Spring 2021 (Volume 31, Number 1)
Physician Well-being in the Midst of a Pandemic: From Individual Well-being to Compassion Culture
By Allison Crawford, MD, PhD, FRCPC
Download PDF
There is an inter-relationship
between our own
wellness as health providers,
and our ability
to deliver quality healthcare
to patients and
families.1 Further, given
that we invest so much
in caring for others, we
should also ensure that
we thrive, individually
and within our families
and communities. And
yet, even prior to the
pandemic, physician well-being was a concern.
A recent review summarizes the alarming statistics that
up to 42% of physicians in the U.S. report experiences
consistent with burnout, with 14% experiencing thoughts
of suicide.1,2
Compounding this, even in the most severe
instances, only a third seek treatment.1 In a 2018 national
survey by the Canadian Medical Association, similar findings
showed that 30% of Canadian physicians reported
high levels of burnout, 34% had symptoms consistent with
depression, and 8% had thoughts of suicide in the preceding
12 months.3
The COVID-19 pandemic has added additional strain
for all, and for those health providers already struggling,
well-being and resilience may be further eroded. During
the pandemic, health providers have shown higher rates
of distress, insomnia, anxiety, and depression, particularly
for those engaged directly in the treatment of patients with
COVID-19.4 Additional stressors contributed by the pandemic
include: uncertainty and anxiety for the well-being
of self and loved ones; increased workflows and demands
at work; increased isolation and decreased opportunities
for protective activities, such as social connection; and, for
many, losses, including losses of patients.5 In addition to
the direct impact of increased demands and exhaustion,
many have also identified the psychological toll of moral
distress, or the distress that ensues when one’s values and
beliefs come into conflict with existing circumstances.6
What are the warning signs of burnout?
- Feeling down, sad, depressed
- Feelings of anger, impatience, irritability
- Thoughts of death or suicide
- Decreased feelings of satisfaction
and meaning from work
- Increased absenteeism from work; or
conversely, trying to work more/harder
- Decreased feelings of compassion for patients
- Increased medical errors
There are also self-report measures that can be used
to assess symptoms of burnout. The most commonly used
is the Maslach Burnout Inventory.5 Recent work by Trockel
and colleagues also looks at a continuum of experience
from burnout to satisfaction.7
How can we ensure that we sustain our own
well-being?
Polizzi, Lynn and Perry (2020) offer a useful framework
for considering useful interventions, focusing on control,
coherence, and connectedness.8
Control includes activities that shore up our personal
resources by engaging in protective practices such as establishing
routines, sleep hygiene, and exercise. We can
draw upon our self-awareness of coping practices that have
helped in times of previous adversity, and can use tracking
tools such as mood, sleep, and activity journals to look for
areas that require attention.
Coherence emphasizes the importance of the meaning
that we make out of adversity. Asking ourselves what our
narrative is of the current pandemic, and of ourselves, as
well as reflecting on our own values can help us gain new
perspective on current events, and our own role within
them. They suggest reflective questions, including, for example,
“What is important to you?” “What makes you feel
good, even when confronted with a situation you can’t fully
control?” Reflection can be complemented with practices
such as mindfulness that can also nurture more acceptance
of our emotional reactions, and also of situations
over which we have little control.
Connectedness emphasizes our need for others and for
support, and the known benefits of social connection to mitigate adversity. They encourage finding ways to maintain
meaningful connection, even in the midst of public
health measures that can intensify isolation.
However, the effectiveness of interventions to reduce
burnout and boost resilience requires more research. A recent
Cochrane review demonstrates the limited evidence
for interventions to support health providers during a
pandemic.9 Factors that were associated with effective implementation
of interventions included adapting interventions
for local needs; effective communication in organizations;
and ensuring that learning environments are safe
and supportive. Corollary barriers to supporting health
providers during a pandemic included both individuals
and organizations being unaware of supports that are needed,
as well as a lack of equipment, staff time, and skills
needed to support interventions.
The findings of this review suggest the importance of a
fourth "C" which may be called Culture, or perhaps Compassion
Culture. Organizational culture and support is
critical to the well-being of health providers. In the Canadian
Medical Association survey, one of the most notable
findings was that even personally resilient physicians were
not immune to experiencing burnout.3 An overemphasis on
individual coping and resilience will likely only compound
burnout. It is up to organizations to prioritize the wellbeing
of all providers and to create a culture of compassion
in which well-being is modelled and supported at all levels
of the organization, and time and resources are devoted
not only to ensuring the resilience of individuals, but also
the resilience of teams.
Resources
If you are experiencing any of the signs of burnout listed above, please reach out to a trusted colleague.
Most organizations have an employee wellness or occupational health program.
Allison Crawford, MD, PhD, FRCPC
Psychiatrist,
Centre for Addiction and Mental Health
Associate Chief, Virtual Mental Health
Associate Professor,
Department of Psychiatry,
University of Toronto
Chief Medical Officer,
Canada Suicide Prevention Service
Toronto, Ontario
References:
1. Yates SW. Physician Stress and Burnout. Am J Med. 2020; 133(2):160-164. doi: 10.1016/j.amjmed.
2019.08.034. Epub 2019 Sep 11.
2. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians: A Systematic
Review. JAMA. 2018; 320(11):1131-1150.
3. Vogel, L. Even resilient doctors report high levels of burnout, finds CMA survey. CMAJ. 2018; 190
(43): E1293.
4. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care
Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020; 3(3):e203976.
5. Norful AA, Rosenfeld A, Schroeder K, et al. Primary drivers and psychological manifestations of
stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States.
Gen Hosp Psychiatry. 2021; 69:20-26. doi: 10.1016/j.genhosppsych.2021.01.001. Epub ahead
of print.
6. Anderson-Shaw LK, Zar FA. COVID-19, Moral Conflict, Distress, and Dying Alone. J Bioeth Inq.
2020; 17(4):777-782. doi: 10.1007/s11673-020-10040-9. Epub 2020 Nov 9. PMID: 33169271;
PMCID: PMC7652046.
7. Trockel M, Bohman B, Lesure E, et al. A Brief Instrument to Assess Both Burnout and Professional
Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical
Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry. 2018; 42(1):11-24.
8. Polizzi C, Lynn SJ, Perry, A. Stress and Coping in the Time of COVID-19: Pathways to Resilience and
Recovery. Clinical Neuropsychiatry. 2020; 17(2): 59-62.
9. Pollock A, Campbell P, Cheyne J, et al. Interventions to support the resilience and mental health of
frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic:
a mixed methods systematic review. Cochrane Database Syst Rev. 2020;11:CD013779.
|
