COVID-19 has taken—and continues to take—a tremendous toll on physicians and other health professionals around the world. While physician burnout has been an ongoing problem in the medical community, the pandemic has, unsurprisingly, exacerbated the situation. As physicians continue to face long hours and an unrelenting patient load, there is an urgent plea for support: Health systems must ramp up their support systems, placing well-being as a top priority moving forward.
For AMA member Heather Farley, MD, chief wellness officer at ChristianaCare in Wilmington, Delaware, that means being in the trenches with her colleagues to better understand their evolving needs. Read about the six ways ChristianaCare attacks stress during the COVID-19 crisis.
During a recent interview, Dr. Farley discussed her outlook for the pandemic’s second year as well as how health systems can continue to address physician burnout and the ongoing stress COVID-19.
AMA: What challenges to professional well-being have you seen at ChristianaCare during the pandemic?
Dr. Farley: COVID-19 has absolutely, profoundly affected the way that we're practicing and working. Now we're communicating through masks, we're caring for patients who are separated from their loved ones and witnessing more suffering and more dying.
I've heard this described as a perfect storm for psychosocial traumatic stress. From the obvious direct threat to our lives, as well as the lives of our loved ones, to the rapidly changing protocols—which is a big one; physicians are feeling like they're practicing medicine on the fly without a playbook. It's definitely gotten better over the last few months. That was pretty acute at the beginning of the pandemic where we're just trying to figure it out as we go along.
We know how to treat this much better than we did before, but that was definitely a huge stressor at the beginning, in the acute phase of the pandemic. All of that leads to clinicians sometimes feeling like we’re not giving the care that we're used to providing and we are definitely seeing some moral distress, and moral injury as a result of that.
AMA: How has that changed now that it’s been a more than a year since COVID-19 was first reported out of China?
Dr. Farley: COVID fatigue is real. Our clinicians are tired. We’ve been at this a while without a break and it's definitely taking its toll. We're seeing clinicians put their heads down to get through it on adrenaline, but that adrenaline runs out and all of your coping mechanisms and reserves are depleted. People are tired—physically tired, mentally and emotionally tired, and still trying to process the continued trauma that they're exposed to.
It’s not easy, but despite all of these stressors, our clinicians are still persevering and delivering great care
AMA: What support resources have been helping physicians and other health professionals the most during this crisis?
Dr. Farley: The framework that we've been using to support our caregivers during COVID-19 was built around those principles from the JAMA article [“Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic”] that Tait Shanafelt, MD, Jonathan
Ripp, MD, and Mickey Trockel, MD, co-authored—the hear-me, protect-me, prepare-me, support-me, care-for-me, and honor-me model.
There are two components that are really helpful to highlight to get a flavor of what the major components are for us that we've been relying on. The cornerstone of our approach has really been rounding. Members of my team in the Center for WorkLife Wellbeing are conducting intensive in-person rounding of front-line health care providers on all shifts, with a heavy emphasis on the COVID units, the emergency departments and the areas that are supporting those units.
The purpose is threefold for the rounding. First, it's to supply basic well-being needs. We push around a cart with food, drinks, and comfort items like ear protectors, lip balm and hand lotion. It's less about what's on the cart, though. What's on the cart is sort of more of an entry into a deeper conversation with our caregivers.
The second part of why we do the rounding is really to be consistent with disaster mental health best practices. We're not waiting for people to raise their hand and say, “I'm in trouble and I need help,” and waiting for them to access resources. We're proactively bringing those resources to them, reaching out to provide in the moment support, finding out how they're really doing and supporting them in real time. Then we serve as a direct pathway to get them connected to more intensive mental health services or peer support if that's what they need. And the third purpose of rounding is that it really helps us elicit concerns and unmet needs. That's reminiscent of the hear-me component of the approach. When we're rounding, we're asking our clinicians what they need. We're able to identify concerns that require escalation to either local leaders or system level leaders. It's led to so many countless system changes like prepaying of child care, providing scrub service, a changing area and the creation of a caregiver relief fund early on in the pandemic. Rounding and listening to unmet needs has helped us to know how our caregivers’ needs are changing over time during the pandemic and to adjust our approach.
AMA: But you’ve also found that a big boost comes when physicians, nurses and other health professionals help each other through your peer-support program. Tell our readers more about that.
Dr. Farley: It has been really an integral part of our response during COVID. ... What we do in health care is not normal, and that's especially true right now. After those traumatic cases, the times when it hits a little bit too close to home, what's been shown to be really helpful is true peer support. Yes, therapists and counselors are absolutely helpful, but what clinicians often say that they want and need in these times is peer support from someone who's been in their shoes to help them process some of the difficult emotions that they experienced after those events.
We now have over 70 volunteer trained peer supporters in a variety of roles and disciplines. Many of those are physicians and advanced practice clinicians (APCs) as well as residents, but we have peer supporters in all different roles as well. What's really unique about our experience is that many of my colleagues in other health systems are reporting that they're very frustrated because they put all these support resources together and people aren't using them. There's a myriad of reasons why physicians and APCs might not be accessing the support resources that are out there, but it's definitely frustrating for leaders who are putting these support resources forward and then having them not be utilized. But our experience was exactly the opposite of that. We actually had a threefold increase in individual peer-support encounters and a 10-fold increase in group support requests during the acute phase of the pandemic versus our baseline. We were already doing 500 a year, so having that much of an increase was a huge uptick.
