By Kathryn Radigan, MD, MSc
Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago
SYNOPSIS: A binational, cross-sectional survey including 431 questionnaires assessing wellness and coping among physicians who worked in the intensive care unit during the COVID-19 pandemic found that physicians experienced moderate intrapandemic moral distress and burnout, yet also experienced moderate professional fulfillment.
SOURCE: Burns KEA, Moss M, Lorens E, et al; Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society. Wellness and coping of physicians who worked in ICUs during the pandemic: A multicenter cross-sectional North American survey. Crit Care Med 2022;50:1689-1700.
The COVID-19 pandemic demanded the development of strategies to increase intensive care unit (ICU) capacity with subsequent changes in personnel, workflow, and workplace culture. Unfortunately, the lack of disaster preparedness in hospitals globally was astounding. The Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society (ATS) investigators conducted a binational cross-sectional survey, administering 431 questionnaires across the United States and Canada between Feb. 6 or 7, 2021, and April 16, 2021, to determine the wellness and coping among physicians who worked in the ICU during the COVID-19 pandemic.
Subjects included attending physicians (adult and pediatric; intensivist and non-intensivist) who worked in North American ICUs. Site leads were identified through the WICC Interest Group of the ATS membership list, colleague referrals, and electronic mail correspondence. The surveys were distributed in the format of an electronic questionnaire to the larger of one-third of attending physicians in a site lead’s ICU. The questionnaire included four validated instruments, including the 27-item Measure of Moral Distress for Healthcare Professionals, two-item version of the Maslach Burnout Inventory, and 14-item Brief Cope scale to evaluate moral distress, burnout alone, professional fulfillment and burnout, and coping. Additional data included respondent demographic data, their practice type and setting, and workload. The final questionnaire included 59 instrument and 25 demographic items.
Of the 1,080 potential respondents, 431 questionnaires were analyzed, with a 43.3% response rate. Attending physicians relayed significant intrapandemic increases in days worked/month (10.1 ± 13.9 to 13.1 ± 15.6; P < 0.001), ICU bed occupancy (from 53.4 ± 43.7 to 76.1 ± 66.5; P < 0.001), self-reported moral distress (56.9%), and burnout (63.8%). Moral distress most commonly was triggered by regulatory/organizational issues, local/institutional issues, or both (n = 2). Moral distress, professional fulfillment, and burnout scores were moderate, with 227 physicians (54.6%) meeting burnout criteria. A dose-response relationship between COVID-19 patient volume and moral distress scores became evident, with increasing days/month and scheduled in-house night shifts a physician worked (particularly combined with more unscheduled in-house night shifts) correlating with increased likelihood of moral distress. To deal with the stressors, attending physicians applied four coping profiles (active/social, avoidant, mixed/ambivalent, and infrequent) that were associated with significant differences across all wellness measures.
Despite moderate professional fulfillment, attending physicians also experienced moderate intrapandemic moral distress and burnout, with one in five physicians using at least one maladaptive coping strategy. Transforming these findings into actionable goals to modify factors at the individual, institutional, and regulatory levels is critical in improving physician wellness.
COMMENTARY
The COVID-19 pandemic has been a global health crisis with catastrophes on many levels. It not only has caused overwhelming morbidity and mortality and taxed our healthcare delivery systems to their limits, but it also has taken a massive toll on healthcare providers. Every physician has been affected and transformed. Despite these concerns, few studies have focused on physician moral distress, burnout, and professional fulfillment. As the consequences of these outcomes not only affect physicians but also have a profound impact on entire healthcare systems, investigators conducted a binational, intrapandemic survey of attending physicians throughout North American ICUs. Although investigators found that physicians experienced moderate intrapandemic mortal distress and burnout, they also experienced professional fulfillment.
This is not the first study to examine physician wellness. In a survey study of U.S. clinicians with 20,627 respondents, burnout increased throughout the pandemic, spiking to 60% by the end of 2021.1 As job satisfaction decreased, intent to leave the profession increased from 24% in 2019 to more than 40% in 2021. Higher burnout was associated with more chaotic workplaces, low work control, and poor teamwork; in contrast, lower burnout was associated with feeling valued. Another survey, which focused on COVID-19-related stress and work intentions in U.S. healthcare workers, found that one in five physicians planned to leave the profession in the following two years.2 Approximately one in three physicians surveyed intended to reduce work hours.
