developed the program, "we trained a large cohort of peer supporters, and nobody called in." Most likely, she says, that was because of stigma. "We didn't remove the barrier of people being worried about stigma and confidentiality and access and those sorts of things."
So she shifted to a "check-in" model. Today, physicians will proactively reach out to their peers after stressful events, or to check in regularly during times of ongoing crisis, as has been the case during the pandemic. "We don't wait until people are suffering," Shapiro says. The way assistance is framed makes a big difference. Doctors reach out to their peers "in a destigmatized, normalized way, by saying, 'Hey, we're checking in with everybody in this unit.' Or, 'We're reaching out to everyone involved in such-and-such event.'"
Shapiro now runs training sessions and has helped dozens of other organizations develop their own peer-to-peer caregiver support groups.
One such program is led by Dr. Megan Furnari, a neonatal specialist with Oregon Health & Science University and director of wellness for the California Oregon Medical Partnership to Address Disparities in Rural Education and Health (COMPADRE). This is an American Medical Association grant-funded collaborative project that's working to prepare culturally competent, collaborative and resilient physicians to practice in rural, tribal and urban underserved communities in Oregon and Northern California.
Furnari was on maternity leave when the pandemic first hit. When she returned in fall 2020, "I was entering a pretty different world as a new mom," she recalls. "And it was really hard because I was also dealing with my own concerns about how to be safe for my family, my baby and my partner."
Furnari recognized that her colleagues were also experiencing extreme stress and trauma related to the pandemic. She and Dr. Maggie Rae, a clinical psychologist at the University of California, Davis, connected with Mount Sinai's Shapiro to establish their own peer-support program for COMPADRE's team. "It was opt-in, and around 45 staff and faculty did the training with Dr. Shapiro," Furnari says.
Since then, Furnari and Rae have led sessions in which faculty and staff offer peer support to one another in group settings. Regular participants include physicians, psychologists and social workers.
The program allowed Furnari to tap into support services. "I've not only given support, but also gotten support," she says, which helped her feel validated about how she was managing her emotions and fears. "It was incredibly, deeply healing. I feel like physicians go around with certain traumas that have never been resolved, and peer support is a place to come when you're ready to have those traumas healed."
Specialty-based support
Some specialties, like emergency departments, have shouldered a larger share of the burden of care during the pandemic.
"In emergency medicine, every patient that comes in is unscheduled," says Dr. Mark Rosenberg, president of the American College of Emergency Physicians (ACEP). "So you never know what your day is going to be like."
Dealing with a mysterious ailment—and extremely ill, contagious patients—has increased emergency workers' anxiety, depression, PTSD and suicidality, Rosenberg says.
Physician suicide in general had already been something of a silent pandemic: in a 2020 Physicians Foundation survey, nearly 1 in 4 physicians said they personally knew another doctor who had died by suicide.
To help emergency-medicine personnel cope with the demands of their job, the ACEP offers a variety of programs. These include a peer-support group, online discussion forums and a video-diary project that helps emergency physicians process their experiences. The video project is a members-only resource for emergency physicians to share with their colleagues what it's been like living through the pandemic, helping frontline clinicians reaffirm why they stay in emergency medicine.
Of course, ER doctors aren't alone in staffing the trenches of this pandemic war, and they're not the only health care professionals experiencing burnout. Dr. Ada Stewart, president of the American Academy of Family Physicians (AAFP), notes that the pandemic has "only exacerbated" issues with family doctors' burnout dating back years.
"Physician burnout is, at its core, a health system, organization, practice and physician culture problem—not just an individual concern," she says. "To overcome this, an evidence-based approach is needed to identify and address the root causes of burnout at all levels of the health care system."
That's why the AAFP has created the Physician Health First initiative, which focuses on improving the well-being and professional satisfaction of family physicians by addressing the root causes of physician burnout. "We also provide town halls and webinars where members can hear from other family physicians about their experiences with burnout and offer insight into how they've been able to cope with these emotions," Stewart says.
Policy changes
At the policy level, efforts are under way to stem the rising tide of providers in crisis. The Dr. Lorna Breen Health Care Provider Protection Act, introduced in late July 2020 by Senators Tim Kaine (D., Va.), Todd Young (R., Ind.), Jack Reed (D., R.I.) and Bill Cassidy (R., La.), is working its way through Congress.
The bill is named for Dr. Lorna Breen, an emergency physician who died by suicide in April 2020 after being diagnosed with COVID-19 and experiencing the trauma of caring for patients with the virus during New York's first brutal surge.
It has been championed by the Dr. Lorna Breen Heroes' Foundation, a nonprofit established in spring 2020 by Breen's family members, who are now determined to protect other physicians from the scourge of burnout and suicide. The ACEP and more than 70 other organizations have endorsed the bill.
The proposed legislation aims to prevent suicide and burnout among health care workers. It will do so by creating grants to fund programming that encourages physicians to "seek help … in a way that's not disruptive to their job or their medical licenses," and doesn't lead to career repercussions, Rosenberg says. "I think if Lorna had had the opportunity to feel comfortable just talking about her stress and what she was feeling, maybe she wouldn't have [died by] suicide."
Changing the stoic 'health care heroes' culture
As difficult as this pandemic has been for health care providers, there is reason to be hopeful, as many clinicians say that attitudes surrounding mental and behavioral health for physicians and other caregivers appear to be shifting.
"There are movements and organizations that are advocating for policy changes and increased awareness of resources, and we hope there's going to be increased federal-funding opportunities," Mount Sinai's DePierro says.
While Shapiro, of Brigham and Women's Hospital, considers herself a "major optimist" about improving mental health among clinicians, she says there's still one major hurdle to overcome: the culture of hero-worshipping clinicians that she believes can be dangerous. "The whole framing of us as health care heroes is a double-edged sword," she says. The intention is to honor the sacrifices frontline caregivers have made, but it "does imply that you've got sort of superhuman powers. That you don't need as much sleep, and you shouldn't be suffering from this because you're a hero. Heroes don't cry too much, do they?"
That's a problem these programs and offerings hope to alleviate. "Let's also remember that we're human," Shapiro says. "We care, and we need help too. We need rest and all those things."
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