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1 abril, 2022
Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice
On the same day in March 2020 that President Donald Trump declared the COVID-19 pandemic a national emergency, researchers at the Larry A. Green Center in Virginia launched an ongoing survey of COVID-19’s effects on primary care practices. Over the past 2 years, more than 36 000 survey responses from clinicians across the country have painted an alarming picture of a workforce that’s increasingly burned out, traumatized, anxious, and depressed. As Green Center codirector Rebecca S. Etz, PhD, summed up her survey’s findings in a recent interview with JAMA, “It’s been bad for primary care over the pandemic and it’s getting worse.”
Another national health care worker survey, the Coping With COVID study, found that burnout approached 50% in 2020 among 9266 physicians across medical disciplines. Last year’s survey results, which haven’t been published yet, are more dire still, according to study coauthor Mark Linzer, MD, a professor of medicine at the University of Minnesota whose research focuses on burnout. His takeaway: burnout has increased considerably as the pandemic has dragged on.
“It has been a very, very trying 2 years for the clinician workforce, and the health care workforce in general,” Linzer said in an interview. “Particularly over the last 6 months, I think people have really just needed to process what they’ve been through and have time to recuperate. But there really has not been time, given all the pent-up demand for care and the continuing pandemic and the Omicron surge.”
Meanwhile, Lotte Dyrbye, MD, MHPE, chief well-being officer for the University of Colorado School of Medicine, said that some physicians have had the opposite experience during the pandemic—too little work. “An important thing to realize is that how the pandemic has affected physicians is incredibly heterogeneous,” she said in an interview.
Many medical specialties saw the workload decrease in the pandemic’s first year and even during subsequent surges, when demand for non–COVID-19–related visits and elective procedures evaporated. Some practices watched their business and finances dry up.
Experts warn that the COVID-19 pandemic, now entering its third year, has pushed an already fragile workforce to the brink. For many clinicians the workplace challenges—ranging from high stress and burnout to understaffing and reduced income, often in combination—have become insurmountable
Worsening staffing issues are now the biggest stressor for clinicians. Health care worker shortages, especially in rural and otherwise underserved areas of the country, have reached critical and unsustainable levels, according to the National Institute for Occupational Safety and Health (NIOSH).
“The evidence shows that health workers have been leaving the workforce at an alarming rate over the past 2 years,” Thomas R. Cunningham, PhD, a senior behavioral scientist at NIOSH, wrote in a statement emailed to JAMA.
In the absence of national data, Etz says the Green Center data point to a meaningful reduction in the primary care workforce during the pandemic. In the February 2022 survey, 62% of 847 clinicians had personal knowledge of other primary care clinicians who retired early or quit during the pandemic and 29% knew of practices that had closed up shop. That’s on top of a preexisting shortage of general and family medicine physicians. “I think we have a platform that is collapsed, and we haven’t recognized it yet,” Etz said.
In fact, surveys indicate that a “great clinician resignation” lies ahead. A quarter of clinicians said they planned to leave primary care within 3 years in Etz’s February survey. The Coping With COVID study predicts a more widespread clinician exodus: in the pandemic’s first year, 23.8% of the more than 9000 physicians from various disciplines in the study and 40% of 2301 nurses planned to exit their practice in the next 2 years. (The Coping With COVID study was funded by the American Medical Association, the publisher of JAMA.)
A lesson that’s been underscored during the pandemic is that physician wellness has a lot to do with other health workers’ satisfaction. “The ‘great resignation’ is affecting a lot of our staff, who don’t feel necessarily cared for by their organizations,” Linzer said. “The staff are leaving, which leaves the physicians to do more nonphysician work. So really, in order to solve this, we need to pay attention to all of our health care workers.”
Nurses who said they intended to leave their positions within 6 months cited 3 main drivers in an American Nurses Foundation survey: work negatively affecting their health and well-being, insufficient staffing, and a lack of employer support during the pandemic.
