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A doctor in scrubs stands against a wall looking tired

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Coping with sickness and stress

Ken Budd , Special to AAMCNews
April 10, 2020

Clinicians across the country are dealing with stark increases in COVID-19 infections and anxiety. The emotional and physical toll on them is only starting to emerge.

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As she works 12-hours shifts, seven days a week, Evelyn Granieri, MD, MPH, is surrounded by death. “We have twice as many people on ventilators as we have beds in the ICU,” says Granieri, a longtime geriatrician at the NewYork-Presbyterian/Columbia University Medical Center. “The emergency room is packed. People are being intubated with regularity. People are dying with regularity.”

As COVID-19 cases overwhelm the hospital, doctors and nurses are also becoming infected. “I have friends who’ve been home for two weeks because they could hardly move,” says Granieri. “They’ve been hypoxic and short of breath. They have GI problems. At least a dozen have been symptomatic and close to hospitalization. Our administrator just got it yesterday. She’s sick as a dog at home. I have two friends in the ICU.”

Such grim lists are only growing. On April 1, Frank Gabrin, DO, a 60-year-old doctor at East Orange General Hospital in New Jersey, became the first U.S. emergency room physician to die from COVID-19. More than 100 health care workers worldwide have died, including doctors and nurses in 12 states from Alabama to Washington. In Italy, 61 doctors have died. In Spain, 15,000 health care workers are reportedly sick or isolated due to COVID-19. Many U.S. doctors have updated their wills and prepared funeral plans.

“I’ve heard a level of distress that I’ve never seen in my career,” says Darrell Kirch, MD, president emeritus of the AAMC and co-chair of the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience, which offers resources for coping with COVID-19. “I have seen it in individual hospitals faced with a tragedy. Katrina and Sandy were examples of that. But I’ve never seen it across the system as vividly as I see it now.”

Although COVID-19 threatens clinicians’ health, the distress stems mainly from challenges to patient care. Many physicians are seeing more patients die than at any point in their careers — and it’s taking an emotional toll, says Jonathan Ripp, MD, MPH, chief wellness officer and senior associate dean for well-being and resilience at the Icahn School of Medicine at Mount Sinai in New York. “We’re seeing the emotional strain on our workforce and this is likely to have impact well beyond the pandemic,” he says.

Kirch describes it as a parallel pandemic: “Just as we are all talking about the curve of infection and death, for clinicians there’s a curve of burnout and other forms of mental distress.” And for front-line medical workers, he adds, that could lead to another condition: post-traumatic stress disorder (PTSD).

“I’ve heard a level of distress that I’ve never seen in my career. I have seen it in individual hospitals faced with a tragedy. Katrina and Sandy were examples of that. But I’ve never seen it across the system as vividly as I see it now.

Darrell Kirch, MD
National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience

Stress — the second pandemic

Mental health, declared a recent opinion piece in STAT, is “the COVID-19 crisis too few are talking about.” For physicians, it starts with the plight of patients, many of whom are dying alone. Granieri works with dementia patients — frequently men — who are scared and confused by the masked faces in their rooms and deliriously call out the names of their wives. “It’s a terrible way to die,” she says. “It keeps me up at night.”

Many doctors also worry about personal protective equipment (PPE) shortages and bringing the virus home to their families. Malika Fair, MD, MPH, a physician in the Department of Emergency Medicine at George Washington University, is concerned about her four-month-old daughter. “I’m glad that children have not been as adversely affected with COVID-19, but I just read that a six-week-old died in Connecticut. So I’m nervous about it,” says Fair, who is also the AAMC’s senior director of health equity partnerships and programs. “I don’t think people are afraid to take care of patients. This is part of our purpose and calling. But we don’t want to jeopardize our families.”

Family worries can also increase stress. Mona Abaza, MD, is an otolaryngologist at the UCHealth University of Colorado Hospital and a professor with the University of Colorado School of Medicine, and she’s married to a small business owner whose sales dropped by 98% over four days at the start of the pandemic. “My husband is on conference calls trying to figure out how to keep people employed,” she says.

She’s also coping with challenges to her work life: “I’m an otolaryngologist trying to see patients through virtual visits,” says Abaza. “I can’t see the organ I take care of without specialized scopes and I can’t do that virtually.”

