​ Behavioral Health

An Epidemic Within a Pandemic

System-Level Changes for Physician Wellbeing

By Michelle D. Sherman, PhD LP ABPP, Adam Sattler, PhD LP,  Barbara Carver PsyD, LP, Rosean Bishop, PhD LP,  Jennifer Nelson Albee, MSW, LICSW

n recognition of research showing over 50% of United States physicians report significant symptoms of burnout,  in 2017 the National Academy of Medicine created the Action Collaborative on Clinician Well-Being and Resilience.  This program aimed to increase attention to the epidemic of clinician burnout and to advance research-based solutions to provide support. Similarly, conceptual models have been offered (e.g., Shanafelt & Noseworthy, 2017; Shapiro et al., 2018) identifying key drivers of burnout, organizational strategies to mitigate burnout, and systems-level interventions. Efforts such as these are important and necessary, but broad application to everyday practice and measurable impacts have yet to be seen. Then, the COVID-19 pandemic suddenly and intensely hit our world in March 2020, therein exposing many societal issues (e.g., health/wealth inequities along racial lines) that adversely impact physician well-being and the patients they serve. Medical school did not prepare anyone for the challenges 2020 would bring to the healthcare system and our patients.

As psychologists/social workers embedded in family medicine residency programs at four large healthcare systems across Minnesota, we see and truly hurt for our physician colleagues serving on the front lines of the COVID pandemic. The levels of stress are palpable. Emerging research is documenting healthcare providers’ elevated rates of insomnia, anxiety, and depression (Pappa et al., 2020).  Anecdotally, we hear some colleagues questioning if they want to continue their careers as physicians. Many have taken pay cuts over the past year due to financial challenges faced by healthcare.  Witnessing such high rates of illness and death can be traumatic, and we worry about short-and long-term trauma-reactions including but not limited to PTSD, increased rates of self-harm and suicide, increased rates of substance use disorders and overdose, moral injury, and more. So, we see and honor physicians’ exhaustion, fear and anxiety, anger, sadness, sense of feeling overwhelmed and inability to do their jobs due to shortages of resources, and grief at lost colleagues, family, and friends. Of note, these struggles are not exclusively due to the pandemic, and they will not spontaneously remit once this virus is under better control. We thank physicians for their sacrifices, commitment, and courage during this incredibly stressful time.

​Counseling must be made accessible, and barriers need to be eliminated.

Well-intended efforts

Across our healthcare systems, we have seen many well-intended efforts to support the healthcare workforce. EAP services, webinars, free pizza, resource toolkits teaching coping skills, emails offering appreciation….many of these individual efforts are important and definitely may be helpful to some people.

However, for many physicians, these efforts are not only falling flat but are actually offensive. For example, a wellness guide was emailed to physicians in one of our systems; residents found the suggestions of deep breathing and exercise to be really missing the mark in light of their current levels of stress and pain. Instead of experiencing the well-intended resource as helpful, it was a source of derision and mockery. Offering such resources without acknowledging the broader systemic issues affecting physician well-being has backfired; efforts such as this may be inflaming physicians’ longstanding and deeply held frustrations with the system. Further, many overwhelmed physicians experience resilience suggestions (e.g., exercise more, meditate more) as something else that they aren’t doing well – thereby worsening their well-being rather than improving it.

Steps for making change

We are committed to work alongside our physician colleagues in the journey ahead to build the healthcare system back to a place that is better than pre-pandemic time. This rebuilding may provide an opportunity to thoughtfully examine some long-standing systemic issues that impact well-being. The solution is NOT more resilience training focused at the individual level. Physicians are resilient people. Below are some specific systemic steps we urge healthcare leaders to consider to effectively support physicians.

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Ensure all healthcare providers have sufficient PPE, regular testing, and early access to the vaccine. Allocation of sufficient resources to help keep our frontline providers safe is essential. A recent article (Chin et al., 2020) found that routine testing of asymptomatic providers substantially reduces the risk of outbreaks. However, to the best of our knowledge, this is not routinely occurring in any of our healthcare systems. Professional sports teams, yes. Front line doctors, no. We are grateful that states are vaccinating healthcare providers first so that they can stay well physically and care for their communities.

