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Medical News & Perspectives
May 20, 2020

Prioritizing Physician Mental Health as COVID-19 Marches On

JAMA. 2020;323(22):2235-2236. doi:10.1001/jama.2020.5205

In the spring of 2013, Eileen Barrett, MD, MPH, lost a colleague to suicide. The two worked at the Indian Health Service’s Gallup Indian Medical Center in New Mexico, where Barrett was the deputy chief of medicine. Even before the tragic event, she saw workers struggle under administrative burdens and hold themselves personally responsible for problems outside of their control.

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With her coworker’s death it became painfully clear that clinician wellness had to become a higher priority. “It made me really think that we needed to do more for everybody on the health care team,” Barrett, now an associate professor of medicine and an academic hospitalist at the University of New Mexico in Albuquerque, said in a recent interview with JAMA.

As the school’s director of graduate medical education wellness initiatives, Barrett has spent a lot of time focusing on physician care since the coronavirus disease 2019 (COVID-19) pandemic began. She wants physicians to remember what she learned in Sierra Leone during a 6-week stint as an Ebola health worker in 2014. Surrounded by the very real risk of death, she realized that she’d be of no help to anyone if she herself fell ill. In fact, forgoing her own physical or emotional health could jeopardize her patients and fellow health workers.

The following is an edited version of JAMA’s interview with Barrett.

JAMA:Does the Ebola crisis have anything in common with what health care workers are experiencing with the COVID-19 pandemic?

Dr Barrett:Absolutely it does, in lots of different ways. Some of it has to do with the nature of being in uncharted territory. Some of it has to do with the nature of being in communities, locations, and institutions where the patients can become catastrophically ill. There are places with some pretty dire shortages of personal protective equipment (PPE). And, also, when I was working on Ebola, although there were treatment protocols, there wasn’t actually any known treatment per se. There was a lot of supportive care. And that’s really where we are right now.

JAMA:What are some of the key stressors that physicians are dealing with during this crisis?

Dr Barrett:I think a really critical one is uncertainty. And that uncertainty is: What does tomorrow look like? Because every time you open the newspaper, every time you look online, there are more cases. For the clinicians who are in hot spots, there is the suffering of the patients and of their peers. There also is the trauma of knowing that there is a risk to your own health.

For people who are in places where there aren’t very many cases, there also can be the fear of what’s coming. A colleague described it to me as being on the beach before the tsunami. Lastly, there’s also the quite reasonable concern for the safety and well-being of your own patients, who you care so much about, and your family and friends. Particularly the concern that you could bring it home to them, because all of us, of course, can be vectors.

JAMA:What’s the psychological toll, in your opinion, that a crisis like this can take on a physician?

Dr Barrett:There’s actually some data for that. JAMA Network Open had a paper on more than 1200 health care workers in China and their mental health outcomes. They found that there were specific risk factors for negative mental health outcomes. Specifically, those included being in Wuhan, being a frontline health care worker, being female, and being a nurse, among some others. Negative mental health outcomes can include anxiety, depression, and posttraumatic stress disorder. Then there are things like loneliness, imposter syndrome, or survivor’s guilt if you feel like you’re not doing enough.

JAMA:You mentioned loneliness. How does that affect physicians during a time like this?

Dr Barrett:We came into this time with really unprecedented levels of burnout in the profession. It’s always awful to have our health systems and our personal strengths tested. But in a time when people were feeling so much more stress, distress, and burnout in the profession, then it’s particularly hard to have another layer on top of that. A lot of people have been experiencing professional loneliness and isolation having to do with spending more time behind screens, having less time with our patients, having less time with our peers. And more “pajama time” after hours on the electronic medical record and away from our friends and our families. And then when we put on top of that the need for social distancing—I really appreciate when people refer to it as physical distancing—we can really feel isolated. Also, when you are wearing your PPE, you are physically separated from other people and there is no human touch.

JAMA:What are some things that health care leaders should be doing to look after their workers’ mental and emotional health? Are there examples from your hospital that you could share?

Dr Barrett:The people who carry explicit leadership positions have very explicit duties. There are ethical and administrative duties. Some of those are to provide people with the tangible, but also the intangible, support that they need. It’s not just about having your PPE. It’s also about having the childcare and the connections to mental health services. I think that every leader has a duty to create systems for people to have peer support, in addition to having access to telemedicine for mental health services.

Making sure that everybody has enough hand sanitizer. Making sure that they have enough scrubs. That they are able to do their telemedicine from a place where they’re not physically on top of another person or put together with another person. So that they can have their social distancing and feel safe when they’re providing care to patients.

Also, communication with transparency about why difficult decisions are being made and avoidance of overly normalizing or overly catastrophizing what’s going on. Being factual. Showing very tactical support, such as things like meals, while also saying thanks as often as possible. I really appreciate that we have lunch available for us every day. It’s a small gesture. I know that my colleagues have appreciated that if someone offers to buy breakfast for the nurses, the institution is saying yes and thank you. Because we are all in this together.

Some other, bigger gestures can be giving people explicit time to disconnect from the work and a mechanism to catch up. It’s okay to disconnect from the work, to be outside, to spend some time with your family, to recharge, so that you can come back and bring your best work to the job.