“I don’t think people are afraid to take care of patients. This is part of our purpose and calling. But we don’t want to jeopardize our families.”

Malika Fair, MD
AAMC Senior Director of Health Equity Partnerships and Programs

At Mount Sinai, many physicians who worked in outpatient settings are now caring for patients on the inpatient side. “If you’ve been a doctor or nurse in the outpatient setting for 15 years, and now you’re being told, ‘We need your help taking care of inpatients,’ it’s stressful,” says Ripp.           

Even in locations not yet overwhelmed with patients, fear of what’s coming can fray nerves. “It’s hard managing our own fears and emotions while we watch what happens in places like New York or New Orleans or Washington state,” says Justin Coomes, MD, the emergency department medical director at Mercy Health – Fairfield Hospital in Fairfield, Ohio, and a spokesman for the American College of Emergency Physicians. Many physicians also worry about their front-line colleagues, such as respiratory therapists and nurses, who spend significant time with COVID-19 patients.

“They’re constantly donning and doffing their PPE,” says Granieri. “They’re providing hands-on care. They’re cleaning the patients. Those are the people I’m most worried about.”

Emphasizing staff wellness

As the first coronavirus cases began appearing in New York, Ripp’s wellness team at Mount Sinai began addressing the staff’s emotional well-being. “We realized pretty quickly there are huge emotional needs,” says Ripp of the pandemic. He and his team have focused on three key areas, which are featured on Mount Sinai’s COVID-19 staff resources webpage:

  • Basic needs for staff. “Services that were almost taken for granted before COVID-19 became central, particularly in the early phase of the pandemic,” says Ripp. How will staff commute to work without getting infected or infecting others? How will they take care of their children now that they’re home? “For someone who doesn’t know what to do with their kids, that can be the central stressor in a time like this,” he explains. To help address the situation, Mount Sinai has compiled resources on basic needs such as child care, elder care, transportation, housing, personal safety, and protecting family. It’s also providing programs such as Sinai Together, which enlists volunteers to help with tasks such as grocery shopping, child care, and pet care.
     
  • Mental health support. Mount Sinai’s mental health resources include counseling, support groups, self-care activities, and confidential support and referral lines. Ripp plans to ramp up resources to address “the clear psychosocial need and mental health need from these enormous stressors that people are facing.” Other health systems are similarly adapting and expanding mental health programs to assist staff during the crisis. INOVA Health System in Falls Church, Virginia, offers COVID-19 wellness assistance such as counseling, stress-reduction programs, lunch-and-learn sessions on stress and depression management, and financial and legal assistance. Future plans include PTSD and grief support.
     
  • Essential communications. Too much communication can be overwhelming, so Mount Sinai sends a single daily email to employees. Its president also hosts a daily virtual town hall where he answers staff questions. For communicators, the emphasis is on honesty: The daily communication includes the number of infected patients. “It may be sobering to see those numbers,” Ripp says, “but it’s probably better than the uncertainty of not knowing.”

Transparency has become equally important to Coomes, who sends a daily email and text to his team of 10 physicians and 10 full-time advanced practice providers (using a separate text chain for each group).

“Communication is everything,” he says. “The more that people are getting consistent daily communication, the better they feel they can trust what they’re hearing. If everyone doesn’t feel like they’re getting answers, it creates a lot of anxiety.”

“Communication is everything. The more that people are getting consistent daily communication, the better they feel they can trust what they’re hearing. If everyone doesn’t feel like they’re getting answers, it creates a lot of anxiety.”

Justin Coomes, MD
American College of Emergency Physicians

Communication can even fuel solidarity and teamwork. Granieri, who started her career during the AIDS epidemic, sees a collaborative spirit and a degree of altruism that — despite the physical and emotional pain of COVID-19 — is bigger than anything she’s experienced in her 35-year career.

“There is so much camaraderie,” she says. “Not just the docs, but the nurses, the phlebotomists, the unit clerks, the housekeeping people — all the colleagues that you see every day. It really has brought together people as a family of caregivers, whether your job is clinical or clerical or somewhere in between. That is a support mechanism that all of us rely upon.”

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