Coverage of the current COVID 19 pandemic has highlighted our dependence on frontline healthcare personnel in emergency departments and intensive care units (ICUs). These clinicians are typically high achievers who are passionate about their work. They usually take pleasure in possessing the energy and enthusiasm that their jobs require and having the knowledge to make the swift decisions necessary to keep someone alive. They like being proficient in cutting-edge technical skills that make a difference in life-and-death situations. Furthermore, these sorts of intensive care doctors and nurses tend to be perfectionistic and possess high standards for the care they provide. Sadly, these desirable traits make them more susceptible to burnout.
The current COVID19 pandemic is challenging our frontline health care workers in new ways. This pandemic has necessitated that they work longer hours than usual, while continually stressing over the availability of necessary equipment. They are handicapped by higher workloads, difficult schedules, lack of days off, constant interruptions, and delays. These factors commonly exist within their world of emergencies and critical care, and as a result, these kinds of providers have experience ramping up for disasters, such as hurricanes, mass shootings, major floods, or multi-vehicular trauma. They know from experience how these situations play into the normal ebb and flow of hospital emergencies. However, the current situation—our COVID19 pandemic—differs significantly from other emergencies we have endured by the types of patients we see and by the moral distress we feel.
Our emergency and critical care providers are reporting the trauma of witnessing the deaths of their peers—fellow doctors and nurses, the deaths of their own family members, the unexpected deaths of young, healthy adults, and the lonely deaths of older Americans who are without family members by their side. Our intensive care clinicians are hindered by the personal protective equipment (PPE) they must wear to protect themselves. This PPE serves as a constant physical barrier between them and their patients. Lost is the ability to personally touch your patient. Your patients can neither see your eyes nor appreciate the look of genuine care or concern on your face.
Perhaps most importantly, these current pandemic emergencies differ by the moral distress our caregivers feel. This distress is caused by the fear of contracting the virus, the fear of transmitting the virus to their family members or their children. Save for working in a war zone, no other emergency causes such fear of being “in harm’s way.” (New York Times 5-4-20)
In 2018, the AMA physician survey found the highest prevalence of burnout among certain medical specialties: critical care (48 percent) and emergency medicine (45 percent) were among the top five specialties. The National Academy of Medicine, in its October 2019 report, “Taking Action Against Clinician Burnout,” estimated that 35 percent of U.S. nurses and 54 percent of U.S. physicians have substantial symptoms of burnout. Unfortunately, burnout feeds on energy, enthusiasm, passion, and compassion, those qualities most notable in emergency & intensive care providers.
The causes of burnout among today’s physicians and nurses delineated by the National Academy of Medicine report include excessive workload, inadequate staffing, unmanageable schedules, obstructions to workflow, interruptions and distractions, administrative burdens, and inadequate technology usability (electronic medical records). Patient factors and moral distress also contributed.
There is a psychological continuum between chronic stress and burnout. Physical and emotional exhaustion—one hallmark of burnout—are not recognized immediately. Their onset is more subtle, even insidious. First, one notices a lack of energy; you feel really “tired.” This fatigue leads to feeling drained or depleted, as if you are “running on empty.” You may notice symptoms of anxiety, panic, or insomnia. You may notice impaired concentration or an inability to focus while working in the emergency department or ICU. Some people develop headaches, become irritable, or display angry outbursts at co-workers. Appetite may be poor. Anxiety may lead to feelings of guilt over not being able to do enough.
In this pandemic, another symptom of burnout—detachment—may be exacerbated by pessimism (lots of people are dying) and feeling disconnected (the awkward PPE barrier between you and your patients). Detachment among healthcare workers is worsened by a lack of enjoyment (this emergency is draining, not invigorating). Remember that critical care providers are generally passionate about taking care of extremely ill patients. We typically think the ICU is not only challenging but also exciting.
The final indication of burnout is feeling ineffective, or no longer making a difference. Fighting a systemic and overwhelming viral infection that is not well understood, one that destroys major organ systems, and one without an effective treatment, is not enjoyable, and it is certainly not fulfilling. Oftentimes it even feels futile. This can lead caregivers to feel hopeless, like nothing they do matters. Finally, they may wonder, “What’s the point?” Apathy in medicine is well known to lead to poor performance and medical errors.
