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Published On July 13, 2020

CLINICAL RESEARCH

The Trauma of Fighting COVID-19

The first surge of COVID-19 led to burnout, debilitating stress and suicide among hospital workers. How can we protect them better as infections once again start to rise?

At the height of the first pandemic surge, emergency physician Craig Spencer took to Twitter with concerns about his coworkers at NewYork-Presbyterian/Columbia University Medical Center: “I’ve never seen my colleagues so afraid, so unsettled … Every day someone calls me crying. How long will they hold? How long will I hold?” At Massachusetts General Hospital, “panic attacks among clinicians were common, and for some they happened many times a day,” says Martha Kane, clinical director of ambulatory psychiatry.

As the critical mass of patients begins to wane, the toll of the crisis among front-line clinicians is coming to light, and especially its cost on their mental well-being. While their needs were keen, they were often drastically underserved. The consequences were brought into sharp relief at the end of April, when the medical director of the emergency department at NewYork-Presbyterian Allen Hospital in Manhattan took her own life. The doctor’s family reported that she had been devastated after seeing scores of her patients dying, sometimes before they could even be taken out of the ambulance.

In some sense, the pandemic added fuel to a fire that was already burning. In January, nearly half of U.S. physicians already described themselves as feeling burned out, according to a survey by the American Medical Association. And although hospitals have rolled out many programs to mitigate stress, substance misuse and depression in recent years, physicians often haven’t embraced them. “Some worried that an intervention in their workplace might affect their job security or medical license or present yet another demand on their time,” says Jessica Gold, assistant professor of psychiatry at Washington University in St. Louis. Other doctors find the hospital efforts inconvenient, condescending or simply not helpful.

But as the pandemic arrived and fanned innovation in patient care, it also seemed to break barriers for clinicians themselves, leading more to embrace mental wellness programs offered by their workplaces. Hospitals, for their part, also looked to learn from past mistakes and put forward programs with a proven track record.

Some turned to “Stress First Aid,” a style of intervention widely used by emergency medical services, the police and the military to help people experiencing disaster, trauma or terrorism. At the University of North Carolina’s health system, for instance, clinicians were taught to assess their colleagues’ level of functioning on a scale from green to red. At the green end, people feel “in control, prepared, and as mentally and physically fit as possible to do their jobs while in a constant state of crisis,” says Echo Meyer, vice chair of psychological services at the UNC School of Medicine. But when stress and anxiety pushed them toward the red of the scale, they showed disabling levels of distress.

The intervention was intended to quickly identify those who were suffering and bring them the help they needed. Overstressed clinicians could join small support groups, conducted online, five days a week. Providers also had the option to log in anonymously to webinars run by local psychiatric staff or receive one-on-one therapy. Those who reached the red zone were automatically referred to the department of psychiatry for more intensive treatment.

Institutions also looked for ways that providers could use services without the perceived baggage of participating in a hospital-sponsored mental health program. “Providers didn’t want to have to ask for help through the Employee Assistance Program,” says Meyer. “They didn’t want to give the impression that they weren’t operating at an optimal level. We worked to remove the stigma of asking for help.”

At Massachusetts General Hospital, the team moved to focus on teaching their clinicians coping skills—how to feel capable and resilient so that they could move through this crisis with as little psychological damage as possible. The hospital also took steps to improve access to this care, a lesson learned from previous efforts. “We are connecting people who call us to mental health care that same day, which is very unusual during normal times,” says Justin Chen, medical director of ambulatory psychiatry at MGH. The hospital also isn’t documenting requests for counseling or billing insurance for initial counseling sessions during the COVID-19 crisis.

Psychiatry teams are also learning from strategies that clinicians themselves develop to stay sane. At UNC, some providers built human connections—a key principle of Stress First Aid, according to Meyer—by participating in Pictionary and other games via Zoom. One physician cooked daily meals for the 12 providers who work with her on a COVID-19 unit, an act that made her feel “rejuvenated.” At MGH, the physician-in-chief offered free haircuts to staff members. Other clinicians wrote notes to patients’ families. “That type of altruism makes people feel better,” says Martha Kane at MGH.

Discovering what interventions ultimately work—and which should be used in the future—will get a boost from a research project called the HERO Registry (heroesresearch.org) at Duke University. To date, more than 13,000 health care workers across the country have signed up to answer questions every two weeks about their emotional well-being. “Besides understanding the challenges health care workers are facing and how those change over time, we also want to learn which strategies and interventions implemented by health systems have worked,” says principal investigator Emily O’Brien, assistant professor of population health sciences at Duke University School of Medicine.

Those insights will be critical for a number of reasons—not only for future waves of COVID-19 or the ongoing burnout crisis, but also for the psychological aftershock of the pandemic’s first months. A study on China’s 2003 outbreak of another deadly coronavirus—severe acute respiratory syndrome (SARS)—found that hospital staff working in SARS wards had a higher future risk of alcohol misuse and symptoms of PTSD and depression. Another study showed that 10% of those hospital employees developed severe PTSD. “We are expecting an uptick in psychological problems two or three months after the current COVID-19 crisis abates,” says Kane, “once clinicians have had a chance to process the trauma they’ve experienced.”

The hope is that lessons from the COVID-19 crisis will improve mental health support for clinicians—and make them more open to receiving it. “In medicine, we’re trained to suppress our own needs; duty to patients comes first,” says Justin Chen at MGH. But providers’ mental health crisis during the pandemic may have opened doors. “Removing barriers to mental health care now is providing the impetus to get care and pursue therapy,” says Chen. “That’s very positive.”