High and increasing rates of burnout among healthcare providers are well documented. Large scale studies have revealed job-related burnout (JRB) rates of more than 50% across all medical specialties nationwide. In some specialties burnout rates approach 70%, as in emergency medicine. The three hallmarks 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 that is often felt first or most keenly.
The underlying drivers of JRB – generated up to 90 percent by work environment – arewell established. They are work overload, lack of control, insufficient reward,
breakdown of community, absence of fairness, and conflicting values. Together, these drivers of burnout can cause providers to question their very choice of careers in medicine.
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.
Of the six drivers of burnout, consider how each of them are being additionally negatively impacted by the COVID-19 pandemic.
1. Work Overload: In hot spots, providers are being asked to work longer hours or more shifts. As the providers themselves are more exposed, they are at a much higher risk of testing positive for the virus or becoming sick. Then, they must quarantine. This shifts their workloads to those who remain healthy, which further increases individual workloads.
2. Lack of Control: This pandemic has transformed the way providers deliver healthcare. Through the necessary use of gloves, masks, face shields, gowns, and other protective barriers, the simplest and sometimes most effective forms of human interaction have been eliminated—a reassuring touch, a smile, a therapeutic hug, a handshake.
3. 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 work to erode 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 hard work and dedication.
4. Breakdown of Community: 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. With the pandemic, providers have had to isolate even more at a time when support from others is especially critical. Doctors and nurses are isolating themselves from the ones they love to reduce 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.
5. Absence of Fairness: Doctors and nurses have become surrogate family members for their patients. Families have been kept separated from their critically ill and 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 demoralizingly unfair to everyone involved.
6. Conflicting Values: A quarantined or ill provider feels more like part of the problem rather than part of the solution. Their values become compromised because they are not allowed to do what they were trained to do and want to do, which is take care of patients. Healthcare providers put themselves at risk every day. COVID-19 is just the latest in a long line of risks providers readily accept as part of their jobs. Keeping them from doing their jobs conflicts with their values.
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 of providers over time. This has already been demonstrated through national surveys. Add the negative impact from COVID-19 and the consequences could become dire.
Every member of the healthcare team must make self-care their #1 priority. This isn’t being selfish. 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 parts in ensuring the health of the workforce. Making certain providers take breaks, stop to eat meals, take scheduled time off, are not routinely overworked, and have the necessary supplies to do their jobs 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 remits, 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 normal, whatever that may be. Then, and only then, will we ascertain the extent of the damage to an already stressed healthcare system.
A version of this article first appeared on the website of the North Carolina Professionals Health Program, www.ncphp.org.
Dr. Clark Gaither is Medical Director for the North Carolina Professionals Health Program. He is a board-certified family physician who has dedicated much of his professional career to helping physicians and other medical professionals overcome job-related burnout. He is an author and frequent presenter on the topic of professional burnout.
Great article. I heard on the news about an emergency physician in New York who commited suicide after recovering from COVID-19. This gives me some understanding of maybe why that could happen.
By Helene Harper, MD, FACEP on Apr 30, 2020 at 2:24pm