JAMA:What happens when the PPE is running out?

Dr Barrett:Some of the lessons are from when I was an Ebola worker, so they’re not just for high-resource systems. This can really be done anywhere. When we’re running out of PPE, be smart about how we’re using it. For example, in the hospital, cluster care. And by that I mean if anybody is going into the patient’s room, they’re also seeing what else they can do at the same time. We did this in West Africa. We certainly can do it here.

Very tactically, if someone is getting a medication 3 times a day, instead of having it every 8 hours, it will be at breakfast, lunch, and dinner, at the same time the patient is receiving other medications. And, also, at the same time as they’re getting their meals, maybe they’re getting a blood draw, getting their insulin, getting their vital signs checked. Of course, there are some medications where we can’t make that change. But there’s a lot of cases where we can. We can cluster the care so that we have less instances where we go in and out.

Another thing that we can do is to be innovative and learn from each other. People have put IV [intravenous] poles outside the rooms and then run the IV tubing just under the door and into the patient. The medications or IV fluids can be hung without having to go in and out of the room. In the hospital we can provide patients with tablets so that they can see their health care worker.

Another step would be to flatten the hierarchy. When the work needs to be done, to the extent that is reasonable, anybody who can take care of that need for the patient will do so. This is done, of course, being mindful that there is work that absolutely can only, and should only, be done by physicians. If I’m going in to see a patient, I will always talk to the nurse to see if there’s anything that I can take care of. Or, if there’s anything I know that the patient needs when I’m coming out, I’ll let the nurse know so they can bring it in the next time.

JAMA:What are some things that physicians can do to look after themselves right now?

Dr Barrett:Doing our best to get a good night’s sleep, using caffeine only strategically, making sure that we’re eating well, and getting a little bit of exercise. Ideally, even a lot of exercise. That can feel like a real luxury for a lot of physicians. I often repeat the story about what we learned when I was in the Ebola treatment unit. If you aren’t eating and you aren’t drinking, you put your peers at risk. If you end up collapsing while you’re at work, then everybody else will have to do the work that will put them at risk to take care of you. Sometimes appealing in that way to physicians can give us permission to actually take that time. In addition to those very practical things, some of the things that will be really important are time outside and some connection to people that is not about COVID.

This is a really nice time for people to think about the sections in our journals that are about our humanity, like JAMA’s A Piece of My Mind. Another thing that we need to do is to cultivate a sense of self-compassion so that we aren’t too critical of ourselves. Sometimes we do everything right and the patient has a bad outcome. And it has nothing to do with what we did. So how do we give ourselves permission to be people? By talking with peers and staying connected to our lives outside of being practicing physicians. And possibly also seeking mental health care if we need to.

JAMA:You’ve talked about the guilt that some health care workers might feel when they don’t have the outcomes they’re looking for with patients. On the flip side, some physicians, like those who are sidelined right now by quarantine or illness, might be dealing with a different kind of guilt. What about that?

Dr Barrett:The guilt of feeling as though we aren’t contributing is really difficult. For those people who feel like they are sidelined, we should normalize it and say, “You’re not alone if you feel that way.”

If they have the bandwidth, they can look for other ways that they might be able to contribute. In my institution, we started a new team of people who are at home and are managing the patients in the hospital who don’t need to be seen in person. It frees up people who are taking care of COVID.

Another opportunity is to advocate. A group of specialty societies representing 800 000 physicians called for social distancing to be implemented widely. This can be a real role for physicians—to demonstrate our leadership in our communities or municipalities, our organizations, our states, to ask our elected leaders to adopt scientific measures to help mitigate the spread of COVID-19.

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    1 Comment for this article
    EXPAND ALL
    Psychologically Immunize Yourself
    Steven Reid, MD, FAANS | Doctor Lifeline, Incorporated
    As the founder and president of Doctor Lifeline, a nonprofit dedicated to preventing physician suicides, I would like to offer a suggestion. First, however, some background. Physicians take their own lives at a rate at least twice that of the general population, and at a rate higher than almost any other profession. Suicide is the second most common cause of death for young doctors, exceeded only by accidents.

    In "normal" times, doctor suicides are a serious problem. In the current surreal times colored by the Covid-19 epidemic, many additional stressors fall upon doctors. These
    include crippling financial damage, especially for surgical specialists, "front line" PTSD, moral ambiguity for older physicians regarding personal and familial risks based on patient exposure, frustrations from lack of evidence based guidelines, delayed tests, inadequate PPE, and many others.

    My suggestion here is to psychologically immunize yourself. By this, I mean, take 10 or 20 minutes to write a letter to your future self while you are still psychologically healthy. Remind yourself why you chose your career and how it rewards you. Remember how important you are to your family. Tell yourself what you would tell a stressed, depressed colleague to help her cope. Rekindle her idealism and enthusiasm. Include contact information for trusted friends and suicide prevention hotlines. Keep this letter on you like a magic talisman. Read it when you feel overwhelmed. Your actions today could save your life in the future.
    CONFLICT OF INTEREST: President of Doctor Lifeline, Incorporated, a 501(c)3 nonprofit working to prevent doctor suicides.
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