By Christian Rose
During the COVID-19 pandemic, physicians and nurses have found themselves on the frontlines of more than just medical care, advocating for their patients, their families, and themselves. Facing overwhelm and burnout at a scale hitherto unimagined, they continue to fulfill their ethical obligations to their communities and their patients. If they don’t, who will?
It was at a medical conference in New York last March that one of my closest friends and fellow emergency physicians contracted COVID-19 — though he did not know it at the time. The disease was barely a whisper of a rumor in New York at the time of this conference, and yet he took it seriously, did not shake any hands and made sure to respect people’s space. Within a few days of returning from that conference, he developed chills and aches and got tested, only mildly surprised to find he had contracted COVID-19.
When the anxiety and fear of how his disease would progress waned, his real concerns crept in. We talked the night of his diagnosis. Despite his feelings of shame and guilt for somehow contracting a highly infectious virus, he felt strongly that he would not be alone in the weeks to come. He felt a responsibility to be open with the community, to help fight anxiety and fear with scientific evidence, so he recorded his experience in a Medium post to share with others. It wasn’t his responsibility, and he did not necessarily feel like a writer, but he could help prepare minds for what was coming, and so he put pen to paper.
Perhaps these shared accounts were what prompted many clinicians to wonder what they would do if they too became ill. Frontline providers realized that they were going to be staring death in the face, literally and metaphorically, on a daily basis as the pandemic numbers began to rise. Fortunately, they thought, they knew how to don and doff PPE and would be safe with the right precautions.
They would then learn that their hospitals did not have enough PPE for everyday use by all staff. Friends reported saving their N95 masks in paper bags and hanging single-use gowns between shifts; others simply wore them non-stop over a shift. Following the lead of others around the country, one close friend from residency set to work testing, validating and producing 3D printed PAPR shields and delivering them to colleagues around San Francisco between her shifts. Before long, another group of colleagues and emergency physicians created a website called GetUsPPE.org to help hospitals and suppliers match needs to product availability. They had little working knowledge of global supply chains or access to high throughput production systems, but no one else seemed to have solved these problems; they could help, if even one gown at a time.
Disparities in access to resources were what had driven some of my closest friends to the practice of medicine in the first place. To them, it came as little surprise when nationwide death rates revealed that those suffering the most severe illness and death during the pandemic were members of communities of color.
But with the events surrounding the deaths of Breonna Taylor and George Floyd, it became evident that no matter how much work they did in the hospital, their efforts to improve the health and wellbeing of their community was nearly impossible without social activism. Equitable care alone would do little to address the root cause of the systemic racism, which put their patients at risk every day — not just during the pandemic. So, when not intubating critically ill patients or volunteering their service in overwhelmed hot spots (including nursing homes and prisons), some of my most resilient colleagues committed themselves to organizing and supporting #WhiteCoats4BlackLives protests or petitioning for legislative change.
At their hospitals, underrepresented in medicine (UIM) colleagues were asked to lead diversity initiatives for their departments and hospitals and to help support and develop equitable hiring strategies or educational curricula addressing social determinants of health. They were not the CEOs or presidents of these institutions, nor political scientists or elected officials, but nevertheless found themselves in the position of responsibility for advocating for their community.
This role became ever more poignant as the fall of 2020 approached and we faced not only a hotly contested election, but the third and worst yet wave of coronavirus deaths. When the possibility of a vaccine became a reality, suddenly many questions representative of systemic mistrust and health care hesitancy boiled to the forefront. Given months of unclear, misguided information coming from our highest medical authorities like the CDC, there were rightful misgivings about the vaccine’s safety as well as its rollout strategy. Was it coming out too quickly, and had it been properly tested?
With a solemn look toward the future and recognition that mass vaccination offered the best possibility of safety for all of our patients, doctors and nurses found themselves at the center of public outreach campaigns and recording themselves getting “their shot” and sharing it across social media. Some took to Twitter or forums like Clubhouse to address misinformation and fact-check rapidly escalating conspiracies. At the moment when the death toll was highest, when health care providers’ regular responsibilities were more important than ever, they found themselves also learning to make TikTok videos and appealing to an audience of patients they may never physically see. They were not public relations experts or news anchors, but there was a desire for truth and they were asked to provide it.
The list of roles could continue on and on. In the wake of almost a year of school closure, some colleagues found themselves acting as home-schoolers — which weighed disproportionately on women. Many have elderly, at-risk family members who require care, so they balanced the risk of exposure from COVID-19 patients with that of infecting their loved ones. Most have become the de-facto “telemedicine” provider for their friend groups, fielding a spectrum of questions and hypothetical scenarios to help them navigate the complexities of our new social lives. All of this in addition to the expanding responsibilities of helping to secure housing, shelter, clothing and food for their patients.
This is not to say that we are the only people playing these roles, but it does leave one wondering: are we really the best people for the job?
I am consistently, profoundly in awe of all that my peers do for their patients and communities. But I am concerned that their much needed work and enthusiasm necessary to fill the vacuum left by institutions, which have continually failed to rise to the occasion, will be at the cost of their personal well-being, and ultimately patient care.
Before the pandemic, the issue of physician burnout was a real and present danger. Not only do we already face a shortage of physicians in the workforce, but we also pay $4.6 billion per year for the economic costs of burnout in the health care system. Numerous studies have shown that the epidemic of burnout within the medical community has continued to worsen throughout the COVID-19 pandemic. One of the greatest causes of this burnout has been our inability to turn our brains off and limit the scope of our practice to our direct responsibilities. We know that the Hippocratic Oath is not a suicide pact, but few can turn away from those asking for their help.
Addressing the issue of burnout in the health care workforce often appears to fall, once again, on our own shoulders. It has been assumed that it is enough to simply offer clinicians resources to address each of the many problems that arise due to systemic failures. But this patchwork approach does little to stem the overwhelming tide of clinician burnout. Organizational change is the only way to create lasting impact.
We need help. In an era where health care administrators outnumber clinicians 10:1, perhaps we can find some support for the non-medical needs of our communities. We need systems that provide the social support we expect and demand — ones that don’t rely on the exploitation of doctors and nurses to provide food, shelter, and clothing in addition to caring for the ill. We need functioning, consistent messaging from the CDC on disease expectations. We need visible support from media moguls. We need industrial support with production and supply chains. We need functioning school boards. If we don’t receive this supporting cast, there might not be anyone left to play the role of health care provider.
Dr. Christian Rose is an emergency medicine informaticist specializing at the intersection of clinical medicine, innovation and humanism. His goal is for our computational systems help to amplify the human experience in medical care.
This post is part of our digital symposium, In Their Own Words: COVID-19 and the Future of the Health Care Workforce.