As COVID-19 surges and recedes in different parts of the country, the one thing that remains consistent is this—the pandemic has brought tremendous stress on neurologists and other heath care workers—whether they are directly caring for patients with COVID-19, or have had their jobs and lives disrupted by changes in the way they worked.
Chethan P. Venkatasubba Rao, MD, FNCS, section head of neurocritical care and vascular neurology at Baylor College of Medicine in Houston, is one of them. He recalled it was that 54-year-old patient he saw in the neuro-ICU early on that underscored that stress. For the first eight hours of care, the patient was relatively stable, said Dr. Rao, who was at bedside.
"I saw this patient go downhill so fast. He required not one critical care provider, but about four intensivists, including neurologists, cardiovascular specialists, and even surgical intensivists," Dr. Rao explained.
"You could not anticipate what's coming next, especially with the initial wave of COVID patients; you had to be on your toes," Dr. Rao said. "Dealing with these extremely challenging cases can be kind of jarring," Dr. Rao added.
"And then imagine, not being primarily trained in medical critical ICU management and then having to learn all these advanced skills on the job," he said.
"We had to make treatment decisions on the spot as there is no proven literature and no obvious methodology to treat so that can be a second layer of stressor for the providers," he told Neurology Today.
Then, he added, we had to go home to our families and worry about possibly getting them sick. "We are health care providers, but at the same time, we are just regular people too."
Amid the COVID-19 pandemic, neurologists and other clinicians are seeing more patients, working longer hours, and juggling family obligations—and they are experiencing burnout, depression and post-traumatic stress disorders.
In interviews with Neurology Today, neurologists and researchers discussed the ways in which their institutions have responded to increased demand for mental health support by bolstering and launching programs to help neurologists and other front-line workers as they navigate the demands of the COVID-19 pandemic.
UCSF: Caring for Caregivers
This is a stressful time for not only attendings but also for trainees as well as fellows, residents, and medical students who are on the front-line caring for patients, said S. Andrew Josephson, MD, FAAN, chair of the department of neurology at UCSF.
Financial strains and the inability to carry on business as usual caring for patients during the pandemic has added to this stress for neurologists—whether they work in academia or community practice, Dr. Josephson said.
Dr. Josephson pointed out that UCSF has long had a number of resources and initiatives aimed at decreasing burnout and helping clinicians cope with trying times in the hospitals but once COVID-19 started the department of psychiatry developed a number of resources for front-line workers.
The UCSF psychiatry department teamed up with the UCSF Center for Digital Health Innovation and Human Resources to establish a new initiative for UCSF staff, trainees, and faculty called the UCSF Employee Coping and Resilency Program.
The program uses a confidential online assessment tool to connect UCSF employees to a number of emotional support services such as interventions for people that required specialized help, timely acess to online clinical treatment and evaluation for individuals with moderate to severe symptoms, and a curated trove of online self-management resources like videos, webinars, and apps.
As a leader in his department, Dr. Josephson worked hard to create a culture in which honest conversations were welcome, so that all his team members could feel comfortable opening up about any concerns surrounding mental health and well-being, he said.
"We're really lucky locally at UCSF to have a culture for many years that cares for our caregivers—but when I look nationally, clearly there is a major issue throughout all of medicine to ensure our doctors are well, because ultimately if we're not well, how are we going to provide good care for our patients?"
Another UCSF program, "Caring for the Caregiver," was launched in 2017 to help clinicians and staff deal with the emotional strain of patient care by providing them support and resources. With COVID-19, it became clear that the need was more acute than ever. The program has seen a rise in the number of people seeking one-on-one support since COVID-19.
One of the program's signature initiatives is a peer-support program. "When we realized that COVID was coming and that people were feeling a lot of stress related to what was unknown and what might happen in terms of their clinical environment, we thought it would be a great time to start working with our peer supporters in different clinical areas," said Kiran Gupta, MD, MPH, the medical director of patient safety and Caring for the Caregiver at UCSF.
The peer suporters are volunteers who are trained to meet with staff, as needed, from numerous clinical experiences, areas, and departments, including pharmacy, physical therapy, nursing, social work, hospital supervisors, spiritual care, and respiratory therapy.
In most cases, through the COVID-19 crisis, peer supporters opted to hold weekly check-in meetings for their team members, Dr. Gupta added.
For a large organization, it can be difficult to know what an experience will be like for a particular individual or clinical setting, emphasized Dr. Gupta. "But you can train people who work in different clinical areas throughout an organization to have some heightened awareness for what things might happen that could be hard for their team members, what to say in the moment, and to be knowledgeable about all the support resources available," she said.
"You can start to really normalize the stressful reactions that people have and get them the support they need. This can promote resiliency at work and help mitigate burnout, which does take a huge toll on those working in health care," Dr. Gupta continued.
To help its health care providers cope with the pandemic, the University of North Carolina has offered a range of supportive programs, including mindfulness training and weekly support groups, said Jason Tuell, MSW, LCSW, a clinical social worker at the university. In addition, the university offers a cache of resources—including everything from financial aid resources, child care support, to tools for coping with loss, Tuell explained.
