It Is Not the Canary — It Is the Coal Mine
‘Most of us feel isolated, overwhelmed, and disillusioned’
Too often, healthcare workers facing a panoply of psychic maladies — burnout, trauma, moral injury — are expected to muster up resilience enough to overcome what is essentially a systems problem.
“We hear talk about building resiliency, but I will tell you, within the healthcare worker community, that’s akin to building a stronger canary,” said Anthony Cirillo, MD, FACEP, an emergency department physician at AdventHealth Dade City, FL. “The answer is not to build stronger canaries; the answer is to fix the coal mine.”
Speaking on a podcast1 held the by the Infectious Diseases Society of America (IDSA), Cirillo said although COVID-19 may have died down in some areas, there are continuing “pockets” of accelerated cases in others. Like weary firefighters, healthcare workers have been battling the pandemic and its various surges and variants for more than two years.
“Words that best describe how most of us feel are ‘isolated, overwhelmed, and disillusioned,’” Cirillo said. “With healthcare workers, there’s always the fear that you are bringing home a potentially fatal disease to your family and loved ones. Every shift is another risk where you go home and wonder, ‘Am I going to harm my family today by trying to do the right thing?’”
Jennifer Casaletto, MD, an emergency physician in Charlotte, NC, and president of the state’s College of Emergency Physicians, tells unmasked patients and visitors that she has two small boys at home. That usually works, she says, but the pandemic is taking an emotional toll on her and her colleagues as it drags on.
“I think like the rest of the world, we’re done,” Casaletto says. “We just want it to go away. A lot of folks have quit. I have talked to so many of my colleagues who are planning their exit within the next five years. There are a lot of folks who aren’t close to 60, who are saying ‘I’m either going to cut down to half-time or I’m out altogether. I need to find something else to do.’”
Of course, a lot of nurses and other healthcare workers have already left, creating a constant challenge to maintain quality care in the ED, Cirillo said.
“Patients get frustrated with long waits, but there is a limit to how much you can give. If you don’t have the right resources, at some point the system really just kind of beats everybody down,” he said. “That’s why many of them are leaving the profession — because they feel like they weren’t supported.”
Deaths and Suicides
Not all healthcare workers left with their lives. It is estimated thousands of healthcare workers have died of COVID-19, although the specific numbers are unknown. An investigative reporting project by two news outlets counted 3,607 healthcare worker COVID-19 deaths in the first year of the pandemic, from mid-March 2020 to April 7, 2021.2 Almost one-third of the deaths were nurses (32%), followed by healthcare support staff (20%), physicians (17%), and first responders (7%).
Globally, the World Health Organization estimated between 80,000 and 180,000 healthcare workers died of SARS-CoV-2 from January 2020 to May 2021, resulting in a median of 115,500 deaths.3 Both reports should be considered undercounts, given the lack of official reporting systems and the vagaries of determining COVID-19 as the cause of death.
“We’ve lost a lot of people in healthcare, and we’ve lost some of them for tragic reasons,” Cirillo said. “[Others left] because they’ve just lost the will to go back and put themselves and their families at risk every day. We are encouraging everybody to get a buddy and be a buddy. We need to stay connected to each other and we need to be intentional about that.”
Some, like Lorna Breen, MD, have taken their own lives. An emergency physician at NewYork-Presbyterian Allen Hospital, Breen committed suicide in 2020 after contracting the virus while treating patients as New York City was overwhelmed by the first wave of the pandemic. Legislation bearing her name has been passed by both the House and the Senate and now awaits the president’s signature.4 The bill’s provisions include establishing grants for training healthcare professionals on ways to reduce and prevent suicide, burnout, substance abuse, and other mental health conditions.
“[The act] provides $140 million worth of new programs for hospitals and health systems, [including] training programs in hospitals and health systems, to take care of the current and future workforce,” said Corey Feist, JD, MBA, Breen’s brother-in-law and co-founder of the Dr. Lorna Breen Foundation.
Breen was worried about losing her medical license in New York for seeking mental health treatment, Feist said on the IDSA podcast. There is no such provision in New York, but credentials are an issue in many states and act as a deterrent for healthcare workers to seek counseling.
A 2021 study5 using pre-pandemic data revealed nurse suicides generally can be traced to three things that caused them to leave or be fired, critically affecting their identify as a nurse: uncontrolled mental health issues, chronic pain possibly due to patient-handling injuries, and substance use disorders. A 2021 survey by the Physicians Foundation revealed 55% of doctors know a physician who has considered, attempted, or died by suicide. The survey was conducted from May 26, 2021, to June 9, 2021, and the data are based on 2,504 responses.
“More than half of physicians (57%) have felt inappropriate feelings of anger, tearfulness, or anxiety because of COVID-19, 46% of physicians have withdrawn or isolated themselves from others, and 34% felt hopeless or without a purpose,” the survey authors noted. “Despite the high incidence of mental health symptoms, only 14% of physicians sought medical attention.”6
A common denominator for nurses and physicians is the perception that seeking mental health is stigmatizing and they will be viewed as weak by both their colleagues and the powers that be in the organization.
Stigma and Licensing
“I was speaking to the widow of a physician named Scott Jolly, from Utah, who died by suicide in the last 12 months,” Feist said. “Scott had to use his own mental health facilities for his first and only inpatient admission to psychiatry. He died by suicide after discharge.”
