Physician stress and burnout is an underdiagnosed epidemic: There was an epidemic that preceded COVID-19, widespread yet unaddressed: physician burnout. We have talked about physician burnout for years, but it has become so widespread that its impact on the nation’s workforce has been recognized as a public health crisis.1-3 It has been described as “an experience of emotional exhaustion, depersonalization, and feelings of low achievement and decreased effectiveness.”1 There is even a tool for measuring it: the Maslach Burnout Inventory.
Physicians love taking care of patients. Physician burnout is not caused by falling out of love with patient care. It is caused by frustration. Physicians are frustrated by the ever-growing administrative barriers to patient care: RVU targets, overscheduling, user-unfriendly electronic health records, prior authorizations, patient satisfaction surveys, and more. Our electronic health care record has been identified as a particularly strong contributor to physician burn-out. As noted this month by Melnick and colleagues, “A strong dose-response relationship between EHR usability and the odds of burnout was observed.”
More recently, physician burnout has been viewed as a form of moral injury, similar to the experience of soldiers suffering from post-traumatic stress.2,3 A recent survey by Merritt Hawkins found that 78% of physicians experienced some symptoms of professional burnout.4 Physicians experiencing burnout were more likely than their peers to reduce their work hours or exit their profession. By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of 84,500 physicians, many driven away from medicine or out of practice because of the effects of burnout.4 Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000 and $1 million.8,9
To this boiling pot we are now adding the potent ingredient that is COVID-19. Through increased burnout, and perhaps even as a result of succumbing to COVID-19, the projected nationwide shortfall is likely to increase. As physicians, we knew this when we accepted an unwritten pact to serve in times of need. However, we have also had an understanding with our health care employer that hospitals and clinics would provide the equipment to properly perform our jobs and protect ourselves.
That is currently not the case for physicians on the front lines of the COVID-19 pandemic. First, physicians are being asked to make impossible patient decisions. In hospitals overrun with critically ill patients, physicians are being forced to ration lifesaving critical care and ventilatory support. Physicians are also being forced to work well outside of their comfort zone. As I write this, some in New York are using a single ventilator on two patients because they have a shortage of ventilators, and physicians in Washington are making their own masks.
Additionally, health care workers fear for their personal safety. These fears have proven justifiable, with significant numbers of health care workers becoming infected by COVID-19. As of this writing, it is not clear whether infected health care workers acquired the infection from a patient, or from the community like everyone else.
COVID-19 has brought another frustration to physicians: profoundly inadequate preparation. Many physicians watched with horror as the reports came in from China about the exponential rise of a novel respiratory virus. We watched with equal horror the dismissive statements of our national leaders, claiming we were “fine” rather than taking emergency measures to save patient lives and protect health care workers. We should have mandated more isolation, produced more PPE, and preserved PPE by stopping elective surgery earlier. Even as we wrote this, elective surgery is continuing in some parts of the U.S. This risks further staff and patient viral spread. It also diverts PPE from the front lines of treating COVID-19. It has resulted in confrontations between anesthesiologists anxious to preserve PPE and follow guidelines to slow the spread, and hospitals interested in maintaining cash flow by continuing to offer elective procedures.
Finally, COVID-19 is making us all paranoid. Health care providers are asking, “Am I asymptomatic but COVID-positive? Am I carrying home the infection to my kids and elderly parents? Am I increasing the mortality risk to my loved ones? How do I explain that to my 2-year-old and 5-year-old – that mommy has to go to work but may not return?”
Certain groups of physicians are more vulnerable than others. Colleagues who are elderly, pregnant, or immuno-suppressed are at increased risk. If PPE availability and universal testing are not adequate, would it be right to expose them to additional risk? On the other hand, if they are not to work, the burden on other members of the team is increased. Increased clinical burden and exposure risk obviously will add to burnout.
Health care providers are also struggling with incomplete information. When can a COVID-positive treated provider return to work? What about people who have tested negative and then tested positive again? What level of PPE is adequate? Should we all be tested every day before work? Should every patient be tested on admission?
What Can Be Done?
Solutions exist at the institutional, departmental and personal level, often requiring all of them to be effective, including:
A robust physician wellness program is crucial. A wellness program with a departmental coach, mental health specialists, and resources for stress management at work and at home is crucial.
The institution must advocate for clinician well-being. Clinicians are a hospitals’ greatest asset. Prepare them. Protect them. PPE availability and universal in-house rapid testing must be made available. A dedicated hotline that employees can access in case of suspected cases with accelerated testing can help alleviate stress and decrease workforce attrition.
A COVID-19 task force with branches at the departmental level can help deal with department-specific concerns about management of personnel and resources. Communication through dedicated online bulletin boards, emails and a dedicated hospital webpage with practice guidelines and videos on management of cases in different scenarios with regular updates can help improve knowledge and practice and improve efficiency, all of which help alleviate work-related stress.
A regular schedule rotating personnel to minimize burnout must be made, particularly if vulnerable populations are to be given the option of fewer shifts, especially calls. Incentivizing call shifts may not be a bad option so that the risk is balanced, or at least taken electively.
Regular online group meetings such as COVID town hall meetings and “Q and A” sessions must be conducted for different sections of employees. These can convey a sense of togetherness, a portal to gain strength from numbers while answering many questions pertinent to employee fears and concerns.
Resources for personal stress alleviation must be made available to employees. Many centers even have a mental health hotline/dedicated psychiatrist who can conduct telemedicine appointments if needed. A sample of personal stress alleviators is offered in Table 1 (page 25).
Resources for back-up child care must be made available, as lack of child care has proved to be a potent stressor and contributor to attrition in the workforce.
In conclusion, these are testing times … in more ways than one. In these stressful times, wherein our skills, resilience and caring for our fellow colleagues are put to the test, readily available and rapid COVID-19 testing is of paramount importance. While rapid testing and new treatment options are being evaluated, keeping our physicians working on the front line mentally and physically fit should be of primary importance to the hospitals and other health care associations.