“Health care is a team sport,” L. Casey Chosewood, MD, MPH, director of the NIOSH Office for Total Worker Health, wrote in the agency’s emailed statement. “When nurses and other support personnel are under tremendous strain or not able to perform at optimal levels, or when staffing is inadequate, the impact flows both upstream to physicians who then face a heavier workload and loss of efficiency, and downstream impacting patient care and treatment outcomes.”
The Pandemic in Primary Care
The pandemic began to take its toll on primary care clinicians early on, says Etz, who is a professor in the department of family medicine and population health at Virginia Commonwealth University. Although primary care offices typically handle the vast majority of respiratory infections in the community, they weren’t prioritized for personal protective equipment (PPE) and other crucial supplies when COVID-19 struck. “Our survey showed, going as far as 6 months into the pandemic, half the [clinicians] still didn’t have PPE,” Etz said. “People were wearing coffee filters and garbage bags to take care of their patients.”
The Green Center survey showed that primary care clinicians’ stress levels improved last summer as vaccines became widely available in the US, but the Delta variant surge reversed this. Since then, physician mental and physical exhaustion has returned to prevaccine levels.
As of this February, only about a fifth of Green Center survey respondents were fully staffed, and 44% had open clinician positions they could not fill. Still, 40% of respondents said they had taken on an influx of new patients whose previous practices closed. The pandemic also required primary care practices to provide new or expanded services—telehealth, home monitoring of patients with COVID-19, and more mental health care, to name a few.
They’ve done all this with limited resources. Throughout the public health crisis, primary care physician practices have struggled with low reimbursement for telehealth and long-overdue payments from insurers, Etz says. Applying for aid, such as Paycheck Protection Program (PPP) or Small Business Association (SBA) loans, was onerous and itself often costly. “The primary care practices that I know that were able to get money from PPP and the SBA loans that were available had to hire accountants to help them figure out how to do it,” Etz said. Unpublished data from various states and task forces suggest that less than 5% of health care sector financial assistance may have gone to primary care, she noted.Trying to do more for patients while dealing with shrinking staff and resources—all during an unprecedented infectious disease crisis—has left some clinicians traumatized. “In our qualitative comments,” Etz said of the Green Survey, “we still get people sharing suicidal ideation. Talking about panic attacks in their sleep and pulling over on their way to work to puke because they’re under so much stress.” Recent survey responses reflect the ongoing distress:
“I cannot continue to work at this pace and retire at 65. I am 50. I am chronically exhausted. There is no relief in sight.”
“I’m burned out. The patients have so much anxiety and it has affected me. I see 21 patients daily for relatively low pay. I’m on my way out of this position—I can’t remain healthy and stay here.”
“I am emotionally traumatized and experiencing severe burnout. I would quit if I was able.”
“I had planned to work for at least 10 more years, now I’m thinking about ways to retire as soon as possible.”
“I have been in practice for over 30 years and have never felt so emotionally and physically drained as I have this year. I have given up trying to correct COVID misinformation and this is so very discouraging.”
“I’ve exited practice. Pray I don’t ever need to go back. It’s miserable with no positive indicators for improvement.”
More Than Words
Etz, who trained as a cultural anthropologist, sees a troubling pattern in the responses: lack of hope. Hopelessness was also apparent in a mid-2021 survey by the nonprofit Physicians Foundation. About 20% of 2504 physicians said they knew a physician who had either considered, attempted, or died by suicide during the COVID-19 pandemic.
Today, frontline clinicians are experiencing high rates of depression, anxiety, sleep disturbance, and posttraumatic stress disorder, according to Dyrbye, who is a member of the National Academies of Medicine’s Clinician Well-being Collaborative. “Many of them are running on the very last steam,” she said. She noted that compassion fatigue, a result of high levels of work stress, has also set in for some: “They’re getting tired of taking care of patients who are incredibly sick and aren’t vaccinated.”
“There’s clearly still widespread burnout, fatigue, and frustration not only related to the earlier phases of the pandemic, but also the aftermath related to shortage of staffing,” Lou Baptista, MD, MPH, executive vice chair of the department of psychiatry at Columbia University Medical Center (CUMC), said in an interview.
