Physician Burnout and COVID-19
A stressed and overwhelmed medical system can negatively impact patient care and safety even at the best of times. A global pandemic has made things even harder.
In May, Winnipeg general internist Dr. Jillian Horton wrote an editorial in The Globe and Mail about her concerns over the long-term psychological impact of the COVID-19 pandemic on Canadian physicians. “No longer in fight-or-flight mode, they will be confronted by the enormity of what they experienced, suddenly given time to reflect on what they could or could not do for the sick and dying, and a misplaced sense of guilt at their inability to help everyone,” wrote Dr. Horton.
On a daily basis, physicians operate under the most stressful of circumstances. When COVID-19 arrived, it only heightened the intensity of workplace pressures. The rising prevalence of burnout among clinicians has led to very real concerns about its toll on physician health and wellness. The effects of burnout also pose a risk to access, and quality of care.
Burnout can threaten patient safety when depersonalization — the development of a negative and cynical attitude toward patients and their concerns — leads to poor interactions with patients and poor decision-making. It can also create problems by impairing attention and memory. Doctors who suffer burnout are also more likely to leave practice, which reduces patients’ access to continuity of care.
Before the arrival of COVID-19, the College recognized that many physicians were tired, overworked and on the brink of burnout. But this deadly virus saw new stressors for front-line workers: ever-changing protocols; information overload; inadequate access to personal protective equipment; concern about a potential scarcity of ventilators; and, of course, fears about their own personal safety, and passing the virus on to their family members.
There is no doubt that the pandemic — and its attendant sacrifices — are compounding the issue of physician burnout, especially for those doctors involved in acute care. “They are working without sufficient resources, and, in some cases, they are living apart from their families to avoid exposing them to COVID-19, wrote CPSO Registrar and CEO Dr. Nancy Whitmore in a message sent to physicians on Doctor’s Day. “Many physicians are working around the clock. In addition to their clinical work, some are also helping to clean rooms, volunteering to examine and treat patients in long-term care homes, and working beyond regular scopes of practice to ensure patients receive the care they need.”
In her message, Dr. Whitmore noted that a New York City emergency physician, whose hospital was in the epicentre of the crisis, died by suicide. Dr. Lorna Breen’s family said they believe that trying to care for so many dying patients took a toll on Dr. Breen.
Last fall, well before the arrival of COVID-19, the College conducted an informal poll of 263 physicians. Nearly 20% described themselves as being in ‘survival’ or ‘burnout’ mode. That number, however, is likely an underestimation. These doctors, who were volunteers in a pilot of our Quality Improvement program, were providing their response through a poll conducted by their regulator.
The Ontario Medical Association and the Canadian Medical Association have separately suggested that the number is more likely between 27% to 32% of physicians are clinically burnt out, with female physicians on the higher end of the scale.
We believe that the uncertainty and fears generated by the pandemic will only see that percentage go up.
Long-Term Stress Reaction
Burnout is a long-term stress reaction marked by physical and emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.
The concern is such that the Ontario Medical Association has created a Burnout Task Force and made it one of its top priorities for 2020. The Burnout Task Force is exploring the issue in depth and will be making recommendations on system-wide issues that contribute to burnout. They will also make recommendations to prevent burnout, advocate to government and other stakeholders and co-ordinate with national and provincial organizations.
Addressing the causes of physician’s stress has also been high on the College’s agenda. We cannot expect physicians to safely care for their patients if their own physical and mental health are compromised.
Dr. Whitmore said that when she began at the College in June 2018, the issue of burnout came up regularly in conversations she had with physician groups. “And it became quickly clear to me, that many doctors working within our stressed system were finding that the regulatory environment was further adding to their challenges,” she said.
To counteract this, the College has become more sensitive to the issue of physician burnout, without abdicating our paramount duty to serve the public interest. “I think our adoption of right-touch regulation will help achieve a much needed balance,” Dr. Whitmore said.
Right-touch regulation, she explained, sees regulators intervene only when necessary and interventions are appropriate to the risk posed. “We needed to change our mindset and work to identify how much regulatory force was actually needed to achieve a desired effect,” she said.
In too many cases, she said, we were targeting everything with an energy that was excessive for the circumstances. This regulatory overdrive created stress in situations that did not call for it. “And having medical practitioners that are stressed and burnt out is not in the best interests of anyone — including patients. It is a barrier to quality care,” she said.
How has the College addressed burnout?
Recognizing the extraordinary toll this pandemic is taking on Ontario’s doctors, the CPSO has created a physician wellness page on our website, where we share resources and other important information. We also encourage physicians to get in touch with the Physician Health Program (PHP) if they or a colleague needs support. During this challenging time, PHP is also offering MD-led virtual chats to provide peer support to physicians during COVID-19. Sessions are held daily and are led by a psychiatrist, who is an expert in group therapy. Here are some other steps we took prior to the pandemic to help improve:
- Introduced Alternative Dispute Resolution mechanism as an option for the handling of low-risk matters;
- Decreased the time to complete a complaint by 47% in 2019, compared to 2018;
- Promoted connectedness through the quality improvement’s (QI) emphasis on peer interactions;
- Encouraged professionalism to flourish by developing a QI framework that allows physicians to self-direct their learning;
- Redesigned policies that allow physicians to immediately understand and access College expectations.
The College’s Practice Guide also recognizes the importance of physician wellness as a critical component of the professional practice of medicine.
Good physical and mental health is necessary, it states, to provide high quality care to patients because physicians cannot serve their own patients if they are not well, physicians may have to put their own needs for wellness ahead of the needs of individual patients or the public as a whole in some circumstances.
The best interests of patients are served when physicians take time to meet their own needs and are continually aware of their own wellness. This means recognizing limits imposed by fatigue, stress or illness and taking care to ensure a healthy work-life balance.
This is not always easy, and certainly exceptional crises such as COVID-19 can make it nearly impossible for those on the front line.
“I am grateful that we have, up to this point, been able to avoid a massive surge in critical care, and that our numbers in Ontario are improving. However, that does not mean that the weight of this pandemic won’t take a toll on many of you. It is now more important than ever that we take care of ourselves and our colleagues,” said Dr. Whitmore.