"It's intended to not only refer a person to a specific resource, but also to offer a brief intervention to help support someone through what may be a moment of distress, where it's not quite pushing them to visit a primary care provider or go in for maybe a visit for mental health. But they know that they need a warm voice in somebody to talk to and share what's going on," Tuell told Neurology Today.
Tuell said several people within his department were pulled aside by clinicians for support and guidance as they struggled to cope with all of the stress and general work fatigue associated with COVID-19—stressors related to not knowing what to do, dealing with rigorous and strict protcols around infection, or the challenges of triaging patients. These incidents prompted the department to develop a hotline, he said.
The Healing Heroes Hotline, which has been in place for a few months, aims to address more acute incidents of distress, Tuell noted. It is a call-in resource offered weekdays from 8 am to 7 pm to UNC health professionals across the state. Through the helpline, health professionals are connected to a mental health worker that will assist them by referring them to resources, connecting them to confidential faculty run support groups, offering skills-based consultation, or a direct referral to the appropriate therapy.
Aware of the stigma around seeking mental health support as a health care professional, Tuell noted that the hotline is completely confidential and free so there is no contact with insurance.
Communication and Compassion to Strength Teams
Burnout has affected both nurses and physicians, noted Dimitri Krainc, MD, PhD, chairman of the department of neurology at Northwestern Memorial Hospital in Chicago. Nationally, there has been an increase in depression and suicide among health care workers, Dr. Krainc explained.
Across the board both the general public and health care workers have limited access to mental health care because of the COVID-19 pandemic, noted Dr. Krainc. "There is normally a shortage of mental health care professionals that was only exacerbated by the COVID pandemic," Dr. Krainc told Neurology Today.
The initial shortage of personal protective equipment led to fear and anxiety among some health care workers, Dr. Krainc explained. However, once there was an adequate amount of PPE, things quickly improved, he added.
In the neurology department, we foster a community for engagement through very open communication in a number of ways, Dr. Krainc emphasized. "Sometimes these difficult times can serve as a very strong unifying force, for people to pull together and to work through things together."
Dr. Krainc pointed out that navigating challenging times like these requires compassion, open communication, and flexibility especially for people arranging care for child. "In addition to that, we have services that are dedicated to health care professionals that have mental health problems to help them out."
"If people are engaged, if we have communication and use this difficult time as an opportunity to get more unified, to get more engaged with each other, and really to focus on our values and commitment to serving our patients, and to helping each other, that's the day to day activity that will have a positive impact on the post-COVID situation," he said.
Not taking this approach during the pandemic, could lead to problems later, Dr. Krainc noted. "We take this very seriously, and we try to prevent any PTSD that would occur post-COVID. Hopefully, we will be successful, but I can't predict that right now."
Supporting Trainees During the Pandemic
In mid-March, neurologists at University of California. Los Angeles (UCLA) had their first COVID-19 positive stroke case. The residents and the stroke team went into the emergency department and noticed evolving use and application of PPE, noted S. Thomas Carmichael, MD, PhD, professor and chair of neurology at the David Geffen School of Medicine at UCLA.
In some cases, the application of PPE was not quite clear in the setting of an acute stroke case, with patient transport to adjacent imaging sites and then back again. Residents were at the front lines of this situation and had questions that required fairly immediate actions, Dr. Carmichael noted.
Some of the non-COVID-19 causes of stress and burnout have been exacerbated by the pandemic, he noted. "The two main things are essentially a lack of local control in those two areas and possibly anxiety over ultimately getting the disease and not knowing how to completely eliminate that possibility," Dr. Carmichael told Neurology Today.
UCLA has offered wellness classes, free lunches, sponsored coffees, and dedicated town halls to express concerns to the leadership in an effort to support clinicians through these difficult times, noted Dr. Carmichael.
For clinicians who are apprehensive about stepping forward to use such resources, Dr. Carmichael suggests, that there be an opportunity for "a critical, open and unencumbered listening session" for faculty and staff. Many times these sessions need to be done privately and anonymously through anonymous surveys and in some cases in a town hall setting. This creates an opportunity for leadership to understand what's producing the burnout or mental health issues among faculty and staff, he emphasized.
From there, Dr. Carmichael recommends operationalizing the information in a second phase by offering meditation, small discussion groups, stress and resiliency training.
Within his department, Dr. Carmichael's faculty, staff and institution have offered mindfulness, well-being, and yoga sessions for neurology trainees and neurology faculty. However, the attendance hasn't been ideal, so efforts are underway to ensure things are more individually tailored, he explained.
Baylor University's Dr. Rao pointed out that sometimes the simplest of gestures can assuage stress. He pointed to a local high school student who started an initiative through which local restaurants that were closed down due to the pandemic provided hot meals for health care workers.
"A warm bowl of pasta in the middle of your work, because all the restaurants are closed, can make a big difference. Sometimes we used to go eight to 10 hours or 12 hours without drinking or eating because you don't want to scrub in and out and you don't want to go home for a bite. So that small bowl of pasta really does make a big difference," he said.