The impact of COVID-19 on resident burnout and how we can combat it

Despite the pervasiveness of mental illness and burnout among medical providers, only in the past decade have providers begun to acknowledge and explore the psychological distress so many struggle with. As a resident, I have observed how COVID-19 has further complicated this situation by dramatically increasing stress while limiting our capacity to deal with that stress. This dangerous combination is setting us up for a surge in already sky-high burnout rates that will resonate through the profession for many years to come. Those affected slog through their work, feeling unfulfilled, and sometimes even providing substandard care. Many walk away from the profession altogether, easing their own exhaustion but leaving another gap in an already strained health care system.

Everyone at every level is working tirelessly to do right by patients, but all too often, we simply can’t. With the sudden strain on resources, my resident colleagues and I are encountering issues that rarely came up during our training. I’ve seen countless delayed tests and surgeries; nurses needing to minimize patient contact; a lack of student access to critical learning opportunities; and furloughed providers who are suddenly unavailable to patients they have known for years. This list could go on, but one common element is clear: our ability to feel like we are providing the best possible care has been devastated, leaving many of us with the crushing feeling of personal failure.

This is a problem we may never solve because being a doctor is a difficult job in the best circumstances. However, residency programs can alleviate some of the moral injury by providing adequate resources and facilitating their use. Confidential, free counseling programs are crucial for wellness, but they do nothing if we are left with no space or energy to use them. We need funding for more residency spots, and we need programs to take advantage of funding when it is available. If there are enough residents, staff, and midlevels to comfortably cover all required locations, we would be able to take time off for a doctor’s appointment without feeling guilty about dumping our work on someone who is already overtaxed. We would also have more time for self-care and wellness activities, extracurricular activities like research, volunteer, or committee work, and even just more time with our loved ones.

The necessity of social distancing, both at work and at home, is already becoming a driver of burnout because we, as health care workers, have been forced into profound isolation. For example, my residency program used to meet every Friday afternoon for protected learning time. While we still have lectures on Zoom, the feeling of distance is palpable, especially now that we are welcoming a new class of interns. Before COVID’s social distancing, we had lunch together, played ping pong between lectures, and commiserated about our sorrows and frustrations over the coffee maker. Each passing interaction brought us closer and made the challenges of our work a little more bearable. At the same time, as we’ve lost this protective factor, residency itself has become even more difficult.

Team sizes must be minimized, increasing the amount of work for each individual. Residents, like nurses, are at high risk of exposure, so we are frequently called in to cover for colleagues in quarantine. It can be hard for our families and us to cope with the amount and intensity of work in a typical residency; longer, less predictable hours strain relationships and can even breed resentment. When we know our colleagues personally, being asked to come in for extra work feels less like a burden they’ve placed on us and more like an opportunity to help. A sense of camaraderie is critical for keeping workers engaged; as that mutual trust breaks down, we lose one of the most potent protective factors against burnout.

Excessive documentation and clunky electronic health records are consistently cited among the top drivers of burnout. None of us went into medicine to do paperwork, and it detracts from time spent on direct patient care, education, and home life. Clerical work is the new scut work, making residents sometimes feel like little more than highly trained secretaries. These are the low hanging fruits of burnout intervention, and perhaps COVID will kick-start the pruning process. Health care networks could, for example, encourage staff to directly submit ideas for more streamlined systems, hire more scribes, or negotiate more reasonable documentation requirements from insurance companies. If successful, providers at every level will benefit from increased work satisfaction and better work-life balance, providing a counterbalance to the unique stressors of working in a pandemic.

In addition to these emotional liabilities, providers may soon have to worry about legal liability for patient injuries caused by COVID-19 policies and system failures. While we are currently protected by our status as trainees, moving towards independent practice in an increasingly litigious system is a scary concept. Malpractice insurance will already comprise a significant dent in our earnings, and that will only continue to increase if we are held personally responsible for the health care failings of the pandemic. Besides the additional financial burden to young, indebted physicians, the threat of any lawsuit carries a psychosocial toll that will be exponentially magnified if we fear retribution for circumstances outside our control. This is a prime opportunity for medical societies to intervene in burnout prevention by proposing additional protections for practices or alternative paths to compensation for patients indirectly affected by the pandemic.

Perhaps most frustrating and destructive is the lack of support so many experience at their home institutions. Many hospitals, clinics, and care facilities still struggle to access basic PPE in sufficient quantities. When employees try to stand up for themselves, all too often, they are silenced, even punished, by the vast health care networks we depend on to do our jobs. Treatment of trainees, particularly residents, ranges from adequate to abusive and rife with blatant ACGME violations. Months into the crisis, inefficient pandemic management continues to consume every spare ounce of our already limited time, energy, and attention. This is a problem at all levels, from hospital administration through the highest branches of government and the clear solution is that the people holding those positions need to be more responsive to the needs of workers. We, as workers, then need to hold them accountable for our well-being, as residents in Washington have been struggling to do.

As the pandemic continues to exploit every gap and flaw in our health care system, there is a heavy temptation to close our eyes and try to power through as we always have. But that is becoming less and less possible. Much like COVID itself, the longer we ignore the root causes of burnout, the worse it will become. With all this additional strain, residents must team up with our more experienced colleagues and pressure health care policymakers to change the way we practice medicine going forward.

Now more than ever, Americans need providers to be at the top of our game. If we hope to live up to the title of “heroes,” I believe we must take this opportunity to push for the systemic support we need to prevent burnout. Anything less will just be a band-aid, because, at its core, burnout is a symptom of a system that isn’t working for patients or providers. COVID-19 is a test of our health care system’s resilience, and if we fail, we risk a world where none of us are satisfied with the care we can provide patients.

Kaci McCleary is a neurology resident.

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