Emergency physician Andrew Cohen, DO, doesn't remember exactly when it stopped being a struggle to walk into work at St. Joseph's University Medical Center in Paterson, NJ.
At the height of the COVID-19 pandemic in April, he would pull into the parking lot and sit in his car for 15 minutes, 20 minutes, half an hour, overwhelmed by anxiety, stress, and guilt. Anxiety that he would become ill himself or bring the virus home to his wife or their children, ages 8 and 11. Guilt over the patients he couldn't save. Guilt over the deaths of his in-laws, who often babysat for the children and who died within days of each other in March. After their deaths, he took a couple of weeks off, and then found the thought of returning absolutely paralyzing.
“I had known a lot of people who dealt with anxiety in their lives, and prior to all this, I felt very fortunate that I had never had issues with that,” Dr. Cohen said. “But in the middle of all this, it was just devastating. Especially the first time back to work after both my in-laws had passed away, I came very close to just calling out sick and not showing up because I was just that terrified. I didn't, but it was quite a process of talking to myself to get in there.”
Perhaps no other individual day was as difficult as that first day back after his in-laws' deaths, but for a good two to three months, Dr. Cohen went through a struggle every time he went to work. “I have been an emergency attending for 11 years, and prior to that, I did four years of emergency residency. In 15 years in the field, I've never seen anything like what I saw when I came back in April—and supposedly I missed the worst of it,” he said. “At home, I had remote access, and I would look at the patient lists from the waiting area in disbelief. There would be 60 or 70 people in the waiting room, and some of them would have oxygen saturation in the 70s. Normally they would immediately be brought back, but these people would have to wait because there was physically no room.” (St. Joseph's ultimately transformed the ED waiting area into a temporary treatment space to accommodate the additional patient load during the height of the pandemic.)
Stress on Top of Stress
Like many emergency physicians, he fought through the worst of his anxiety and stress over the pandemic without a lot of outside help. “It's almost a suck-it-up-and-deal mentality. We don't talk about it, which obviously has its flaws,” Dr. Cohen said. “When I first came back, a couple of people opened up to me. But although I'm not a person who's opposed to seeking help, my wife and I have been able to do that for each other. She is also in health care, and we're very in tune with each other, so we do checks on each other. If we felt like we weren't able to do that, I'd say it's time to go see someone.”
Sometime in late June or early July, though, it started getting less and less difficult to walk into the ED. “I had found a cartoon rendition of a COVID molecule looking very scary and a health care worker standing in front of it giving it the middle finger,” he said. “I keep it in my car. There were times when I'd have to sit and stare at that thing for a long time before I could walk into a shift. I don't know how it would help me, but I'd stare at it and think, ‘I can do this.’ I haven't had to do that in a month or so, maybe longer.”
The mental health effects of the COVID-19 pandemic on emergency physicians and other clinicians have yet to be fully understood. Rates of burnout, PTSD, and suicide were already high among these physicians even before the pandemic hit, and although no major U.S. studies have yet been published on how that may have increased over the past six months, recent research from China, Canada, and Italy points to increased rates of anxiety and depression. (JAMA Netw Open. 2020;3(3):e203976, https://bit.ly/2ExynMy; Potloc, https://bit.ly/3gnItx2; MedRxiv, April 22, 2020, https://bit.ly/2CTx5es.)
Dr. Cohen and other emergency physicians in the areas of the Northeast that were hardest hit in the early days of COVID-19—New York City and northern New Jersey—have insights to share with their colleagues in other parts of the country that are still overwhelmed with uncontrolled community spread of the disease.
“Something shared among many is this helplessness that we all have experienced,” said Daniel Lakoff, MD, an assistant professor of clinical emergency medicine at Weill Cornell Medicine in New York City. “Despite all the knowledge and skills that we have, there was a limit to what we could do for these patients. I was imagining what it must have been like to be a doctor in the 1800s or early 1900s, when you're watching people sick and dying with no tools to help them. We have learned a lot since March and April, and our ability to manage COVID patients has improved, but I'm sure our colleagues across the country are still in that situation now.”
Stemming the Tide
Loice Swisher, MD, an emergency physician at Mercy Philadelphia Hospital and the vice chair of the American Academy of Emergency Medicine Wellness and Burnout Committee, said she's beginning to grapple with the fact that COVID-19 is not going away. “We still see it all the time. It isn't like where we were at the peak, but it doesn't feel under control, not in any way. The feeling of sadness and hurt and impotence in being unable to stem the tide is overwhelming,” she said. “A lot of the stresses I see have to do with the realization that this is long term, and we're going to have to figure out new ways to do things.”
