The Unique Mental Stressors of COVID-19's Second Wave

Lloyd I. Sederer, MD


February 08, 2021

Lloyd I. Sederer, MD: I'm Dr Lloyd Sederer, and you're watching COVID Conversations, a collaboration between BongoMedia and Medscape. My two guests today are Dr Don Berwick, senior fellow at the Institute for Healthcare Improvement, and Dr Esther Choo, an emergency physician and professor at the Oregon Health & Science University.

This second COVID surge is more pervasive and deadlier. Esther, from your perspective, what do you think the impact of this is on our medical workforce?

Esther Choo, MD, MPH: During the first wave, there was a lot of adrenaline and a wave of energy to put toward an immediate crisis. I think there's an extent to which we operate like that in healthcare and in the hospital. We're used to these discrete events where everyone needs to step up, like a natural disaster that affects a state or a region, or a mass-casualty event. We're used to facing an unexpected crisis, where everyone dives in and gives it their all.

The first wave was much more extended than we thought. The gravity of it, and the extent of disease and death, was surprising. It was psychologically very hard, and there were also a lot of unknowns. Operating in an atmosphere where you aren't even certain of the care that you're giving and are trying to learn on the fly while you have this huge patient volume, and such severe disease and death, was really hard. But I do think we had that kind of adrenaline push and sense that we're all in this together.

Sederer: There was a paper in General Hospital Psychiatry about the psychological distress that New York City healthcare workers experienced as a result of COVID-19. It revealed a loss of control, fears of transmitting the disease to their family and friends, and the distress of needing to be socially distanced from them to prevent transmission. Do you believe that this is also the same experience the second time around?

Choo: I think there are better things and tougher things about this second time. We're approaching a full year of sustained efforts in trying to deal with this, so the mental fatigue is huge.

But there are some aspects in which there's less uncertainty, and that's given us a little bit of a mental break. Now we can feel a lot more confident when we go into patients' rooms that we know the core safety measures we need to achieve. Some of the care feels very routine. It's more at our fingertips, but the science is still evolving.

This has been such a sustained crisis that I think people are really burned out. It is hard to feel anxious and scared for that long of a period. Really, we started at burnout. Now it's beyond burnout, beyond stress, beyond anxiety.

Sederer: It's a question of, where are you going to draw that will and that energy from?

Don, what are your thoughts about this as someone who's observed healthcare systems in hospitals for a very long time?

Donald M. Berwick, MD, MPP: Dr Choo's on the front lines and speaks with more direct experience of what it's like. We need to listen to her words.

I notice what she's noticing. On the positive side, it is very impressive how the expertise in managing this illness has grown. We know so much more now, both about the scientific approaches to management — what works and what doesn't — and about helping these people clinically through serious phases of illness. The results speak for themselves. So, the good news is the improved pedigree behind the protocols and guidelines that people are using.

On the other hand, the chronicity of the stress, as Dr Choo said, is extraordinary. I believe that in some ways there's more uncertainty with the second wave. The first time there was a kind of feeling that maybe we'll do this and this thing will be behind us. Instead, now we don't know how many more waves there will be. When will this wave tail off? When will the vaccine start to actually show an effect? People are living with a much cloudier horizon now than we had when this thing first hit.

I've had more colleagues leave the emergency department, leave frontline care, than I've ever seen before.

Not insubstantially, in the Northern Hemisphere, we're heading into the dark months when the days are shorter, nights are longer. Effectively, it's already a hard time. That means, for both patients and staff, the chance to get outside, be in the fresh air, socially distanced, maybe eating outside, is now much more constrained. That adds extra wear and tear, so it's a very difficult time.

Sederer: If the adrenaline that drove clinicians during the first wave has been depleted, what keeps you and others going?

Choo: Not everyone is still going. I've had more colleagues leave the emergency department, leave frontline care, than I've ever seen before. I haven't seen statistics; I just know that we're all sharing stories of beloved colleagues that we've worked with for many years who are looking for a different type of job — telehealth or a desk job — or simply deciding to retire a little early.

I think it's the convergence of a number of things. We're not used to sustaining efforts like this for so long. The uncertainty and anxieties have shifted from pure clinical care to the whole picture of whether we're going to be able to even get out of this. We're having to learn new skills every day. We don't always feel well supported by our systems. The communication hasn't always been good. There have been times when public sentiment actually seems to be directed against healthcare and frontline workers, and that's incredibly discouraging.

This has taken so many twists and turns. Right when you think you turned the corner, there's another holiday and we watch in amazement as public behaviors are not what we're hoping, and then we enter another surge. There are so many different stressors and not a ton of wins in proportion to the stressors and the disappointments.

I think those of us who are staying are feeling like there is light at the end of the tunnel, as Dr Berwick noted. There are incredible scientific advances here. We got a vaccine within a year of even hearing about the virus. There are these things that keep on giving us hope. Those of us who are able to focus on the hope and just keep on moving forward are able to stay in. But I think there are a lot of professional casualties here as well, and we're not going to really appreciate them until we're through.

Sederer: What's the effect on younger docs, those in training, those beginning their career this past year?

Choo: Our trainees have had a rough time. They first were removed from the bedside, and so they had this tremendous disruption in their training at a time when they were so excited to be there. Then, at different times of the pandemic, they've had to take the brunt of the work as well and be exposed to a lot of risk. Yet in some places, we're told, they weren't the first priority for things like vaccine. It's been a lot of whiplash for them in terms of how their training has played out and whether they're the most important or the least important members of the team.

No generation of physicians has gone through this kind of change and disruption in their training process. I think this will be kind of a historically remarkable class, because they've had to innovate and to balance all the things that attendings are balancing, but without a lot of autonomy or decision-making in the process. I think we'll all look back and realize that it was really an incredible year for residents and for medical students to endure and find different ways to continue the learning process in this really chaotic environment.

