Running on empty

First, doctors say they’re sorry for calling.

Dr. Allison Cotton, a psychiatrist in Reno, Nevada, co-founded the national Physician Support Line in March 2020 to provide peer mental health support to physicians. She says their impulse to apologize shows the need for the service.

“They’re apologizing for using a resource which is literally created for them because somebody else might need it more than them,” she explains.

During the COVID-19 pandemic’s early days, doctors called about feeling exhausted and overwhelmed, which later evolved into sorrow over losing patients.

“When I take calls, a lot of the comments that I hear are things like, ‘I don’t think I can take losing another patient,’” Cotton says. “The ruminating thoughts that they have are things like holding people’s hands while they die alone, having to then tell the families, over and over and over again.”

Another thing Cotton has heard “numerous times” she says, “is having husband, wife and adult child all in the ICU altogether, and then they all just are gone, so watching generations of families pass away.”

Now, she gets more calls from people who are leaving medicine and are heartbroken about it.

Health care professionals in Virginia have experienced the same pain and stress. The pandemic exacerbated the existing burnout problem in health care, which in turn worsened the labor shortage as people left the industry for lower-stress jobs. In late May, U.S. Surgeon General Dr. Vivek Murthy released an advisory titled Addressing Health Worker Burnout.

“As the burnout and mental health crisis among health workers worsens,” Murthy wrote, “this will affect the public’s ability to get routine preventive care, emergency care and medical procedures.”

Health care systems rushed to respond, implementing wellness programs and peer support groups, as well as offering counseling to employees.

“We can’t be all that we want to be to everybody,” says Dr. Sandy Simons, who, prior to the pandemic, in 2015, sought treatment for depression. An emergency medicine practitioner at Bon Secours’ Richmond Community Hospital, Simons was featured on the cover of Virginia Business’ July 2020 issue for a story about front-line health care workers in the pandemic.

Having previously established boundaries between her work and personal lives, Simons was able to appreciate her contributions during the pandemic. She feels that physicians can compartmentalize well.

“We’re generally, for better or for worse, pretty good at turning it off when we come home,” she says. “But I think for me the big thing in the pandemic was that when I came home, you didn’t have all of the ways that you typically decompress: the gym and seeing friends and seeing family.”

Health systems recognize their employees’ struggles.

“They’ve been running a marathon like it’s a 40-yard sprint,” says Paul Hudgins, senior vice president and chief human resources officer for Roanoke-based Carilion Clinic. “Like other health care organizations’ staff … they’re tired and fatigued, and they’ve done an incredible job self-sacrificing in many ways during this entire pandemic.”

Medscape’s Physician Burnout & Depression Report 2022 found that 47% of physicians said they felt burnt out in their jobs in 2021, up from 42% in 2020. A March 2021 study published in the Journal of Advanced Nursing found that 34% of nearly 19,000 nurses studied were experiencing emotional exhaustion because of the pandemic.

Cotton says that doctors calling the hotline have expressed shifting emotions and frustrations, including a sense of personal failure and anger at their hospitals, politicians and even themselves “for any number of things — for not setting better boundaries, for neglecting [their] children and living away from them for six months.”

Instead of “burnout,” some doctors including Cotton, prefer the term “moral injury,” referring to instances when a workplace asks employees to oppose their values, such as requiring them to spend an unreasonable amount of time away from their families.

The problem of physicians’ stress gained national attention following the suicide of Dr. Lorna M. Breen, who killed herself in April 2020 at her family’s Charlottesville home.

The head of emergency medical services for several New York-Presbyterian system campuses in New York City, Breen “was a victim of this guilt that you feel when you can’t see more patients, you can’t work another hour, you can’t go another 10 minutes without eating or using the restroom,” Cotton says. “My personal belief is that this moral injury contributed to her ultimate suicide.”

Stigma and silence

Health care professionals face a deep-rooted professional stigma against seeking help for — let alone discussing — their mental health struggles.

“There is a culture in medicine of ‘It’s not about you anymore.’ … There is a shared understanding that as a physician, you will make sacrifices so that your patients get the best treatment possible,” Cotton explains, including missing significant family events or otherwise straining personal relationships.

About 20% of physicians reported to Medscape that they worried they would be shunned by colleagues if they sought help for depression, and 43% of physicians said they would not seek help for depression for fear someone would disclose it to the medical board.

State medical license applications often ask whether the applicant has sought treatment for a mental illness. In Virginia, applicants must disclose whether they currently have a mental health condition that affects their abilities to perform the obligations and responsibilities of their professional practice safely and competently.

Consequentially, many Virginia physicians falsely assumed that if they sought help for a mental illness, a therapist or colleague might be legally compelled to report them to the state board, says Clark Barrineau, the Medical Society of Virginia’s assistant vice president of government affairs and health policy.

“Rather than seek that help, and particularly put that risk on themselves, they said, ‘I just won’t,’” Barrineau says.

