16 Apr Healthcare Provider Burnout and COVID-19: A Battle on Two Fronts by Clark Gaither, MD, MRO, FAAFP
High and increasing rates of burnout amongst healthcare providers has been well documented. Large scale studies have revealed job-related burnout (JRB) rates of over 50% across all the medical specialties nationwide. In some specialties burnout rates approach 70%, as in emergency medicine. The three hallmarks, or symptoms, of JRB are emotional exhaustion, the development of cynicism with detachment, and a lack of a sense of personal accomplishment. It is the emotional exhaustion component which is felt first or most keenly by many. Some refer to it as compassion fatigue. Others call it a form of moral injury. Those who suffer from it know the emotional devastation and monumental unhappiness which results from it.
The underlying drivers of JRB have also been well established. They are work overload, lack of control, insufficient reward, breakdown of community, absence of fairness, and conflicting values. Negative pressure on these arenas are the causes of burnout, which are generated ninety percent of the time by the work environments. Together, these drivers of burnout can cause providers to question their very choice of careers in medicine, some to the point of an existential crisis. Little wonder rates of depression and suicide are so disproportionately high in the healthcare fields compared to other careers. Richard B. Gunderman said it best:
“Burnout at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.”
As if things weren’t bad enough and getting worse on the burnout front, the COVID-19 pandemic has only served to amplify the symptoms and drivers of burnout. Our healthcare providers—doctors, nurses, and ancillary service providers—are on the front lines of this pandemic, especially Emergency Department personnel.
Of the six drivers of burnout, consider how each of them are being additionally negatively impacted by the COVID-19 pandemic.
- Work Overload: In hot spots, providers are being asked to work longer hours or more shifts to meet the growing patient load demands. As the providers themselves are more exposed, they are at a much higher risk of testing positive for the virus or becoming infected. Then, they must quarantine. This results in a shift their workloads to those who remain healthy which further increases individual workloads.
- Lack of Control: This pandemic has caused providers to deliver healthcare in more constrained ways than normal. Through the use of gloves, masks, face shields, gowns, and other protective barriers, the simplest, and sometimes most effective, form of human interactions have been eliminated—a re-assuring touch, a smile, a therapeutic hug, the handshake.
- Insufficient Reward: A provider’s greatest rewards are more often intrinsic—using their natural talents and abilities in a way that is personally satisfying while helping others. New protocols, increasing mandates, and administrative responsibilities have been eroding the doctor-patient relationship. Now, video conferencing, text messaging, emails, and phone calls have put even greater distance between the patient and doctor, reducing person-to-person interactions, something most prized in the healing arts. Then, there is the ever-present danger and fear of becoming infected by a potentially lethal virus, definitely not a reward for one’s hard work and dedication.
- Breakdown of Community: Physicians used to be more collegial. They spent time talking with one another discussing their problems, diagnostic dilemmas, successes, failures, the weather, and whatever. With increasing administrative responsibilities, many providers have found themselves slogging away at work eight to twelve hours a day and then working an additional one to three hours at home finishing their charts. They have become estranged from their colleagues. They have become estranged from their families. Then there is the myriad of committee meetings, a requirement if you hold hospital admitting privileges. Who has time to be collegial? Physicians began to feel all siloed up and isolated from one another. With the pandemic, providers have had to isolate even more at a time when support from others is even more critical. Doctors and nurses are isolating themselves from the ones they love in order protect them from the risk of possible viral exposure. Family members have had to shoulder the additional burden this imposes, leaving the provider vulnerable to feelings of guilt which further accentuates their unease.
- Absence of Fairness: Doctors and nurses have become surrogate family members for their patients. Families have been kept separated from their critical or dying family members to reduce the spread of the virus. This is anathema to healthcare providers who not only provide comfort to patients, but to their families as well. From their perspective, another bond in the doctor-patient relationship has been severed through no fault of the patient or their own. It is perceived as demoralizingly unfair to everyone involved.
- Conflicting Values: A quarantined or ill provider feels more like part of the problem and a burden rather than a solution. Their values become compromised because they are not allowed to do what they were trained to do, what they want to do, which is take care of patients in ways they believe are best for them. Healthcare providers put themselves at risk each and every day. This viral pandemic is just the latest in a long line of risks providers readily accept as part of their job. Keeping them from doing their job conflicts with their values, their need to do the next right thing for the patient.
The emotional exhaustion, cynicism, and feelings of inefficacy directly follows the negative impact on these six domains. Negatively impact one or two of these domains and you might burn out a few providers. Negatively impact all six to a considerable degree and you will burn out the majority over time as has already been demonstrated through national surveys. Add the negative impact from COVID-19 on top of the majority of providers who were already suffering from burnout and the consequences could become dire.
It is incumbent on healthcare providers to take extra special care of themselves through this crisis, something most providers aren’t very good at doing. The reasons are clear. Their primary concern is, first and foremost, the patient. Their needs get supplanted for the care and concerns of the patient. I believe this model of care is no longer workable in today’s healthcare work environments.
Everyone on the healthcare team must make self-care their #1 priority. This isn’t being selfish. It is self-interest. Self-interest means I want to be the best I can be, using my own unique set of talents and abilities in a way that is personally satisfying to me while helping others. For the good and proper care of patients, especially now, this kind of attitude becomes paramount.
How can anyone in healthcare be the best they can be if they are too tired, too lonely, too hungry, too angry, if their emotional needs are not being met, if they don’t exercise regularly, if their physical health is bad, if they are ignoring their spiritual needs, or if they have no one to talk to about their problems and concerns? I have always contended and endorsed the notion that excellent care of patients begins with excellent care of self.
Healthcare organizations must also do their part in ensuring the health of their workforce. Making certain providers take breaks, stop to eat meals, take scheduled time off, are not overworked, and have all of the necessary supplies available to do their job in a safe manner is a proper beginning. Beyond that, having decompression sessions, assigning mentors, forming emotional support groups through video conferencing, providing anonymous mental health services, installing instant crisis help lines, and eliminating redundant administrative duties illustrates a higher level of commitment.
These measures aren’t suggested just for the time being or until the viral spread brakes. Just as migraine headaches do not usually occur in times of stress but more often when stress is let down or relieved, the majority of the emotional impact of COVID-19 on healthcare providers might not be seen until after the highest risk levels have passed and life begins to return to normalcy, whatever that may be. Then, and only then, we will ascertain the extent of the damage to an already damaged healthcare system.