That utilization really speaks to the importance of having a robust system in place. It's a system that is trusted and it's hardwired in and seen as a natural go-to during times of crisis. So it just made sense for our caregivers and our leaders who were seeing distress and experiencing distress to say, “Oh yeah, we've got care for the caregiver and of course that's where we're going to go.” It also speaks to the importance of proactively reaching out to offer support.
We are very fortunate to have a culture where we've decreased the barriers to help-seeking behavior, which leads to that really impressive utilization. That's going to continue to serve us well as we're moving into the next phases of the pandemic. Clinicians are needing to continue to process some of the difficult experiences that they've had. That processing is going to be super important in helping them decrease the likelihood of developing chronic stress reactions.
AMA: As we navigate 2021, do you expect to see more long-term effects with physician burnout and post-traumatic stress disorder (PTSD)?
Dr. Farley: For many months people had their heads down, but they're now starting to process what they've been experiencing. One of the important points is that clinicians everywhere are struggling. But those who have access to support resources, who work in health systems with that robust well-being infrastructure in place or have a way to access support by other means—they have a better shot at healthy coping and recovery, and they're less likely to experience chronic suffering like PTSD and burnout.
AMA: Do you have plans set for this year to address the long-term effects of the pandemic?
Dr. Farley: Continuing to provide the services that we have been, considering that we're still in record numbers of COVID patients, is going to be essential, but also starting to plan what the next phases of the pandemic will look like. We're hopefully winding down in the near future and at some point, it's important for us to start thinking through how we help people make sense of what has happened in our country, in our health systems, in their practices, with their patients and teams. How do we help them to experience and strive for post-traumatic growth? Again, making meaning around what has happened is an essential part of that.
For example, one thing we have discussed is that we have anniversaries coming up. We've learned from 9/11 and the experience with first responders in New York City that it is important to attend to anniversaries and to help people develop rituals where they're able to process and mark those anniversaries in a meaningful way. We’re approaching the one-year mark of the first COVID patient that we had in our health system. It’s not a happy anniversary, but how do we mark that for people, give it the attention it deserves, and honor the import that has in people's lives?
Then, thinking about what we can and should hold on to, what have we learned during this period that we want to bring with us into our future practice? Those are some of the things we're starting to think through, tapping into experts in trauma-informed care to help us create those experiences for people so that they have the best shot at healthy coping and recovery.
AMA: You took part in the AMA 2020 Joy in Medicine CEO Consortium where leaders covered six areas health systems need to focus on long after the pandemic ends. What should leaders do next to support the well-being of physicians and other health professionals?
Dr. Farley: One of the important things to keep in mind is that there were all these preexisting stressors— burnout, compassion, fatigue, moral injury and moral distress—before the pandemic. Now that's potentially all even worse. All of the stuff that caused distress before is still there, so we still need to attend to that and attend to how the pandemic has added on another layer. That work really needs to start now.
Executive leaders should embrace the idea that we need to fix the coal mine and not just the canaries. You can't take the canary and teach it to be more resilient and stick it back in the same coal mine and expect it to survive. You actually have to change the coal mine. That means changing the environment surrounding the clinicians, fostering a culture of well-being and removing inefficient administrative burdens, for example.
Then second, for executive leaders it's really important to understand that you have to build it carefully. If you build it, they might not come. Oftentimes the first go-to for support services is around employee-assistance programs. Employee-assistance programs are not enough. They're essential, but not enough.
We need to really think about how we can build a truly effective well-being program that clinicians will actually use and that requires a much more comprehensive multimodal approach.
Fundamental to implementing an effective well-being program is having the support of an enlightened executive team who embrace clinician well-being as a critical success factor for their organization. That requires financing a robust well-being infrastructure. Yes, it takes money. You can get creative, but it takes staffing, a budget and political backing. It has to be a commitment by the organization to clinician well-being. That also includes making clinician well-being a key quality metric for organizations, something that we measure, we track and we hold ourselves accountable for just like quality metrics, patient experience scores, or financial margins.
Every storm runs out of rain and this too will pass. Not fast enough, but it will pass. Consider arming yourselves and your teams with psychological first aid training resources so leaders can recognize—and teams can recognize—early warning signs of distress and employ effective support strategies. That's something that we've done. We have recurring monthly training for leaders in our health system on psychological first aid.
We've trained 200 leaders so far on psychological first aid and that's been really instrumental in helping them feel equipped to respond to the distress that they're seeing in their teams. Right now, clinicians really need to work in an environment where it's okay to not be okay, where we can talk about our distress with our colleagues, with our leaders and know that many of us will need and benefit from support resources.
Then, finally, remembering that you're also a role model for your team. It's important to attend to your own health and well-being—taking time to breathe, decompress, recharge, get away for breaks while also meeting your team. That's super important.
AMA: What else should physicians and others be thinking about in terms of pandemic stress and burnout?
Dr. Farley: Remember that there's reason for hope. For many clinicians, the availability of the vaccine feels like the first real sign that there is indeed a light at the end of this very long tunnel. We still have some difficult months ahead of us, but there's hope that we're going to get through this and get through it together.
There's a quote by Judith Herman, MD, that I really like, “The solidarity of a group provides the strongest protection against terror and despair, and the strongest antidote to traumatic experience.” We are seeing evidence of our clinicians tapping into that collective strength to get through this together and feeling inspired by each other and by the dedication and love that we're demonstrating to one another and to our communities that has really helped carry us through and will help carry us through the next phases.
