The COVID Healthcare Professional Grind

Burnout in healthcare professionals, physicians in particular, was high pre-COVID.

We are hearing stories every day about healthcare delivery professionals being caught up in the stress of the intense, long hours necessary to deliver care to COVID-19 patients. There have been an ebb and flow in the intensity and the number of patients for just about a year now. Presently, after the major winter holidays, the surge has been as predicted, but now at unprecedented levels. These changes are not just limited to affecting physicians, either. The delivery of this care involves so many different factors and a wide variety of individuals, all playing an integral part, and it is leading to a significant, singular, unintended result – burnout.

Let’s start with a definition of burnout. Edelwich and Brodsky define it as “a state of physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations.” That definition could not describe this pandemic any better, with the effects being so far-reaching, affecting the lives and daily activities of just about everyone. This writing will focus on the direct and indirect care of patients, and those delivering it.

Is it Just Stress?

Suffice to say, stressors are not inherently the cause of burnout – it is the individual’s perception and reaction to the stressors that can trigger the burnout cycle.

Is Burnout the Same as Post-Traumatic Stress Disorder (PTSD)?
PTSD is typically associated with military conflict, and not necessarily with workplace challenges. It has been said that in the recent past, there were generally not life-threatening situations in the workplace, but that is not the case today. Healthcare workers are being exposed to workplace dangers of many kinds, including contracting COVID, and many have acquired the disease and died. Yet, healthcare workers carry on with the performance of their duties, utilizing their skills. Dr. Geri Puleo has provided a brief comparison of six similar elements of both burnout and PTSD:

Understanding a Cause of Burnout
I want to take a slightly different approach of looking at some of the causes of burnout in a pandemic, some of which still existed in the pre-pandemic era. It is well beyond the scope of this writing to review burnout statistics among healthcare professionals, but the rate is high. Burnout in healthcare professionals, physicians in particular, was high pre-COVID. According to the Cleveland Clinic, “while physician burnout is not new, the pandemic is rapidly accelerating the many negative repercussions of uncertainty and inadequate support, and the consequences are being felt by patients, physicians, and healthcare systems.” 

Although the following paragraphs talk mainly about physicians, it is really all about the entire healthcare continuum. Every part of that continuum has its own story, from pre-hospital care to end-of-life care. And then there are the patients and the families.

Elisabeth Kübler-Ross, MD, in the classic book “On Death and Dying,” talks about the five stages of grief and grieving in illness and death: denial, anger, bargaining, depression, and acceptance. As providers of patient care and family support, we have had to learn to help our patients and their families understand their journey through these stages. We must not only know how to help our patients learn how to live, but we also have an obligation to help them learn how to die. Our problem is also this: how do we help ourselves transcend these stages in our personal grieving of patient suffering and loss? You may argue that we cannot allow ourselves the luxury of going through these stages, since we must maintain objectivity, but that is not correct. We face them whether we are aware of it or not. We owe it to our patients and their families to understand that which we teach. Take a typical day in the life of a practicing physician, pre- and during COVID. In the course of treating anywhere from 10 to 50 patients every day, the following types of scenarios may occur:

• Outlining a plan of treatment for a diagnosed illness;
• Meeting a patient for the first time for an acute illness and ordering tests and X-rays;
• Telling a patient that he or she has cancer, and answering the questions of the patient and family;
• Pronouncing the expected or unexpected death of a patient who we may or may not know and spending time speaking with the family, maybe even crying with them (yes, crying is OK);
• Telling a patient that he or she is cured of a malady;
• Going through routine hospital and office visits;
• Going back to the hospital after office hours to check on a critical or postoperative patient;
• Calling the intensive care unit upon arriving home to find out how a patient is doing; and
• Making numerous phone calls and/or going back to the hospital in the middle of the night while on call.

That workload has increased due to the pandemic.

We go from patient to patient to patient, changing emotions, changing mental pathways, constantly, without missing a beat. We never get the time to account for our own emotions and feelings. Doing this day after day after day empties our emotional bank, whether we are aware of it or not, leading to the point of overload or even bankruptcy of our own personal ability to continue to deal with the stress. We never allow ourselves to process our grieving, and over time, this “bankruptcy” of emotions can lead to burnout. We can’t take it anymore.

How do we treat burnout? How do we reinspire our love for what we do? Truly, healthcare workers are the best at what they do, with skills refined through years of dedication. We must allow ourselves not the luxury, but the necessity, of going through the grieving process. It will help to decrease stress. We need to reignite the fire of passion for the practice of medicine and surgery again. If it is good enough to teach our patients, then, as the Bible says, “physician, heal thyself” (Luke 4:23). This advice applies to all healthcare workers: heal thyself.

This may make me sound like a Pollyanna (a person regarded as being foolishly or blindly optimistic). But I don’t think there is a person reading this article that doesn’t realize that healthcare workers across today’s pandemic continuum are suffering from burnout. I also believe that we understand the “why” it is occurring, but may not internalize it. From the tragic scenes to be dealt with, to the overwhelming number of patients, lack of personnel available, changing responsibilities, furloughing of staff, lack of equipment and resources, risks of acquiring the disease, lack of personal protective equipment, fear of spreading the infection to family members, long hours, the list goes on and on and on. In addition, rationing of care is here, and it is going to get worse. This is more than a paradigm shift; it is a life-altering sea change.

Healthcare workers are a strong group, and will survive this, and emerge stronger because of it. In her book “Kitchen Table Wisdom,” Rachael Naomi Remen, MD, says it so well: “it is not that we don’t care; we care too much.”

Programming Note: Listen to Dr. John Zelem report this story live today during Talk Ten Tuesdays, 10 a.m. Eastern.