Since the beginning of the COVID-19 pandemic, healthcare workers—especially those caring for the acute and critically ill—have faced constant, often unimaginable and unending pressure from working in settings that were all-too-often understaffed, underresourced, and seemingly under siege. Aside from the stress and fatigue of being overworked from taking care of profoundly ill patients with a new and highly contagious virus, clinicians were further burdened by the very real risk of contracting the disease themselves and placing their loved ones at risk illness as well. These pressures are likely worse in the ICU and in related high acuity settings, where the most seriously ill patients are treated and where physicians and other providers already labor under conditions of heightened stress that make them even more prone to burnout, moral distress, and emotional angst (1–3).
We have long been aware of burnout among healthcare professionals, and we are just beginning to understand its extent and pervasiveness. We have similarly begun to realize that the impact of burnout goes far beyond the affected individuals themselves, as overworked, overstressed, and burnt-out staff are more apt to make mistakes, deliver substandard care, and ultimately expose their patients to potential harm (4,5). Similarly, we now better understand who are most likely to suffer from burnout along with the main factors—such as increased workload, excessive night duty, unfamiliar job responsibilities, and excess patient mortality—most associated with burnout, moral distress, and personal despair and depression (3–5). As society has moved from a relatively stoic and suppressive culture of “keeping things to oneself” and “sucking things up” to a more humane, more nurturing ethos that encourages awareness and intervention when something may be wrong, we need to better understand how healthcare professionals cope with stress, deal with untoward demands, respond to moral distress, and the extent of both healthy and maladaptive coping strategies.
In this issue of Critical Care Medicine, Burns et al (6), on behalf of the Diversity-Related Committee of the Women in Critical Care interest group of the American Thoracic Society, assessed wellness and coping strategies in physicians who cared for critically ill adults and children during the COVID-19, via a survey of attending physicians who worked in adult and PICUs. They observed, similar in part to observations from others, that almost all physicians reported more time worked per month, a higher patient census under their care, increased physical and emotional exhaustion, and lower levels of professional fulfillment. Half of the physicians surveyed reported suffering from signs and symptoms of burnout and also reported greater indifference and more callous behavior toward their patients. They further observed that burnout, moral distress, and apathy toward one’s patients were associated with other, perhaps more subtle, factors beyond the usual culprits of longer work hours, more days worked, and higher patient loads, most notably increased nighttime duty and a greater number of unscheduled, unplanned shifts. Perhaps counterintuitively, stress levels did not differ between intensivists and other noncritical care physicians who were called upon to provide ICU care during the pandemic during times of high demand and shortages. However, most alarming was the fact that about 20% of physicians reported maladaptive, personally dangerous coping strategies, such as excessive self-blame, avoidance tactics, and abuse of alcohol and drugs (6).
One can easily state that the COVID-19 pandemic represents an unusual, perhaps catastrophic, and maybe once-in-a-lifetime period that would intuitively be associated with unusually high levels of burnout and moral distress. Although this may be a correct observation, the acceptance of this premise risks minimizing the extent of burnout and stress that was evident and even endemic before the COVID-19 pandemic hit. This in it of itself represents a potential setup for a perilous trap that must be avoided, as it can lead to the false assumption that when life returns to “normal,” the problem will resolve.
The dynamic and tenuous nature of critical illness, by implicit intuition, undoubtedly fosters excess stress and tension, and this may have worsened over the years from the general loss of autonomy and control that have arisen from the many changes in healthcare delivery, organization, and financing that have taken place over the past several decades. When combined with the burden of pandemic care, coupled with the moral distress that emanates from powerlessly watching previously healthy patients suddenly die from the unfamiliar position of clinically ineffectiveness and impotence, the risk of burnout and its untoward manifestations of dissatisfaction, insomnia, anxiety, despair, and even depression foment and fester (7). A vicious cycle then ensues, which both providers and those under their care. In essence then, as Hartzband and Groopman (5) write, “burnout is toxic for patients as well as physicians… .”
Although the findings from Burns et al (6) help to highlight the scope and breadth of this issue, one should recognize the limitations of the study by Burns et al (6). The results themselves may not be representative of the behavior, attributes, and responses of all physicians who care and cared for critically ill patients during the pandemic, as the majority of those who responded were male, university hospital-based physicians, who had been practicing for a mean of approximately 10 years. Furthermore, the physicians—both responders and nonresponders who were surveyed—were directly or indirectly selected by the researchers themselves, which creates an inherent potential bias. However, despite these and other limitations and despite the shortcomings of survey data in general, the messages warrant attention and even action.
Clearly, this starts with a greater awareness of burnout and moral distress even when it does not overly manifest and when it is not readily apparent, especially in those deemed to be most at risk. We also need more research to better understand the root causes and epidemiology of burnout along with more effective interventions to reduce the dangerous effects of burnout for both the afflicted survivors and the patients they treat. From the standpoint of pandemic preparedness, one of many lessons that we must heed from COVID-19 is the need proactively develop functional plans to staff ICUs and all high acuity areas with approaches that minimize potential uncertainties and stressors. But as we eventually move beyond the COVID-19, we should acknowledge that the conditions that incubate burnout and stress are not unique to the pandemic and hence warrant greater concern and closer attention.
1. Kleinpell R, Moss M, Good VS, et al.: The critical nature of addressing burnout prevention: Results from the critical care societies collaborative’s national summit on prevention and management of burnout in the ICU. Crit Care Med. 2020; 48:249–253
2. Gomez S, Anderson BJ, Yu H, et al.: Benchmarking critical care well-being before and after the coronavirus disease 2019 pandemic. Crit Care Explor. 2020; 2:e0233
3. Moll V, Meissen H, Pappas S, et al.: The corona disease 2019 pandemic impacts burnout syndrome differently among multiprofessional critical care clinicians – A longitudinal survey study. Crit Care Med. 2022; 50:440–448
4. Friedberg MW, Chen PG, Van Busum KR, et al.: Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q. 2014; 3:1
5. Hartzband P, Groopman J: Physician burnout, interrupted. N Engl J Med 2020; 382: 2485 – 2487
6. Burns KAE, Moss M, Lorens E, et al.; Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society: Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey. Crit Care Med. 2022; 50:1689–1700
7. Murthy VH: Confronting health worker burnout and well-being. New Engl J Med. 2022; 387:577–579