The New York City EMDR Trauma Recovery Network, a chapter of the nationwide EMDR Humanitarian Assistance Program, formed after the terrorist attacks on 9/11, provides six to 10 sessions of pro bono EMDR therapy for trauma and stress-related symptoms after a local disaster. The team is currently serving health care professionals and first responders dealing with the COVID-19 pandemic. Linda Kocieniewski, LCSW, who leads the New York program, said her group was “ramped up and ready to go” in March, but at first the hospitals were so overwhelmed and staff so overloaded that they couldn't even get through.
“The staff was working so hard and was so exhausted that they didn't have time to pick their heads up to think about taking care of themselves,” Ms. Kocieniewski said. “Since then, word of mouth has been getting around, but it remains challenging getting clinicians to seek help because there is a lot of stigma surrounding seeking help. Some people are so guarded that they don't even want to give us their last name or the hospital they work at, so we only ask the bare minimum questions. The team's services are completely confidential, though, and services are provided without sharing any identifying information to their employers or anyone else.”
Ms. Kocieniewski urged hospitals, health systems, and emergency departments to be proactive about managing their clinicians' stress during the pandemic. “Don't wait until down the road, or it's like a wound that gets infected,” she said. “If you deal with trauma preventively and early in the acute phase, you may be able to prevent it from becoming a chronic problem or long-term PTSD.”
She cautioned that the mental health effects of the pandemic on emergency physicians, nurses, EMS personnel, and other clinicians may be delayed. “When we worked with first responders after 9/11, people would call quite a bit later with delayed reactions, sometimes years later” she said. “In fact, during this pandemic we've gotten calls for help from 9/11 first responders because they're having flashbacks. There is no end in sight to the uncertainty of this pandemic, and you have people afraid to go home to their families, doctors afraid to hug their kids, young doctors writing their wills. And we're hearing a lot of moral injury—doctors unable to live by their own ethical standards, dealing with conflicts over who gets a respirator or feeling unable to comfort the dying.”
Support for the Front Line
Some hospitals have put in their own mental health support programs for clinicians, either prior to the pandemic, such as the NYC Health + Hospitals' Helping Healers Heal program or in response to it. “They have things like peer counseling, respite rooms with massage chairs and low lighting, meditation programs, and so on,” said Ms. Kocieniewski. “But I'm hoping there will be more preventive efforts going forward. When I've talked to hospitals about offering services, I recommend offering interventions to a whole group, not just individuals who reach out because they are struggling. This gives young doctors the impression that we all need help and prevention is important, and takes away the stigma.” Some institutions have initiated reverse rounds, in which the psychiatric check in with the medical staff to provide support and stress management.
After Lorna Breen, MD, the chair of emergency medicine at the New York Presbyterian Allen Hospital, died by suicide in April, her family created the Lorna Breen Heroes Foundation to build a community of support for improving the mental health and wellness of physicians and other front-line health care providers. (https://www.drlornabreen.com.)
In addition to these organized programs, Dr. Lakoff stressed the importance of ad hoc peer support efforts. “In our department, we set up a WhatsApp chat to share some of the things that were happening, positive outcomes, memes and jokes—things to connect us when we were so disconnected,” he said. “That was the most important thing to me, having a group of friends to communicate with, to debrief and discuss the situation so we could take care of patients in the best way, but at the same time take care of ourselves and share a few laughs.”
Dr. Swisher agreed. “Relationships are among the greatest protectors of mental health. And those things that you can do to increase the density and depth of your relationships, I think, will help keep you afloat,” she said. “We all need to find ways to reach out to each other so that we feel less alone. You may think you're alone because we've gotten so good at putting on our doctor persona and being the one in charge that we're not as good at being vulnerable when life feels out of control. But if you're having trouble, reach out. I promise you are not alone.”
Resources for Physicians
- The American College of Emergency Physicians' COVID-19 assistance programs: https://bit.ly/32gXQCi. ACEP also offers its members access to three free counseling or wellness sessions through its Wellness and Assistance Program.
- The NYC Trauma Recovery Network: https://www.nyctrn.org
- EMDR Humanitarian Assistance Programs: https://bit.ly/2QnBIki
- Project Parachute (pro bono therapy for front-line health care providers): https://project-parachute.org
- The Lorna Breen Heroes Foundation: https://www.drlornabreen.com
- The American Medical Association mental health resources for clinicians: https://bit.ly/2CTxAVR
- AMA guidance for leadership: https://bit.ly/3lgwjd1
- Psych Hub COVID-19 mental health resources: https://psychhub.com/covid-19/
Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.