Article In Brief
For many clinicians, beginning another year of a relentless pandemic has compounded the feelings burnout and exhaustion they were already feeling. Many clinicians, including neurologists, do not feel valued by the public, by legislators, and by their own institutions. Here is what some leaders and institutions are doing to create cultures of wellness and provide the right resources.
In Spring 2020, hospitals in the Northeast were overrun by the first wave of the COVID-19 pandemic in the United States. Beleaguered physicians, nurses, and other health care workers cared for patients in virtually impossible conditions. And as critical care and emergency physicians became overwhelmed by both the volume and the severity of these patients, clinicians from other specialties, like neurology, were called upon to fill in wherever they could.
In that moment of crisis, health care workers were hailed as heroes. Community volunteers banded together to make plastic face shields in bulk for local hospitals. In a divided nation, there was the sense that almost everyone was united in honoring the extraordinary care being provided by the medical community.
Fast forward nearly two years later. Beleaguered physicians, nurses, and other health care workers have had brief periods of relief over the past 22 months, as vaccines and boosters became more available, but as the pandemic enters its third year, health care workers are once again overwhelmed by an avalanche of patients—emergency departments and ICUs have filled up with patients with delta and/or omicron variants.
After two years of never-ending combat against COVID-19, the applause has stopped, and anti-science rhetoric and conspiracy theories have driven a small but loud and potentially dangerous segment of the population to see doctors, nurses, and other medical professionals as the enemy. Doctors and nurses get regular death threats. Hospital staff take off their scrubs before heading home or going to the grocery store out of concern that they will be threatened or harassed. Grieving family members accuse doctors of deliberately killing their loved ones. Vaccine clinics are sometimes forced to shut down by mobs of protesters. All of that has had an effect on morale among health care providers.
According to a survey released in October 2021 by Morning Consult, 18 percent of health care workers have quit their jobs during the course of the pandemic, while another 12 percent have been laid off. Among those who have kept their jobs, 31 percent have considered leaving, citing pressures of the pandemic, feeling unsupported by their employers, and feeling burned out or overworked. (And that was before the omicron wave. While the survey hasn't been repeated, it's not unreasonable to assume that the situation has likely gotten worse rather than better.)
With a health care workforce that was already facing high rates of burnout even before COVID-19 struck, what is happening at all levels—from national initiatives to hospital and departmental programs—to help support clinicians' mental health and resilience? Neurology Today spoke with several neurologists leading wellness initiatives to find out.
New National Resources
One initiative that holds promise is the Dr. Lorna Breen Health Care Provider Protection Act, which Congress passed in 2021, several neurologists told Neurology Today. Dr. Lorna Breen was a New York emergency physician who died by suicide in April of 2020 in the midst of the first wave of COVID-19. Her family founded the Dr. Lorna Breen Heroes Foundation, which has become a force for well-being advocacy. Expected to be signed by President Joe Biden soon, the legislation will:
- Establish grants for training health profession students, residents, or health care professionals in evidence-informed strategies to reduce and prevent suicide, burnout, mental health conditions, and substance use disorders.
- Identify and disseminate evidence-informed best practices for reducing and preventing suicide and burnout among health care professionals, training health care professionals in appropriate strategies, and promoting their mental and behavioral health and job satisfaction.
- Establish a national evidence-based education and awareness campaign targeting health care professionals to encourage them to seek support and treatment for mental and behavioral health concerns.
- Establish grants for employee education, peer-support programming, and mental and behavioral health treatment, prioritizing health care providers in current or former COVID-19 hotspots.
- Establish a comprehensive study on health care professional mental and behavioral health and burnout, including the impact of the COVID-19 pandemic.
And in July of 2021, the Health Resources and Services Administration announced $103 million in grant funding to address burnout in the health care workforce, focused on “implementation of evidence-informed strategies to help organizations and providers respond to stressful situations, endure hardships, avoid burnout, and foster healthy workplace environments that promote mental health and resiliency.” Recipients of the grant funding were announced at press time, including many major academic medical centers.
The National Academy of Medicine, whose Action Collaborative on Clinician Well-Being and Resilience released a consensus report on burnout and clinician well-being in 2019, now offers a resource compendium for health care worker well-being, highlighting “strategies and tools that health care leaders and workers can use across practice settings to take action toward decreasing burnout and improving clinician well-being.”
The overarching conclusion of the consensus report, said Neil A. Busis, MD, FAAN, professor of neurology at NYU Langone Health, is still on target: “Fundamentally, burnout is a mismatch between job demands and job resources as filtered through an individual's strengths, weaknesses, support, and needs. But certain aspects take on a different meaning because of the pandemic. Issues like moral distress, shortages of resources and manpower were all significant before, but they are much more acute now. We have a good idea what burnout is and the actions we need to take, but the question is, how does COVID change the equation and what do we do about it?”
The Action Collaborative's COVID work group has two primary charges: first, to extend the literature review from the consensus study into the COVID-19 era, and also to consider personal experiences and “gray literature” such as news reports.