Make confidential, free mental health services easily available – on work time. Our physician colleagues have shared that this is the most stressful time of their careers, and many desire psychotherapy. However, carving out time during their already extremely busy schedules is hard, especially when balancing this with family needs. Counseling must be made accessible, and barriers need to be eliminated.

Reduce the frequency and burden of non-essential demands on physicians’ time. After a busy clinic day or shift in the hospital, physicians often spend evening or weekend time attending to administrative tasks. Leaders can strive to minimize such burdens by limiting emails to those which are absolutely essential, combining and reducing required trainings, and releasing expectations for immediate responding when not on call. Similarly, increasing meeting efficiency and shortening required meetings can be very helpful; structuring meetings such that participants attend only the parts that apply to their role is useful.

Foster an intentional culture of appreciation, connection, and focus on meaning in work. Although leaders need to carefully consider and respond to patient complaints and system breakdown, is equal (or more) attention paid to patient compliments, team successes, and bolstering team cohesiveness? Everyone in the clinic benefits when team members at all levels make intentional efforts to affirm, celebrate, and build relationships.

​Dr Fauci’s leadership has inspired people to want to serve as physicians.

In addition, encouraging physicians to reflect and draw upon the reason they chose the career of medicine and the meaning they derive from work can be useful. How does each person’s contribution connect to the broader clinic’s values and mission? Although the drive home from work can be a natural time to focus on the day’s challenges, can leaders encourage intentional reflection on one positive interaction or progress on a project? In academic institutions, preceptors can specifically encourage trainees to reflect on one thing they learned and one patient they positively impacted that day.

Eliminate state medical boards’ restrictions on licensure for physicians seeking therapy or experiencing mental illness. Asking for help for mental health concerns is hard, especially for physicians who dedicate their careers to helping others. We need to eliminate this substantial barrier of fear of negative licensure repercussions of seeking help. Clearly the medical boards have a societal duty to ensuring physicians are competent and able to provide care to patients, but the current stringent rules in many states deter physicians from seeking much-needed mental health care.

Dedicate funding to research and clinical initiatives to understanding and appropriately addressing physician well-being. We applaud legislation such as the The Dr. Lorna Breen Health Care Provider Protection Act (S. 4349; HR 8094) which aims to “reduce and prevent suicide, burnout, and mental and behavioral health conditions among health care professionals” by grants, training, service provision, public health campaigns, and research. Funding to accomplish these goals is imperative. Prevention and early intervention approaches must be developed and evaluated.

Begin this mindset shift in early years of medical training. According to the Association of American Medical Colleges, the number of applicants to medical schools is up 18% in 2020 compared to 2019. Some have termed this the “Fauci effect,” as Dr Fauci’s leadership has inspired people to want to serve as physicians (Marcus, 2020). Given the anticipated shortage of physicians with large numbers retiring in the next decade, recruiting and training physicians is important. However, medical school and residency are known to be extremely stressful times with elevated rates of mental illness. Thus, systematic changes are necessary to recruit, retain, and graduate physicians who will choose to stay in this stressful career.

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Many of these long-standing problems require system-level changes that take commitments of time, energy, and money. Our physician colleagues are exhausted and overwhelmed by caring for patients during this extremely difficult time. We need to broaden the locus of responsibility for physician well-being from an individualistic (physician, heal thyself) to a broader communitarian response. Just as a vaccine is offering hope for gaining some control over COVID, a substantive transformation of the healthcare system is necessary to sustain and offer hope for our greatest asset, our healthcare providers.

Michelle D. Sherman, PhD LP ABPP, North Memorial FMR Program, University of MN

Adam Sattler, PhD LP, North Memorial FMR Program, University of MN.

Barbara Carver PsyD, LP, St Cloud FMR Program, CentraCare, University of MN.

Rosean Bishop, PhD LP, Mayo Clinic/University of MN FMR Program.

Jennifer Nelson Albee, MSW, LICSW, Duluth FMR Program, Essentia Health.