In May 2019, burnout was redefined as a syndrome linked to chronic workplace stress by the World Health Organization in its International Classification of Diseases (ICD-11). A recent meta-analysis of research evidence from neuroscience, behavioral psychology, and psychiatry indicates that burnout and depression symptoms overlap greatly. The emotional exhaustion component of burnout involves fatigue and depressed mood. Other symptoms of depression, such as loss of emotional involvement, irritability, and disengagement, all occur in burnout.
After 33 years of practicing neonatology, the intensive care of premature and critically ill newborns, I suffered from burnout—the full syndrome. It snuck up on me slowly, insidiously. I recognized it once I finally showed all the symptoms and caught myself actively dreading heading into the neonatal ICU for my shift. I was working too many hours and taking too much night call in the hospital. Over the final years of my practice I grew weary of seeing bad things happen to little babies. I had stood by too many premature infants while their parents and I watched them breathe their last breaths. I had helped too many families decide when the time was right to remove their baby from the ventilator. I had counseled too many parents facing imminent delivery of an extremely premature baby at 23- or 24-weeks’ gestation.
Most notably, when I suffered burnout, I no longer felt that I was making a difference (even though I was). I grew pessimistic and cynical, and my burnout felt exactly like depression. Fortunately, I was not suicidal; some physicians are. Nor did I abuse drugs or alcohol, as many physicians do. More importantly, it took me nearly two years to fully recover. And my burnout did not involve any feelings of fear or guilt; theirs will. Perhaps their burnout will resemble post-traumatic stress disorder (PTSD), much like that seen in so many of our returning soldiers.
So why inform you, the public, of all this? Why should you know about burnout in our healthcare clinicians? Because those brave frontline healthcare workers—our loved ones—will need help with healing and time to heal once they emerge from this pandemic. Whether they are showing signs of burnout, depression, or PTSD, they will need all of us, their friends, their co-workers, and their families to understand, at least partially, what they have been through.
We may be able to recognize the symptoms that they refute. They may say, “I’m fine, just tired.” They may say, “I don’t need to talk to anyone. I just need some down time.” They may say, “I just want to be alone,” or pour themselves a drink. These efforts to deny the problem, or to cope by isolating themselves, or drinking, are counterproductive. Remember that physicians are at a higher risk for suicide than all other professional groups.
What can we do to lessen their burden? Celebration of successes—a positive reinforcement of their medical effectiveness—is already happening throughout the country. We all happily watch on TV as medical personnel discharge home their surviving and recovering patients amidst applause, signs, music, and balloons. Clapping, singing, and praise from your balconies during shift change gives them inspiration to press on. Other solutions might include improved peer support within the hospital. When there is time, peer gatherings should be encouraged via debriefing sessions, coffee breaks with snacks, or dinners brought into the hospital. A study at the Mayo Clinic found that facilitated small group discussions and other techniques promoting physician solidarity were helpful to diminish symptoms of burnout.
Family members will want to promote their loved ones’ self-care, such as taking time for adequate sleep, exercise, escapes into nature, playing or enjoying music. Other helpful practices include meditation, mindfulness, massage, or yoga. Currently, it may be difficult to incorporate these into a seventy to ninety-hour work week, but these techniques are usually helpful to provide work-life balance. I joined a handbell choir at my church. Despite being a below average musician, playing and hearing the gorgeous music immediately carried me away from all my worries and dreadful feelings.
Talking with a trusted supervisor or mentor at work may be helpful. However, some of our loved ones will need psychotherapy—work with a psychiatrist, psychologist, or other trained mental health counselor. The importance of mental health support cannot be understated. Listening to and understanding people who live with burnout allows them to unload some of their pain. Burnout is a real affliction, one with serious consequences, and one that should not be ignored. Our frontline healthcare workers are giving their all to fight this pandemic and to save as many lives as possible. They deserve no less from us.