“Do we have to change our conceptual model and emphasize some things in a way we didn't before?” Dr. Busis asks. At a meeting expected to be scheduled in March 2022, the work group will seek input on strategies that have and have not worked for addressing burnout in the COVID-19 era. “Then our steering committee will propose a national strategy to Surgeon General Vivek Murthy, MD, who now serves as a co-chair of the Action Collaborative, and other leaders within the government.”
Make People Feel Valued
What's needed now at the hospital and departmental level to address these historic levels of burnout? It starts with keeping the lines of communication open and not making assumptions, said Jennifer Bickel, MD, FAAN, the senior member of the department of neuro-oncology and the chief wellness officer at the Moffitt Cancer Center in Tampa, FL.
“When we talk about burnout, people get very passionate about it and there's a lot of controversy. It's important to understand that burnout results from a combination of systemic and individual drivers, and it can rarely be reduced to one factor and one solution. What ends up happening is that when you create solutions that don't resonate with an individual, they think it's the ‘wrong solution.’ But the truth is that what people really need is to feel valued, recognized, that their own values align with organizational values, and that they are able to use their talents and their skills to the top of their abilities.”
Moffitt recently conducted a survey of approximately 800 of its physicians and nurse practitioners, asking them to rate about 20 different practices and interventions as to how much of an impact it would have on their sense of feeling valued.
“We created that list after I spent about 300 hours listening to doctors and APPs [advanced practice practitioners] talk about what would be most important to them in feeling valued,” Dr. Bickel said. “Right now it's not just the pure exhaustion and the moral injury, it's also the sense of not feeling valued by the public, by legislators, and by their own institutions. I don't know that we've ever truly understood what health care workers need and how they need to be valued. We need a more in-depth understanding of that.”
Of course, burnout doesn't just affect residents, junior, and mid-level clinicians. The departmental, division, and program heads who are seeking strategies to alleviate burnout are facing their own struggles. “We have to care for everyone, from front line workers to leaders and everyone in between, and realize that fatigue is universal,” said Rebecca Miller-Kuhlmann, MD, a clinical assistant professor of neurology and neurological sciences at Stanford University, where she is the well-being director for the department of neurology.
“But we do have to continue to take the time to acknowledge people. That doesn't ‘fix’ things, and some parts of this aren't fixable. But we have to continue both acknowledging the problem and having the conversations. Even if it's the 37th check-in you've done with your group, you have to keep doing them. What are their needs, what do they see as the barriers to having those needs met, and which things are we able to address? The goal of these check-ins should be to see what is solvable, and acknowledge what isn't.”
Early on in the COVID-19 pandemic, Stanford's WellMD & WellPhD Center held multiple listening sessions with 69 groups of physicians, nurses, advanced practice clinicians, residents, and fellows, asking what they were most concerned about, what messages and behaviors they needed from their leaders, and what other tangible sources of support they believed would be most helpful to them. An article based on their findings appeared on April 7, 2020 in JAMA; the needs it summarized are still relevant two years later.
They framed what health care professionals were asking for as a series of five requests:
- Hear Me: Listen to and act on health care professionals' expert perspective and frontline experience, by creating an array of input and feedback channels and making sure their voice is a part of the decision-making process.
- Protect Me: Reduce the risk of health care professionals' becoming infected with COVID-19 or transmitting the virus to family members, by providing adequate PPE, rapid access to testing, and accommodation for those at high risk.
- Prepare Me: Give training and support that allows health care professionals to provide high-quality patient care, with rapid training, appropriate backup, and access to experts—while always acknowledging that everyone is experiencing novel challenges and no one needs to make difficult decisions alone.
- Support Me: Provide support that acknowledges human limitations in an extraordinary time. This includes support for both physical needs (access to healthy meals and hydration, lodging and transportation assistance, support for childcare and assistance with other tasks) and psychological/emotional needs, including psychological “first aid” for all delivered via tools like webinars as well as individual support for those in greater distress.
- Care for Me: Provide comprehensive support for individuals and their families who need to be quarantined, including lodging support, paid time off, support for tangible needs like childcare, and emotional support and frequent check-ins.
This framework helped spur a series of actions and interventions. “They increased our childcare backup benefits and became more flexible with how they could be used. They added staff who call any clinician who gets sick and connects them with resources,” said Dr. Miller-Kuhlmann.
Stanford also provided no-cost housing for health care workers who required quarantining because of exposure, as well as for faculty and staff who did not test positive but desired to live away from family while working with COVID-19–positive patients, had short cycle times between shifts, had long commutes to the hospital, or had other reasons why they needed to live away from family (such as family members with high-risk health conditions). “All of this went a long way toward our feeling valued instead of like some expendable resource.”
Practically speaking, what is done to ease the burden of the pandemic on health care professionals depends on the structure of the institution.
“Some chairs have more power of the purse, or over resource shifting or scheduling, than do others. And each division has different needs,” said Dr. Busis. “But at every institution, there are a few things we can all do, and it starts with this: as a leader, you have to be on the side of your people. No one is restricting your ability to empathize, bond, and engage. If you can empathize with your people, you can create a culture of wellness even if resources are constrained and really bad things are happening that are out of your control. Everything we're going through is more palatable if you're not alone, and you have colleagues who have your back as best they can. Even if you've got nothing else, you've still got each other.”