Article In Brief
Losing community, weighing long-term consequences, and burnout are some of the factors at play in the emotional toll of COVID-19 on the neurology workforce. Here, neurologists share their experiences, and how they are navigating the emotional burden of the pandemic.
As a pediatric movement disorder specialist, Abigail Collins, MD, was only one of a handful of fellowship-trained specialists in the field in the United States and the only one within a greater than five-state region. When COVID-19 struck and her clinics were cancelled in mid-March, she converted to full-time telehealth and within two weeks her schedule was packed again.
But working from a windowless room in her basement left her feeling drained and exhausted at the end of the day. She struggled to complete her notes and had no energy for outside activities. When she returned to work a few days a week in May, she was working alone, physically isolated from her colleagues due to safety measures instituted at work. The joy of practice outside the clinic room was gone.
“The burden of everything that goes into taking care of patients was really weighing me down, and I was feeling that weight that I was carrying with me every day and all the time,” Dr. Collins said. “I asked for help and when I was told that help was not forthcoming, I fantasized about running away and disappearing,” she continued.
“I started feeling like I just want this to end, and when I considered my options to escape—including ending it all—I realized that was a serious warning sign,” she added. “It scared me and made me realize I needed to make a big change.”
Losing Our Community
“When we lose our community and feel a sense of isolation, we also lose our first line of defense—our colleagues,” said Jennifer Bickel, MD, FAAN, employee wellness officer for the COVID leadership team at Children's Mercy Hospital in Kansas City, MO. “Often, it is they who can tell something is not right with someone and it is they who intervene before a tragedy occurs.”
“Our emotional wellbeing is being threatened more than ever before and our minds are responding to the demands of the COVID-19 pandemic in myriad ways,” she added. “Right now, the number one symptom we are seeing is weariness; people are just bone tired.”
The feeling of exhaustion is pervasive, Dr. Bickel pointed out, and coping skills that we have used before don't seem to be working.
“Normal activities that brought us joy before—attending a meeting, playing sports, getting together with friends—are no longer options as outlets for release.”
There is a reason why breaking bread is part of almost every culture, Dr. Bickel said, explaining that sadly, this has been taken away from us. “While it sounds almost frivolous in the setting of all this human suffering, those were the pre-pandemic ways we bolstered each other and maintained our morale,” she continued.
Janis M. Miyasaki, MD, MEd, FAAN, director of the movement disorders program at the University of Alberta and a member of the AAN Board of Directors, is also concerned about the consequences of a lack of contact with co-workers.
“A lot of my enjoyment at work comes from interacting with my colleagues, and now, as a result of COVID-19, there is less collegiality and less awareness of how our colleagues are doing because they are not in front of us,” she said.
“Furthermore, we no longer get affirmation from our colleagues from casual hallway discussions of how we managed a challenging case. Those interactions can be very helpful in a day that is depleting, and we don't have that now,” she continued.
Suffering Multiple Simultaneous Disruptions
Moreover, physicians are reluctant to seek help. In a JAMA article published in April, “Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic,” Tate Shanafelt, MD and co-authors wrote: “Health care professionals are often self-reliant and many do not ask for help. This trait may not serve them well in a time of burgeoning workload, redeployment outside of a clinician's area of clinical expertise, and dealing with a disease they have not previously encountered.”
Dr. Shanafelt, who serves as chief wellness officer at Stanford Medicine, pointed out that the pandemic has struck the medical community on multiple fronts. Indeed, neurologists have been confronted with inadequate personal protective equipment and personal safety concerns, concerns about being exposed at work and infecting our families, inadequate access to child care, anxiety over clinical competence in tasks in which neurologists have not received prior training, job insecurity or outright loss, and financial uncertainty from pay cuts, among others.
“We are dealing with a bombardment of stressors: concern for physical injury (not only for ourselves, but for our patients and loved ones); grief (not only of the loss of life but the loss of what our lives used to be); the potential moral distress of triage decisions as our hospitals continue to fill; and just plain fatigue from everything,” said Jennifer R. Molano, MD, FAAN, co-chair of the AAN Wellness Joint Coordinating Council and associate professor of neurology at the University of Cincinnati. “It's a lot and it's challenging,” she added.
“When a disruption occurs in our lives, it is usually limited to one domain—health, family, community or work—so we are able to build our resiliency because we still have our sources of support in other domains,” Dr. Bickel explained. “But now almost everyone has had all their domains affected, and that makes it much harder to bounce back.”
Many health care workers are unable to stop long enough to experience their loss and deal with their grief, as they are still needed to soldier on at their workplaces and on the frontlines, mental health experts worry.
“Furthermore, there is a lot of anger in the medical workforce: anger that the pandemic was not controlled as it should have; anger that the public is not cooperating with public health measures; and anger that many are questioning our credibility and the science,” Dr. Bickel said. “It is the ultimate slap in the face of sacrifice of health care workers. When we turn away from our inner feelings, they linger under the surface and come out in other ways, and when we don't give anger and grief its space it can turn into a chronic dysfunction.”
The Risk of Long-Term Consequences
Dr. Miyasaki, who was a medicine intern during the AIDS epidemic in 1988-1989 when she, along with only a second-year resident and two medical students, were responsible for 64 patients on the AIDS team.
“It almost broke us,” she admitted. And in 2003, she experienced the SARS epidemic under a severe shortage of gowns and staff. “One of our colleagues was admitted to the ICU with SARS, and it was extremely stressful,” she recalled. Now, in the midst of her third pandemic, she finds herself experiencing heightened anxiety once again over what is going to happen to her hospital, her city, her patients and her colleagues.
Some experts in post-traumatic stress disorder (PTSD) are concerned that the COVID-19 pandemic may have long-reaching consequences on the psychological well-being of healthcare workers and first responders. Research from the SARS outbreak suggests that those who had been quarantined, or worked in high-risk locations such as SARS wards, or had friends or close relatives who contracted SARS, were two to three times more likely to have high post-traumatic stress symptom (PTSS) levels, than those without these exposures.
More recently, a systematic review of studies conducted in the context of the three major coronavirus outbreaks of the last two decades focusing on investigation risk and resilience factors warned that there is evidence of high risk of PTSD and PTSS and that health care systems should also focus on preparing to roll out treatments should prevention strategies fail to work.
A recent New York Times story cited numerous reports of doctors and nurses retiring early or leaving their jobs. Some, it reported, left over concern about their own health because of age or a medical condition that placed them at high risk; others stopped practicing during the surges and did not have the energy to start again; some needed a break from the toll that the pandemic had taken among their ranks and their patients.
The entire medical community, including neurology, already stretched thin by a workforce shortage, is at risk. There have also been anecdotal reports of neurologists taking early retirement, leaving clinical practice or quitting their positions during the pandemic. Dr. Collins is among them. When she realized the gravity of her situation, she decided to leave her job. She applied for positions in the pharmaceutical industry, received three job offers, and is excited to start a new position before the end of the year.