Much has been written about the challenges frontline health care workers have faced during the COVID-19 pandemic. Long hours, excessive death, and fear for one’s own safety and the welfare of family and colleagues have been a consistent theme over the past 22 months. Physicians and nurses started as heroes, but due to strained politics and social-media misuse, they’re now branded by a substantial swath of society as pariahs and purveyors of a medical hoax. The timing of this pandemic could not have been worse: According to the Medscape National Physician Burnout & Suicide Report 2021, 79% of physicians stated their burnout had started before the COVID-19 pandemic.
The pandemic has placed a spotlight on a system strained by burnout and moral distress. Hospitals have always been a safety net for society’s sickest and most vulnerable patients, leading to daily stressors that became accepted as part of one’s job. In addition, the past decade brought with it new challenges that have led to the gradual erosion of safety, respect, and civility, both within hospitals and also for frontline staff.
At baseline, it’s estimated that 75% of workplace violence happens within the health care system. This likely underestimates the actual number, as most frontline workers consider verbal and physical assaults to be part of their job. The American College of Emergency Physicians has stated that 70% of emergency department clinicians have reported acts of violence, while only 3% have pressed charges.
The opioid epidemic brought more risk to frontline staff, as physically addicted patients sought access to pain medications. These interactions often led to verbal and physical threats against both doctors and nurses. Moral and ethical distress was profound as clinicians attempted to navigate the crisis and discern objective pain from opioid-abusing behavior.
Politics began infiltrating the health care system long before the pandemic. Clinicians were accused of advocating for “death panels” by politicians opposed to the Affordable Care Act. Clinicians are now witnessing needless suffering and death due to the politicization of the COVID-19 vaccine and misinformation surrounding appropriate treatments. COVID-19 has brought a new reality: patients and families not only willingly make decisions that place themselves and others at risk of great harm, but also actively deny basic scientific facts and accuse clinicians of lying to them about their illness. Last year in Ohio, a hospital was ordered to give Ivermectin to a COVID-19 patient by a local judge (a decision that was subsequently overturned), despite no current scientific consensus that it provides any benefit. This erosion of basic respect for science, along with the loss of professional autonomy, has only worsened the sense of helplessness sustained by health care workers.
Where do health care workers go from here? What’s needed to prevent a continued exodus from the frontlines and to ensure that patients will have continued access to high-quality, evidence-based care?
1. Health care systems need to eliminate all barriers to frontline workers receiving mental health treatment. One model will not work for every system, but some combination of onsite counseling and easy-to-schedule, off-campus treatment is urgently needed. Opt-out (auto-enrollment) programs have been shown to increase the use of mental health resources in resident-physician training programs. State medical boards need to either eliminate mental health questions entirely from applications or ask only about current impairment. Historically, these questions have made clinicians reluctant to seek much-needed mental health care.
2. Increased investment in making hospitals safer. This will require a combination of more security staff, zero tolerance for threatening behavior, and eliminating the culture that physical and verbal assaults are “just part of the job”. In our appropriate quest for patient-centered care, we must not allow behaviors in hospitals that are not tolerated (and often prosecuted) in other sectors of society.
3. Health care systems should consider sabbaticals at the end of the pandemic for the most affected frontline workers. Short-term costs would pale in comparison to long-term expenses associated with the loss of experienced staff, and the costs of recruitment and training to replace them. The business world has recognized paid sabbaticals (usually for workers who have at least three years of tenure, with a duration of one to six months) to create more productive, focused, and innovative staff. Although this might be considered radical, it has the potential to reduce overall costs for strained hospital budgets and allow health care workers to come back to work mentally and physically healthy.
These steps are just a start. Additional innovative, actionable ideas are required, which should include taking a holistic look at a system that depends on surgical procedures to keep hospitals financially viable. Rolling cancellations of non-urgent surgeries revealed just how much hospital budgets rely on procedures, not medical patients, to remain profitable (and in turn, capable of funding programs and schedules that prevent/treat burnout). Time is of the essence, as the needs of frontline workers to address PTSD, guilt, anger, depression, and anxiety will be there long after society has moved on from the pandemic.
Dr. Hilger has been a hospitalist for 20 years with HealthPartners in Minneapolis. He is the system utilization management medical director for HealthPartners, an adjunct associate professor of medicine, University of Minnesota Medical School, and the current chair of SHM’s public policy committee.