HealthJune 24, 2020

Clinician well-being: An ongoing conversation

By: Stacia Dearmin, MD

COVID-19 has presented additional challenges to clinician well-being. Read about the causes of physician burnout and steps to physician wellness.

Donovan is a young emergency medicine physician from southern Michigan. Four years ago, when he completed residency, the hospital where he trained offered him a well-paid, full-time position, and despite the distance from family, he chose to stay on in New York City.

Back when he signed on, no one could have predicted what 2020 would have in store. Despite attending lectures in residency on clinician well-being, Donovan never could have imagined feeling so powerless to avert patients' deaths, and, like many of his colleagues, he finds himself physically exhausted and emotionally depleted. He often thinks about his father and his aunt, his favorite physician role models, and wonders whether they have ever felt as overwhelmed as he does right now. Despite his commitment to his specialty and the community he and his colleagues serve, he often finds himself lonely and longing to return to the warmth and safety of family and home.

Sixteen years Donovan's senior, his aunt Eliza marked her 50th birthday quietly in the midst of quarantine. A long-awaited beach vacation with three college friends wasn't meant to be. The crushing impact of COVID-19 on her three-physician practice discourages Eliza, a hard-working general internist. She deeply feels the disproportionate impact of the disease on her urban patient population, not to mention the crippling financial impact on the office. The burnout Eliza has felt simmering for several years has now reached a boiling point. She finds herself angry much of the time, even with her patients, and feels guilty to find herself dreaming about early retirement in the midst of the pandemic.

COVID-19 and physician well-being

Prior to the arrival of COVID-19, the U.S. healthcare community had been engaged for well over a decade in a discussion regarding physician burnout, with its hallmarks of emotional exhaustion, depersonalization and loss of our sense of personal accomplishment. As Donovan and Eliza's stories suggest, a wide array of experiences associated with the pandemic will likely create or amplify burnout, with all of the questions it raises regarding what we ought to do about it.

In her talk "Clinician Well-Being," now available for CME credit through AudioDigest, psychologist Ana Rivas-Vazquez, PhD, defines burnout as a negative reaction to stress that has personal, professional and financial impacts for the person experiencing it. Burnout can occur in any stage of a physician's career and in any specialty, she indicates, but tends to be most prevalent mid-career and in frontline specialties such as emergency medicine, internal medicine and family medicine, although radiologists are also heavily affected.

To listen to the full lecture, visit AudioDigest.

What causes physician burnout?

In her prepandemic presentation, Dr. Rivas-Vazquez explores seven of the leading sources of stress contributing to the epidemic of burnout among U.S. physicians:

  • Loss of autonomy.

  • Perceived lack of appreciation, due in part to changes to the structure of healthcare which have resulted in a loss of attachment between patient and physician.

  • Regulatory and insurance hurdles, which create frustration and reduce our sense of efficacy in our patients' lives.

  • Electronic health records.

  • Higher case loads with lower reimbursement, often resulting in longer work hours.

  • Medical malpractice litigation.

  • Increasing imbalance between work/role demands and leisure.

While all of these factors remain, in the context of COVID-19, I would add several other sources of stress to the list:

  • A sense of powerlessness for some in the face of unremitting patient numbers, critical illness and death.

  • A sense of instability for some produced by unpredictable patient volumes, pay cuts and furloughs, even among front-line specialties.

  • Fear associated with a new level of risk to our own health and that of our loved ones.

  • Exponentially greater risk of moral injury, secondary trauma and becoming a second victim, any of which can contribute to PTSD, anxiety and clinical depression.

  • Exacerbation of the preexisting perceived lack of appreciation brought on by conspiracy theorists and anti-scientific propagandists, as Clarissa Barnes writes on KevinMD. Their messages often leave healthcare workers feeling maligned as a class.

3 steps to improve your well-being

While the COVID-19 pandemic is with us, we all have little energy to address the larger systemic factors that hinder clinician well-being. That does not mean that we are powerless, however, to take steps to support ourselves in the meantime. Here are three to try:

1. Engage in micropractices

I recently had the opportunity to interview Dr. Roxanne Sukol, an internationally recognized expert in preventive medicine and well-being. She described One-Minute Meditation, a rapid technique for slowing the mind and reducing excitability. We took that a step further to a "micromeditation" for hand-washing. Dr. David Fessell and Dr. Cary Cherniss describe a wealth of similar micropractices, whose benefits are documented by research, in their new article in the Journal of the American College of Radiology. All are simple, but in my experience, with a little implementation, the benefits can really outweigh the time and energy invested.

2. Identify your feelings

Dr. Fessell and Dr. Cherniss cite research using functional MRI that shows that naming our emotions has the power to "shift brain activity from the amygdala, the emotional center of the brain, to the higher-order thinking area of the brain, specifically the right ventrolateral prefrontal cortex." This shift can produce a state of greater tranquility.

3. Connect with colleagues

While journaling about difficult experiences has research-proven benefits for those processing a traumatic experience, time alone with pen and paper is not the only way to heal. In her talk, Dr. Rivas-Vazquez emphasizes the powerful, documented advantages of peer-to-peer support to aid us in releasing at least some of the negative effects of the stress of practicing medicine. Peer-to-peer support cannot replace the benefits of connecting with a skilled psychologist or psychiatrist - something I strongly encourage if you are experiencing significant anxiety, overwhelming sadness or any other sensation that feels excessive or disruptive to you - but it offers a powerful reminder that, as lonely as the practice of medicine feels at times, each of us is truly not alone.

Stacia Dearmin, MD
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