The COVID-19 pandemic has sorely challenged the emotional well being of all healthcare providers. Here, a look back is followed by a guide to moving forward.
Nearly 6 months after turning over his large New York City-based ICU to patients infected with the novel coronavirus disease 2019 (COVID-19), Brian Lima, MD, director of heart transplant surgery at North Shore University Hospital, in Long Island, New York, discussed his sudden, month-long switch from a cardiothoracic surgeon to a full-time “COVID-19 doctor” in an interview with Patient Care Online and said:
Although Dr Lima and his colleagues were accustomed to taking care of critically ill patients, the incoming patients during COVID-19 were mostly presenting with advanced respiratory disease.
“Many of these patients did not unfortunately do well,” said Dr Lima. “We had some saves, of course, but day in and day out seeing not much in the way of progress in many patients was tough. And having these patients weather that by themselves with no family made it that much more tragic. It was just nothing we had experienced before.”
Dr Lima is not alone. As COVID-19 infections and deaths quickly and significantly increased in the US, health care professionals and first responders (eg, ambulance personnel, law enforcement officers) suddenly became “COVID-19 specialists” despite exhaustion, insufficient skills and/or training, personal risk of infection, fear of transmission to family members, illness or death of family members and/or friends and colleagues, and the loss of many patients.
All of these factors combined have significantly challenged mental health and wellbeing among health care professionals.
“Doctors are human too… we can suffer from anxiety disorders, depression, trouble with alcohol or other drugs, PTSD, things like that, that people in our general society suffer from,” Michael F. Myers, MD, a psychiatrist who has served the mental health care needs of clinicians and their families for 3 decades, said in an interview with Patient Care Online.
Physicians, as well as other health care providers, historically experience high levels of stress, fatigue, and burnout; however, the COVID-19 pandemic has potentially worsened it.
For over a decade, the nonprofit Physicians Foundation has partnered with health care staffing organization Merritt Hawkins to conduct a biennial survey of US physicians to examine their views on the continuously evolving health care system.
As a result of the COVID-19 pandemic and its profound disruption, the 2020 survey focused solely on the impact of COVID-19 on physicians’ practices and their patients (part 1), the impact on physician wellbeing (part 2), and the impact on the health care system (part 3).
More than 500 000 physicians nationwide received the 2020 Survey of America’s Physicians via email and 2334 physicians responded to the second part of the survey (wellbeing), which was conducted between August 17-25, 2020.
The survey indicated that 58% of physicians often had feelings of burnout, compared to 40% in 2018 as tracked by Physicians Foundation data; 38% of physicians said they would like to retire in the next year.
When asked about the direct impact the COVID-19 pandemic has had:
To cope with COVID-19-related stress and worry, many Americans self-medicated with alcohol or illicit drugs, and the survey showed physicians are no different.
Ten percent of physicians indicated they began use of medications, alcohol, or illicit drugs as a result of COVID-19’s effects on their practice or employment situation. Three percent of physicians did so just once, while 6% did so once a month or more.
Perhaps more concerning is that a larger number of physicians (18%) indicated that they have increased their use of medications, alcohol, or illicit drugs as a result of COVID’s effects, a number reflecting approximately 151 000 physicians.
Another survey, conducted by the Kaiser Family Foundation and The Washington Post, revealed that even one year into the pandemic, frontline health care workers were still facing serious mental health challenges due to COVID-19.
Approximately 1300 frontline health care workers—defined for purposes of the survey as those who work in a health care delivery setting in direct contact with patients or bodily fluids—were surveyed between February 11 and March 7, 2021. The survey participants worked in hospitals, doctors’ offices, outpatient clinics, nursing homes and assisted care facilities, and in home health care.
A majority of participants (62%) reported that worry and stress related to the pandemic has negatively affected their mental health, and approximately 3 in 10 said they either received mental health services or thought they needed them directly as a result of the pandemic.
The major sources of stress reported by participants were concerns about exposing others in their household to COVID-19 (46%), about being exposed to COVID-19 at work (41%), and about having enough personal protective equipment (25%).
Outside of urgent and long-term care, in group and private practice settings, high numbers of COVID-19 patients and most recently helping with COVID-19 vaccination efforts have increased workloads for office-based primary care physicians and increased their stress levels as well.
The Primary Care Collaborative (PCC) has been tracking primary care sentiment since the start of the pandemic. One of the latest surveys conducted between April 9 and April 13, 2021 among over 650 PCPs, showed that while they are keeping up with rising workloads, their mental health might be taking the hit.
Most respondents (91%) reported conducting routine chronic care visits, an increase from 30% reporting such visits in 2020, and a more than 200% increase in health screening activities (eg, substance use, social determinants) since May 2020. Also, 38% of PCPs said their practice is administering COVID-19 vaccines, a marked increased from previous weeks.
Despite keeping up with a rising workload, 7 in 10 PCPs reported that mental exhaustion (both personally and in their practice) has reached all-time highs and nearly 2 in 5 have required mental health support as a result of the pandemic.
It is possible that, for now, the worst of the pandemic has passed in the US. As of July 22, 2021, 48.8% of the total US population has been fully vaccinated, 56.4% have received at least 1 vaccine dose, and new cases have steadily declined.
When asked what could help physicians who have been deeply affected by pandemic events navigate as the crisis recedes, Myers stressed the importance of listening to and looking out for and of paying attention when their own friends and loved ones express concern about their stress levels or uncharacteristic behavior.
“I have been preaching and writing for years … across all health professionals, that we must be our brothers’ and sisters’ keepers,” Myers told Patient Care Online. “The next step is for all of us to pay attention to our own self, our own symptoms and signs, and we need to listen to those loved ones of ours who are concerned about us and reach out to us—our parents, our spouses, our kids—and then, of course, each other.”
In fact, part 2 of the Physicians’ Foundation survey found that personal contacts were the most helpful to physicians in fostering their mental health during the pandemic. Ninety percent said that their family has been somewhat or very helpful in supporting their wellbeing, followed by friends at 83% and colleagues at 73%.
Jan Bonhoeffer, MD, PhD, a global expert on infectious disease and founder of Heart Based Medicine, has a similar viewpoint.
“To me…mental health in primary care is really about a different kind of personalized medicine. Personalized medicine…you and me medicine. We’re human beings. Let’s put the masks down, get real, take care of ourselves, share love, nourish each other, learn from each other,” said Bonhoeffer, who also serves as professor of pediatrics, infectious diseases, and vaccine safety at the University of Basel Children’s Hospital in Switzerland, in an interview with Patient Care Online.
Importantly, when physicians support one another, they can focus on giving the best possible care to patients.
When COVID-19 forced Brigham and Women’s Hospital in Boston to close in March 2020, Marie McDonnell, MD, the chief of the diabetes section in the Division of Endocrinology, Diabetes & Hypertension, shared with Patient Care Online how she and her team quickly worked together to ensure their patients came first.
“It actually makes me emotional,” said McDonnell, “because the day we learned we had to close our clinic in March, the team got together on a phone call. It was a Sunday...and somehow miraculously, I had 20 people on a phone call."
McDonnell said as a group they figured out how to contact and stay in touch with patients which they did for the next 2 months "when we really were not organized around delivering care...Bottom line is…we made sure patients had what they needed...And the team never once said, 'I don't think this is going to work for me.' They instead said, ‘What can we do for our patients?’"
The story doesn’t minimize the depth of loss and personal tragedy of the past 16 months or the overwhelming experience of clinicians, nurses, and allied health workers. It is just a small example of what one group of health care professionals was able to do and how they “showed up” for each other – how they worked to be their brother’s and sister’s keepers.