Some of the things that students did were incredible. They asked, "How can we help if we're shut at home and we can't do our rotations?" They created babysitting services, nonprofit organizations to support people who are struggling, using incredible innovation. I think from that experience will come a lot of our future leaders.

Berwick: I've also noticed that we've used this vocabulary of heroism, cheering in the streets and understandably being extremely grateful to professionals for being heroes. That's a double-edged image.

Sederer: I've heard from some doctors that they don't like being called heroes.

Berwick: Reflecting on my own training, that's a heavy burden to bear, to be expected to produce magic instead of just to do your best and get through it. I think that's a stress on older physicians and nurses as well.

Plus, this is a confused and frightened public right now, thanks in part to problems in our national leadership and the lack of a public health plan. [Editor's note: This video was recorded in December 2020.] That also changes the dynamic for clinicians and patients. Who is expecting what from whom? Testing is now starting to really take hold (finally, I hope, a national testing plan will be in our hands), some treatments like dexamethasone are arriving and really helping, and the vaccine is here. But this is a shifting terrain. Being a professional navigating this and trying to understand what's going on is hard enough, so then dealing with a public that's asking what they should do, and what's going to happen, is a whole other burden.

Sederer: No member of my family or my community wants to hear me be uncertain about what's going to happen over the next 6 or 12 months. We make educated guesses, but we just don't know because the field is constantly moving.

Berwick: That's really been a task for us mentors even before COVID, to help people deal with this image of invulnerability or magical thinking, and how as a professional you can own responsibility and not feel like that. COVID has now just amped up the issue.

Sederer: I had the experience of serving as chief medical officer for the New York State Office of Mental Health after 9/11 and Hurricane Sandy. We came to say that it's normal to feel distress in an abnormal situation, and to learn a bit about what predicts resilience in those people who are in the middle of a catastrophic situation or have had a terrible loss. What do you think makes a difference with doctors, nurses, and others in terms of being resilient, staying the course, and being able to not be scarred by it?

Berwick: First is to recognize their humanity. We're the same as everybody else. To just be able to recognize that and get in touch with one's humanity is key. To do that, it takes others. You need mentors and support systems.

At the Institute for Healthcare Improvement, we have a slogan: "Never worry alone." If I had to pick one thing, it's the capacity to be with others in this time of discomfort.

Sederer: We've been conducting private, anonymized recordings through BongoMedia, in collaboration with NewYork-Presbyterian and Massachusetts General Hospital. It gives doctors and nurses a chance to speak with each other in an unfiltered way without their bosses knowing. This becomes an enormous source of support. It's not worrying alone and it's knowing that you're not in it alone.

Esther, how does that happen on a day-to-day basis with your colleagues?

Choo: I've been so fortunate in some ways to work in a setting where you have to come together as a team. I have colleagues whose clinics have now been changed into them just taking calls from home and they're completely isolated. I go into a job where we all see each other.

Actually, we get ready for trauma and we're gowned up from head to toe, and we'll look around and say, "I think we can give each other hugs," because we're fully COVID protected. We can actually go in for a little bit of a hug for that human connection. The first time we did it, it felt like we were sneaking a treat because we had been forced away from these everyday human connections in ways that we support each other and show that we care.

This is another area where there are these silver linings. Even though being in the emergency room is sometimes stressful, I get to go in and be around peers who are feeling the same way, and we are bouncing feelings off each other the entire shift. You often clearly feel that you're emotionally offloading even as you're working and caring for patients in a stressful environment. Those connections are so key and I feel really lucky.

Sederer: We performed an analysis of the conversations we had with both doctors and nurses at Presbyterian and Massachusetts General Hospital. It showed emotions being just blown away in that first surge. There were emotions of sadness, loneliness, distress, anxiety. It seemed like the best medicine for them was to be in contact with their other colleagues.

Don, what has your experience of resilience been at the Institute for Healthcare Improvement?

Berwick: The Institute for Healthcare Improvement's been working to try to help people connect with each other and organizations. We have something called The Leadership Alliance with about 55 member organizations, including clinicians who we get together virtually on a regular basis.

I have never, ever seen such a hunger for connection. We come together now on almost any topic. And we often have hundreds of people show up just to share what they're finding out, how they're handling particular issues, both for problem-solving and emotional support. It's been very striking.

In the virtual world, there are no hugs, so finding even more vigorous ways to exchange and look at each other has been moving. It's the only pathway I know out of this distress.

Sederer: The irony of COVID is that we want to socially distance to protect ourselves and others, but we're also social creatures who need each other. But we need to keep an eye on those colleagues who will develop a depression or trauma disorder, use too much alcohol and drugs. That's what we need to do as well as talk.

This has been a collaboration with BongoMedia, for which I serve as the chief medical officer. We're glad to have you participate and hope that you'll join us for future videos, in which we'll turn our attention to the homes and families of doctors, nurses, and other healthcare clinicians during this stressful time. Thank you.

Donald M. Berwick, MD, MPP, is president emeritus and senior fellow at the Institute for Healthcare Improvement, and one of the nation's leading authorities on healthcare quality and improvement. In July 2010, President Barack Obama appointed Berwick to the position of Administrator of the Centers for Medicare & Medicaid Services, which he held until December 2011. Berwick has served as clinical professor of pediatrics and health care policy at Harvard Medical School, and is a lecturer in the Department of Health Care Policy at Harvard.

Esther Choo, MD, MPH, is a professor at the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University. She is a practicing physician and a popular science communicator. Choo writes a regular column on healthcare inequalities for The Lancet while also serving as a medical analyst for CNN.

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