In September 2021, the Virginia Board of Medicine released a brief meant to dispel that misconception, telling doctors, “Get help if you need it.” Practitioners aren’t required to self-report.

Wellness focus

Along with increasing pay and benefits — including parental leave — to combat the existing labor shortage, health systems in Virginia have fortified employee assistance and wellness programs.

“We really feel that having the right culture is the best way to retain staff and attract staff,” says Toni Ardabell, chief of clinical enterprise operations for Inova Health System.

Bon Secours, Carilion Clinic, Inova and Sentara Healthcare offer emergency assistance funds for employees in need. Virginia Commonwealth University Health offers crisis packages that, depending on an employee’s needs, can range from child care assistance to temporary housing.

Sentara placed employee assistance program counselors into its hospitals so that they are accessible to employees and can connect providers to free counseling for stress management, caregiver fatigue and more. Carilion Clinic has also increased its number of EAP counselors.

Pediatric emergency director Dr. Lisa Uherick developed Carilion’s “Healthy People Heal People” initiative, implemented in October 2020, which boosts the system’s emergency medicine team with supports like wellness workshops and an “adopt a front-line team” program.

Prior to the pandemic, Bon Secours was already offering employee wellness programs, like LifeMatters, a 24/7 program providing resources such as confidential counseling, legal and financial consultations. In May 2021, the system launched Called to Shine, an employee recognition program. Supervisors award employees points that can be redeemed for items varying from T-shirts to NFL game tickets.

“It’s really about that teamwork, collaboration and making people feel like we’re giving them something different and we’re a family,” says Cassie Lewis, chief nursing and quality officer for Bon Secours’ Hampton Roads market.

Inova employees make rounds with a “thank you cart” with goodies for clinical staff. Both Inova and Bon Secours offer quiet spaces for employees to take breaks, and several health systems now have mobile apps to help employees build resiliency to stress. At VCU Health, therapy dogs sometimes pay a visit.

Peer support

Aside from apps and formal programs, peer support has also become important at Virginia health systems.

In May 2020, Bon Secours started Caring for Colleagues, a confidential peer support group for physicians and advanced practice clinicians that allows a participant to call or text a volunteer. Carilion’s Healthy People Heal People program includes peer support groups, and VCU Health expanded its Stress First Aid training systemwide in February 2021.

UVA Health combined existing trainings in 2017 to form its Wisdom & Wellbeing program, which teaches resiliency skills, works to reduce unnecessary work stressors and provides Stress First Aid training.

“We can’t just say, ‘Suck it up and go back to work’ anymore,” says Scott Austin, nurse manager of the UVA Health COVID-19 unit. “We can’t just keep saying that to health care workers.”

During summer 2020, Austin contacted a Wisdom & Wellbeing co-founder. In addition to ever-changing COVID protocols, his nurses faced significantly increased workloads as other staff stayed out of the unit.

“They went from just being bedside nurses, doing their assessments and giving medications and being there for the patients, to adding in being housekeepers, being dietary folks, being phlebotomists,” he says. One technique Austin learned is texting his nurses to gather, pause and talk about their feelings when they’re in the “orange” on the system’s stress continuum, which ranges from green to red.

During 2020 and 2021, Austin saw more than 10 nurses leave his unit, although not all exited purely in response to COVID-related stressors. As of April, no nurses had left the unit this year, an outcome he attributes to the Wisdom & Wellbeing program.

Grief counseling

In addition to other well-being efforts and programs, some Virginia health systems have added bereavement support for health care workers who have lost loved ones or patients. Bon Secours, a Catholic-affiliated health system, has clergy circulating on “compassion rounds,” and UVA Health’s chaplaincy is open 24/7. Carilion has chaplains on call who can be paged to arrive within 30 minutes to assist caregivers.

In 2021, Inova hired more behavioral health nurse practitioners for debriefs after units faced difficult issues, like someone bringing a weapon into a hospital.

Health care professionals face vitriol from upset patients. One study published in the American Association of Occupational Health Nursing Inc.’s journal in August 2021 found that 51.2% of registered nurses surveyed who cared for COVID patients experienced physical violence at least once, and 73% experienced verbal abuse.

Although the pandemic jumpstarted these programs and raised public awareness, the shift in culture among health care professionals has been slow to spark. Health care professionals are reluctant to talk publicly about the mental health help they’ve received.

“I think it is going to be kind of a generational shift,” Barrineau acknowledges. “A lot of those things are built in almost culturally to the medical profession.”

Students and residents are part of the change. VCU Health extended benefits such as caregiver leave to its residents during the pandemic, and Inova has had student wellness representatives for several years.

Bon Secours’ Simons says she disclosed to her current employer that she takes an antidepressant medication.

“I did it on my own, but I hope that in today’s environment, people feel more comfortable reaching out to colleagues or to their hospitals,” she says, “because at the end of the day, [there are] good people in health care.”