As a result, some physicians are cutting their clinical hours for the first time or jumping ship to different institutions where they feel they’ll be better cared for. Baptista says that many mental health professionals at CUMC are leaving for private practice, where they can work fewer days, make more money, and practice telemedicine from the comfort of their own home
An important mitigator of health care burnout and intention to leave, it turns out, is feeling valued by one’s organization, which Linzer says requires more from employers than simply expressing the sentiment. Dyrbye says health care organizations must undertake systemic steps to improve the work environment. That means finding ways to reduce workload, improve work efficiency, maximize teamwork, and promote a culture of wellness.
Linzer, who directs the Hennepin Healthcare Institute for Professional Worklife, offered a workload solution: if resources allow, float physicians can be hired for periodic coverage, or locum tenens clinicians could be brought in to cover shifts during critical times. “I’m hoping that our health system has learned that as we go through these crises, not unlike in the military, one needs to plan how many times you deploy someone, how long you deploy them for, when you give them a rest to put somebody else in place,” he said.
Early in the pandemic, when time off wasn’t a reality for New York City’s frontline health workers, Baptista helped organize a group of CUMC psychologists and psychiatrists who began volunteering their services to other clinicians in the health system. The program, called CopeColumbia, offered 30-minute peer-to-peer telehealth support sessions, small group sessions customized for different clinical departments, and larger webinars and town halls devoted to topics like stress, trauma, and grief.
“Our thinking was, can we create these brief spaces of just half an hour to give them support,” said Baptista, who last year was named chief well-being officer at ColumbiaDoctors. About a third of the early peer-to-peer sessions led to referrals for clinical care. Over the past 24 months, CopeColumbia has expanded to become the main platform that provides well-being resources and peer support to all medical center employees, not just clinicians.
Last year, NIOSH launched a campaign to address health worker stress, burnout, depression, anxiety, substance use disorders, and suicidal behavior—long-standing problems exacerbated by the pandemic. A goal of the Health Worker Mental Health Initiative is system-wide, organizational-level improvements. The program’s research, funded by the American Rescue Plan Act, could help inform fundamental changes to health care worker shifts, workloads, benefits, time off, and more.
NIOSH’s Chosewood acknowledged the challenge ahead: “The design of work in healthcare needs an overhaul,” he wrote. “Ideally, health worker jobs are so well-designed that doctors, nurses and technicians go home at the end of a fulfilling work day even healthier than when they arrived. I don’t think that’s a pipe dream.”
Linzer agrees that changes are overdue to reduce burnout. “I think there’s a lot of ways that things could be done differently—a lot of work that could be done by others, that would give a chance for physicians to grieve, debrief, heal, and then continue again,” he said. “But the idea of just rushing to start again is, I think, not going to work.”
Conflict of Interest Disclosures: Dr Dyrbye reports being a coinventor of the Well-being Index instruments and receives a portion of any royalties paid to Mayo Clinic for use of these instruments; receiving honoraria for lectures and presentations related to health care professional and trainee well-being; serving as a paid adviser to various medical schools and health care organizations; and receiving grant support from the National Science Foundation. Dr Etz reports receiving funding for work to assess primary care capacity and response to the COVID-19 pandemic from the Andrew and Corey Morris-Singer Foundation, the Samueli Foundation, the American Board of Family Medicine Foundation, and the Agency for Healthcare Research and Quality (AHRQ) and honoraria for related presentations on her data; and serving as CEO of Smart Measures, LLC, which provides electronic ability to field patient-reported measures. Dr Linzer reports being supported through his employer, Hennepin Healthcare, for burnout reduction projects by the American Medical Association, the American College of Physicians, Optum Office for Provider Advancement, the Institute for Healthcare Improvement, the American Board of Internal Medicine, Essentia Health, and Gillette Children’s Hospital; receiving support from the National Institutes of Health and AHRQ; and consulting on a grant for Harvard University on work conditions and diagnostic accuracy. Dr Baptista, Chosewood, and Cunningham reported no disclosures.
Créditos: Comité científico Covid