The Mayo Clinic Proceedings subsequently revealed that U.S. physicians experienced a dramatic increase in burnout and a decrease in satisfaction with work-life integration between 2020 and 2021.3 The mean scores for emotional exhaustion were 39% higher compared to the 2020 survey, while the mean depersonalization scores were 61% higher than the 2020 survey. Authors advocated immediate action to mitigate the findings of their study, especially since they also found escalating rates of depression that were thought to be directly related to work struggles.
It is no surprise that physician wellness is a major issue after the COVID-19 pandemic, and we must develop strategies to mitigate its effects. Moral distress is experienced when an individual feels forced to act or refrain from acting in contradiction to his or her ethical values. It is vital to focus not only on what causes the moral distress to try to diminish the causes that can be controlled, but also to define the coping strategies used and then work to optimize these strategies further.
In this study, moral distress was related to more days worked per month, more scheduled in-house night shifts, and more unscheduled in-house night shifts. There was a significant dose response between higher average patient volume and higher average moral distress. The investigators found that the “need to continue aggressive treatment even though it was not perceived to be beneficial or likely to change outcome” incited the highest moral distress.
Attending physicians processed the moral distress using a variety of coping strategies. Investigators found that “avoidant copers,” who use passive avoidant coping strategies (e.g., self-distraction, denial, substance use, behavioral disengagement, and self-blame) comprised nearly half of the sample (46%), followed by “infrequent copers” (those who did not use any coping strategies) and “active/social copers” (e.g., active planning, positive reframing, venting, emotional support, instrumental support) as the second and third most common ways to cope, respectively. “Mixed/ambivalent copers” (those who used both active and passive or avoidant strategies) were the least common (4.6%) and experienced the highest moral distress and burnout scores and lowest professional fulfillment. The study also highlighted the concern that one in five physicians used at least one maladaptive coping strategy.
Investigators concluded that there are various modifiable factors that could enhance physician wellness. These include interventions at the individual level (coping), institutional level (e.g., patient volume, workload, scheduling of in-house shifts, administrative support, equipment), and regulatory level (e.g., documentation requirements, end-of-life care, inappropriate treatment).
Additionally, another study found proactive measures that may help to mitigate burnout.1 These strategies include making doctors feel valued, which often is directly correlated to receptive leadership, and making tangible changes based on physician feedback, with organization support for work-life integration along with physician self-care. Other measures include giving physicians control over their workload and schedules, eliminating chaos by controlling fast-paced and hectic work environments, and optimizing teamwork that not only focuses on a positive team culture but also on a solid team-based care workflow that allows for efficient task-sharing and minimizing nonpatient tasks for clinicians.
Large-scale change also is critical. The National Academy of Medicine has put their consensus report, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” in motion.4 The U.S. Surgeon General also announced an advisory, “Addressing Health Worker Burnout,” and called for action at all levels of government in addition to healthcare organizations, health insurers, technology companies, training programs, and accrediting bodies.5
Although investigators found that physicians experienced moderate intrapandemic mortal distress and burnout, they also experienced professional fulfillment. It is not only critical that our leaders recognize the moral distress and burnout, but also recognize that there are ways to mitigate these new trends and capitalize on the factors that provide professional fulfillment. It also is crucial for each physician to reflect on the COVID-19 pandemic and how they, on an individual level, can optimize their own wellness. Without substantial efforts to examine, measure, and modify work environments while optimizing fulfillment, morale, and retention, not only will generations of physicians be compromised, but ultimately our entire healthcare system will be.
REFERENCES
- Linzer M, Jin JO, Shah P, et al. Trends in clinician burnout with associated mitigating and aggravating factors during the COVID-19 pandemic. JAMA Health Forum 2022;3:e224163.
- Sinsky CA, Brown RL, Stillman MJ, Linzer M. COVID-related stress and work intentions in a sample of US health care workers. Mayo Clin Proc Innov Qual Outcomes 2021;5:1165-1173.
- Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc 2022;97:2248-2258.
- National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press;2019.
- New surgeon general advisory sounds alarm on health worker burnout and resignation. https://www.hhs.gov/about/news/2022/05/23/new-surgeon-general-advisory-sounds-alarm-on-health-worker-burnout-and-resignation.html
