Addressing Stress and Burnout During COVID-19

Even before the COVID-19 pandemic, physicians were experiencing a high degree of stress and symptoms of burnout. A survey conducted between October 2017 and March 2018 showed that 44% of physicians exhibited at least one sign of burnout and were less likely to feel satisfied with their work-life balance than those in other professions in the United States.

Add to that a health crisis that has put an unprecedented burden on health care providers: a survey conducted between June and September 2020 by Mental Health America found that 93% of health care workers were experiencing stress, and 76% reported exhaustion and burnout.

“As a country, we have had a bill come due about stress on the [health care] workforce,” says Christine Sinsky, MD, vice president of professional satisfaction at the American Medical Association.

“No matter where you start at baseline, crisis comes with stress,” Sinsky explains, but that stress doesn’t have to inevitably lead to stress injury or chronic stress illness. “This is a fixable problem,” she adds. The key is to address the external drivers of that stress.

The COVID-19 pandemic has affected physicians and other health care professionals in unprecedented ways. They are struggling with the stress of caring for a large number of extremely ill patients, worry about contracting COVID-19 themselves, grief over losing patients and colleagues, and concern about bringing the virus home to family and loved ones. Many office-based physicians have new stressors related to decreased patient volume, feelings of isolation from delivering care via telehealth, and competing priorities while working from home.

“Most can stand up to meet a discrete crisis, but when it becomes a steady state, it becomes impossible to continue at that high level,” explains Sinsky.

The longer and more intense the stress, the greater the risk of stress injury or illness, including burnout, insomnia, dysphoria, depression, anxiety, and post-traumatic stress disorder. And even before the pandemic, physicians had one of the highest rates of suicide among professionals.

The problem is not a lack of resilience among physicians, Sinsky emphasizes: “Studies show that physicians have higher levels of resilience than the general population. ” But burnout and resilience are not mutually exclusive. Symptoms of burnout are common even among physicians with the highest levels of resilience, Sinsky adds, citing a July 2020 JAMA study. According to Sinsky, as much as 80% of burnout can likely be traced back to systems factors. Physicians, who are used to powering through difficult situations, may need to be reminded and encouraged to take a break and take care of themselves first.

“Physicians are mission-driven,” Sinsky says. “We’ve gone through arduous periods during medical school and training where we put our patients’ needs and our training above our own needs. We’ve absorbed a culture that encourages a lack of self-care—and, at its worse, venerates it.”

If symptoms in response to stress become overwhelming, then it’s time for professional help, she adds. But the real, long-term fixes lie in systems-based solutions—creating environments that adequately address stress to help promote recovery and prevent dysfunctional responses.

“It’s possible to go through stress and stress injury and come out stronger, but you have to have institutional support to do that,” Sinsky says. Having a chief wellness officer, a well-being program, or other infrastructure in place can help an organization respond more quickly in times of crisis.

But even without those structures, organizations should try to meet the basic needs of health care workers. A 2020 JAMA article by Shanafelt and colleagues summed it up in these five requests: hear me, protect me, prepare me, support me, and care for me. Examples of specific actions within these categories include:

• Hear me: Create space for frontline workers to express their concerns through listening sessions, town halls, check-ins, staff meetings, and other feedback channels
• Protect me: Provide personal protective equipment, access to testing and vaccination, and other measures to ensure that staff and family members are as protected as possible from the spread of infection
• Prepare me: Train and support staff who are re-assigned to a different unit or adapting to new policies and procedures
• Support me: Ensure that staff have what they need to stay strong and healthy, including access to nutritious food and drinks while working, opportunity for rest, and transportation assistance
• Care for me: Offer other emotional and physical supports, such as check-ins, paid time off for quarantine, and safe lodging

Although the current situation is intensely challenging and distressing, Sinsky sees hope on many levels. Some of the policies instituted to speed care and reduce burdens on providers during the pandemic may well continue beyond this crisis. These include increased reimbursement and eased restrictions for telehealth visits as well as the elimination of order requirements for especially low-risk procedures.

Organizations such as the American Medical Association, American Academy of Family Physicians, and other national and local medical societies are also responding with resources, hotlines, and programs to address the needs of the health care workforce .

Above all, Sinsky says, it’s important for health care professionals to recognize that their stress response is not due to individual weakness or personal failing. “It’s not because you didn’t try hard enough. It’s because it’s stressful,” she adds. “If you are feeling overwhelmed and depressed, you are not alone.”

• Irritability
• Muscle tension, headache
• Distressing memories
• Nightmares
• Trouble sleeping
• Difficulties with concentration
• Fatigue
• Feelings of excessive guilt
• Dissociation
• Insomnia
• Anxiety
• Panic attacks
• Desire to withdraw
• Increased use of alcohol or other substances
• Wondering whether life is worth living
• Suicidal ideation

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