Jolly realized that treating COVID-19 patients was harming his mental health and sought more staff support, early retirement options, and other relief to no avail.7 The management of his physician group said they were looking into early retirement options, and Jolly took a sabbatical. Even then, he was worried about licensing problems, supporting his family, and the stigma of seeking mental health. Eventually, he was diagnosed with PTSD. On Feb. 5, 2021, Jolley attempted suicide. He survived, but due to insurance requirements was admitted to his own hospital, where he was known by staff and colleagues. It is hard to imagine a more stigmatizing outcome. Two weeks after discharge, he took his own life at home.
The Breen Foundation is asking all hospitals to tell their healthcare workers what the laws are in their state and facility regarding mental healthcare and medical credentialing.
“We’ve asked every hospital in this country to just publish what the facts are for their workforce,” Feist said. “In this very tangible way, not only are you recognizing and acknowledging that this is a challenge and supporting your workforce, but you’re actually potentially saving lives. There is state licensure, credentialing questions, but also questions that physicians are asked to fill out when they apply to be paid by insurance companies and when they apply for malpractice insurance.”
The only credentialing and licensing issue that should be asked of healthcare workers is, “Do you currently have any condition that would impair your ability to care for patients?” Cirillo said. “They shouldn’t ask about what you’ve done in the past or what you’ve had in the past; that’s irrelevant.”
That is in keeping with what The Joint Commission established as its policy on the matter in 2020 and reaffirmed in 2021, emphasizing it does not require such information, and it should not be a barrier to mental health therapy.
“The Joint Commission strongly encourages organizations to not ask about past history of mental health conditions or treatment, and supports recommendations to limit questions to conditions that currently impair the clinician’s ability to perform his or her job,” the commission wrote.8
Compounding the problem, some state professional boards do not use a clear process for helping clinicians with mental illness, and often default them into a substance abuse track.
“This is unfair, doesn’t get them the help they need, and creates one more level of stigma,” Cirillo laments.
Protect ‘What Matters Most’
How can healthcare leaders help their staff? Removing as many unnecessary tasks as possible, delegating responsibilities, and forming teams to conduct prior authorization should be priorities to free clinicians’ time for their critical encounters with patients, says Rana Awdish, MD, a critical care physician at Henry Ford Hospital in Detroit.
“I think focusing on what actually matters is most important,” Awdish tells Hospital Employee Health. “It’s not about adding and layering responsibilities. It’s about actually taking things away so the clinicians can do the work that really matters to them.”
Awdish is a co-author of a recent article9 that warned against rushing and compressing clinical interactions with patients.
“When clinicians are hurried, they may miss pertinent information, potentially rendering the treatment plan they recommend less effective,” the authors emphasized. “Compressed encounters may mean clinicians don’t have the necessary time to correct disinformation or misinformation that may be influencing patients. Given the questioning of the COVID-19 vaccines that continue to occur, giving clinicians time to cultivate patients’ trust is especially important in the campaign to improve vaccination rates.”
The authors noted Hawaii Pacific Health’s campaign, appropriately titled “Getting Rid of Stupid Stuff.” Employees were asked to nominate the most unnecessary or poorly designed electronic health record (EHR) tasks for possible elimination.
One implemented suggestion was ending the requirement that nurses and nursing aides document their hourly rounds in the EHR, Awdish and colleagues reported. Eliminating the task saved about 1,700 nursing hours per month at the system’s four hospitals.
“I think this is a [concept] that a lot of wise organizations are using,” Awdish says. “They realize that the people actually doing the work will likely have the best idea about how to do that work. This case required open lines of communication between the people who are actively interfacing with the EHR, and the IT workers, so that electronic records are not just a billing tool, but a communication tool.”
With healthcare no exception, there is the temptation in all industries to focus on worker productivity at the expense of less tangible benefits. “If we focus only on productivity, if that’s the only thing that we look at, it can really squeeze the meaning out of a lot of these encounters,” Awdish says.
Although conceding it is more of an aspirational goal, Awdish and colleagues proposed healthcare systems give workers time to replenish themselves and rest between pandemic waves. This would be similar to the “rest and recreation” concept used by the military, showing leadership support for the workforce and increasing system resilience.
“There is so much attrition — the ‘Great Resignation’ has affected medicine as well,” Awdish says. “When there are fewer people to do the work, it’s very hard to allot time for respites. But I fear if we don’t do that, we will be in an even worse position. We need resiliency in the system — not at the individual level, but at the level of the organization.”
REFERENCES
- Infectious Diseases Society of America. Mental health stress and burnout in health care workers. Jan. 29, 2022.
- The Guardian and Kaiser Health News. Lost on the frontline: 3607 US healthcare worker deaths. April 8, 2021.
- World Health Organization. Health and care worker deaths during COVID-19. Oct. 20, 2021.
- Dr. Lorna Breen Foundation. Dr. Lorna Breen Heroes’ Foundation hails Senate passage of legislation protecting healthcare workers’ mental health. Feb. 17, 2022.
- Davidson JE, Ye G, Parra MC, et al. Job-related problems prior to nurse suicide, 2003-2017: A mixed methods analysis using natural language processing and thematic analysis. J Nurs Regul 2021;12:28-39.
- The Physicians Foundation. 2021 Survey of America’s Physicians COVID-19 impact edition: A year later. Feb. 9, 2022.
- Belluz J. The doctors are not all right. Vox. June 23, 2021.
- The Joint Commission. Joint Commission reiterates importance of removing barriers to mental health care for staff. March 31, 2021.
- Berry LL, Awdish RLA, Swensen SJ. 5 ways to restore depleted health care workers. Harvard Business Review. Feb. 11, 2022.
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