Expert Roundtable: Physician Burnout During COVID-19

Since the start of the coronavirus disease 2019 (COVID-19) pandemic, physician burnout has been exacerbated largely due to factors that have previously been linked to increased burnout among providers.¹

In a study published in Clinical Infectious Diseases, Monisha Sharma, ScM, PhD, acting assistant professor in the department of global health at the University of Washington, in Seattle, Washington, and colleagues conducted a survey of clinicians caring for COVID-19 patients. The 1651 respondents were comprised of 47% nurses, 25% physicians, 17% respiratory therapists, and 11% advanced practice providers from all 50 states.²

In another study published in September, authors conducted a cross-sectional survey of 2707 healthcare providers from 60 countries.¹ The rate of reported burnout, measured by emotional exhaustion, was 51% in April. The highest rate (62%) was observed among US providers. Factors associated with burnout included work impacting the ability to perform household activities (P <.001), feeling pushed beyond training (P <.001), exposure to COVID-19 patients (P =.005), and making life-prioritizing decisions due to supply shortages (P =.03).

Other findings have shown elevated rates of burnout among providers in a range of settings, from academic emergency medicine physicians in the United States to medical residents and fellows worldwide.^3,4

To explore these issues and potential solutions in-depth, we interviewed Dr Sharma and Charlene M. Dewey, MD, MEd, MACP, the Joseph A. Johnson, Jr., Distinguished Leadership Professor, assistant dean for educator development, director of both the Educator Development Program and the Center for Professional Health at Vanderbilt University School of Medicine in Nashville, Tennessee, and professor of medical education, administration, medicine, and public health at Vanderbilt University School of Medicine. Dr Dewey coauthored a recent paper published in the Annals of Internal Medicine on the topic of supporting clinicians during the current pandemic.⁵

What is known about the impact of the COVID-19 pandemic on physician burnout?

Dr Sharma: Prepandemic levels of burnout in healthcare providers were already high, and the COVID-19 pandemic is further exacerbating provider burnout by adding the stress of rapidly shifting and uncertain hospital policies, scheduling changes, worries about insufficient resources, long hours, and occupational hazards. Healthcare providers report feeling powerless against a virus with no effective treatment and distressed by watching patients die alone. Many are worried about spreading the virus to their loved ones.

Our research shows that provider burnout was associated with reporting a lack of resources, poor communication from supervisors, and social stigma from the community. Insufficient access to PPE was particularly strongly associated with healthcare worker burnout, and those with a higher workload of COVID-19 patients also faced higher risks of burnout.²

Not surprisingly, having access to PPE is crucial to provider well-being, as it is likely associated with feeling supported by one’s institution and feeling safe during high-risk patient interactions. Providers reporting insufficient access to PPE were more likely to worry about transmitting COVID-19 to their families and to report concerns that the hospital was unable to keep them safe. Similarly, a lack of ICU beds and insufficient staffing, particularly a lack of ICU nurses, was associated with burnout. 

Healthcare providers are also reporting increasing levels of social stigma from their communities. While being portrayed as heroes of the pandemic, they are simultaneously facing ostracism from social gatherings, neighbors, playdates, and other activities because they are perceived to be at high-risk of COVID-19 infection. This can compound the feelings of social isolation due to long work hours and distancing guidelines. The most common concern reported by providers was worry about carrying the infection home to family and community, which was more frequently reported than worries about contracting the virus themselves.

Dr Dewey: Initially, some physicians found a great sense of purpose in assisting in the pandemic, and having a strong sense of purpose is vital for resilience. However, as time continued, the same system challenges exist, but new threats were imposed to individual and family safety, finances, and job security. Everyone’s regular routines – physicians and others – were disrupted in a significant and prolonged way. Routines at home and work were disrupted and that caused chaos for some families, especially for those with dual physician-led homes and younger kids.

All of these new challenges were imposed upon the usual challenges and thus added significant stressors suddenly. These events increase the chronic stress and factors that lead to burnout, especially when there is no control over the events.

What measures could help to reduce burnout and better support physicians during this time and after the COVID-19 pandemic?

Dr Sharma: Adequate PPE, staffing, and clearly communicated hospital policies may lessen the mental toll of COVID-19 and future pandemics on healthcare professionals on the front line. Targeted interventions for hospital leadership can improve communication and convey expectations regarding rapidly shifting protocols. Streamlining hospital communication can improve accuracy and consistency of information. Hospital leadership should provide frequent and honest information and acknowledge uncertainty around decision making. This can reduce inefficiency, renew motivation, and foster the feeling that providers are cared for by hospital management.

Hospitals should employ work schedules that account for patient workload in addition to hours worked because a high caseload of COVID-19 patients is associated with burnout. Implementing a culture that promotes the value of self-care, not as self-serving or a sign of weakness, but as a necessary and ethical response to ensure high-quality care for patients, can encourage providers to take time for their own health.

Providing resources for mindfulness meditation and self-compassion exercises can help lessen feelings of helplessness when caring for critically ill patients and soften the pain of social stigma and isolation. Structured peer support and therapist availability can help reduce feelings of emotional distress before providers become burnt out.

Ongoing assessment of provider wellness can proactively address concerns amidst rapidly evolving pandemic-related challenges.

Dr Dewey: Let’s look at this from an individual and organizational approach. At the individual level, focus on eliminating all non-essential work and activities so you have time to focus on the 4 strategies that support resilience, including self-care. Eat healthy foods and get plenty of sleep, which may require altering home and work activities if needed. Engage in physical activity, even just taking walking breaks when you can. Walk with the family, and have fun engaging in other physical activity with colleagues and family that are socially distanced and safe.

Lastly, use mindfulness practices in prayer, meditation, resting when transitioning into sleep, between patients, etc. Sometimes just stopping to take some deep breaths and reflecting on something you are grateful for allows your catecholamines to calm down when stressed. Also, look for those sources of stress and burnout, and try to address them early.

On the organizational level, people need to feel valued, appreciated, and supported. All leaders should tell their teams – and teams should tell each other – how much they are valued and give encouragement. Find the stressful points in the day or system that can be improved to make the days efficient and easier to allow physicians to focus on what they love most, such as caring for patients, conducting their research, and engaging in educational activities.

I have a quote from the Harvard Leaders in Education Program in which the late Clay Christianson said during a presentation, “Make the right thing to do be the easiest thing to do.” It has become one of my mottos because everything required of the physician should be easy to do. Leaders should get them training if they need skill, use examples and models that are easy, and keep processes simple. Supporting their long work hours by providing snacks and beverages and schedules that give the physician downtime is critical.