In March 2020, Mara Buchbinder, PhD, was struck by the realization researchers should be documenting how frontline physicians were experiencing and responding to the unprecedented work conditions.
“The pandemic brought a long-simmering crisis of health worker stress and burnout to the surface,” says Buchbinder, professor and vice chair in the department of social medicine at the University of North Carolina at Chapel Hill.
Buchbinder led the Study to Examine Physicians’ Pandemic Stress (STEPPS).1 Buchbinder and colleagues interviewed 79 attending physicians and fellows who cared for inpatient COVID-19 patients in 23 hospitals in New Orleans and New York City.
“Physicians often felt complicit in perpetuating racial and ethnic disparities when their hands were tied due to institutional policies,” reports Buchbinder, adding that this caused moral stress for physicians and exacerbated burnout.
The widespread availability of vaccines became an unexpected source of stress to physicians because of public resistance to them. Physicians were facing devastating illness and mortality that, in their view, could have been avoided.
Another morally troubling development was the prospect of so many patients dying alone.
“The pandemic really highlighted how critical family presence is to dying well in the hospital,” Buchbinder says.
Most participants acknowledged limiting visitors was the right policy decision early in the pandemic, before vaccines were available. However, many physicians believe the restrictions went on for too long once personal protective equipment and vaccines were more widely available. Some physicians lobbied for change or developed workarounds (e.g., sneaking in families through the emergency department). “However, some also noted that these workarounds created new sources of inequity that could also result in moral distress,” Buchbinder reports.
Physicians also discussed the difficulties posed by constraints on transferring patients between hospitals. Many community hospitals did not provide extracorporeal membrane oxygenation and had to determine how to select patients for transfer.
“In some cases, informal policies and practices revealed implicit bias that was distressing for some physicians,” says Buchbinder, adding that at some facilities, physicians helped develop formal policies to address this issue.
Overall, the surveyed physicians painted a picture of how systems constraints hampered physicians’ ability to provide adequate care for patients. This threatened physicians’ professional integrity.
“Clinicians’ well-being is undermined if they perceive themselves as unable to provide good care because of lack of resources,” Buchbinder says.
The principal ethical concern is the degree to which moral distress compromises the physician’s effectiveness, according to Paul Hofmann, DrPH, LFACHE, a healthcare ethics consultant and former hospital CEO. A burned out physician’s clinical skills could be affected negatively, or the physician could become less patient, compassionate, and empathetic. “Understandably, when any clinician experiences burnout, it also inevitably impacts relationships with colleagues and family members,” Hofmann notes.
There is no shortage of institutional conditions that impede good care. Administrative burdens, unrealistic productivity targets, lack of sufficient support staff, and cumbersome electronic medical record systems all contribute to physicians’ moral distress. “This is an ethical issue, because a significant percentage of physicians would not encourage their children to become doctors,” Hofmann says.2
Furthermore, more physicians are working part-time or retiring early, exacerbating current shortages. Complicating this crisis is the reluctance of physicians to seek mental health services. “They hesitate to do so because of fears that such information would have to be disclosed when applying or reapplying for medical staff appointment and reappointment,” Hofmann explains.
Simply implementing physician wellness programs is not a panacea. Hofmann suggests ethicists go further by encouraging organizations to actually survey physicians to identify which factors are adversely affecting well-being. “Meaningful change cannot occur without actively engaging physicians in determining what changes they believe will significantly improve their health and well-being,” Hofmann says.
REFERENCES
1. Buchbinder M, Browne A, Jenkins T. Hospital physicians’ perspectives on occupational stress during COVID-19: A qualitative analysis from two US cities. J Gen Intern Med 2023;38:176-184.
2. Cabbabe S. Would you encourage your child to follow in your footsteps and become a physician? Mo Med 2017;114:4-6.
Ethicists should encourage their organizations to survey physicians to identify which factors are adversely affecting well-being. Meaningful change cannot occur without actively engaging physicians in determining what changes they believe will significantly improve their health and well-being.
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