Much has been written about the challenges front-line health care workers have faced during the COVID-19 pandemic. Long hours, excessive death, and fear for one's own safety and the welfare of family and colleagues has been a constant over the past 22 months. Physicians and nurses started out as heroes, but due to strained politics and social media misuse, are now branded by a substantial swath of society as pariahs and purveyors of a medical hoax.
The timing of this pandemic could not have been worse: According to the Medscape National Physician Burnout & Suicide Report 2021, 79% of physicians stated that their burnout had started before the COVID-19 pandemic.
The pandemic has put a spotlight on a system strained by burnout and moral distress. Hospitals have always been a safety net for society's sickest and most vulnerable patients, leading to daily stressors that became accepted as part of one's job. In addition, the past decade has brought new challenges that have led to the gradual erosion of safety, respect and civility within hospitals and for front-line staff.
It is estimated that 75% of workplace violence happens within the health care system. This likely underestimates the actual number, as most front-line workers consider verbal and physical assaults to be part of their job. The American College of Emergency Physicians has stated that 70% of ER clinicians have reported acts of violence, while only 3% have pressed charges.
The opioid epidemic brought more risk to front-line staff, as physically addicted patients sought access to pain medications. These interactions often led to verbal and physical threats against both doctors and nurses. Moral and ethical distress was profound as clinicians attempted to navigate the crisis and distinguish objective pain from opioid-abusing behavior.
Politics began infiltrating the health care system long before the pandemic. Clinicians were accused of advocating for "death panels" by politicians opposed to the Affordable Care Act. Clinicians are now witnessing needless suffering and death due to the politicization of the COVID-19 vaccine and misinformation surrounding appropriate treatments.
COVID-19 has brought a new reality: patients and families not only willingly making decisions that place themselves and others at risk of great harm, but actively denying basic scientific facts and accusing clinicians of lying to them about their illness.
Last year in Ohio, a hospital was ordered to give ivermectin to a COVID-19 patient by a local judge (subsequently overturned), despite no current scientific consensus that it provides any benefit. This erosion of basic respect for science, along with the loss of professional autonomy, has only worsened the moral injury sustained by health care workers.
Where do health care workers go from here? What is needed to prevent a continued exodus away from the front lines, to ensure that patients will have continued access to high quality, evidence-based care?
1. Health care systems need to eliminate all barriers to front-line workers receiving mental health treatment. One model will not work for every system, but some combination of onsite counseling and easy-to-schedule off-campus treatment is urgently needed. Opt-out (auto enrollment) programs have been shown to increase the use of mental health resources in resident physician training programs.
State medical boards need to either eliminate mental health questions entirely from applications, or only ask about current impairment. Historically, these questions have made clinicians reluctant to seek much needed mental health care.
2. Increased investment is needed in making hospitals safer. This will require a combination of more security staff, zero tolerance for threatening behavior, and eliminating the culture that accepts physical and verbal assaults as "just part of the job." In our appropriate quest for patient-centered care, we must not allow behaviors in hospitals that are not tolerated (but likely prosecuted) elsewhere.
3. Health care systems should consider sabbaticals for the most impacted front-line workers. Short-term costs would pale in comparison to long-term expenses associated with the loss of experienced staff, and the costs of recruitment and training to replace them.
The business world has recognized that paid sabbaticals (usually for workers who have at least three years of tenure, with a duration of one to six months) create more productive, focused and innovative staff. Although this might be considered radical, it has the potential to reduce overall costs for strained hospital budgets and allow health care workers to come back to work mentally and physically healthy.
These steps are just a start. Additional innovative ideas are required, which should include taking a holistic look at a system that depends on surgical procedures to keep hospitals financially viable.
Time is of the essence, as the needs of front-line workers to address post-traumatic stress disorder, guilt, anger, depression, anxiety and moral injury will be there long after society has moved on from the pandemic.
Rick Hilger is a St. Paul physician, and chair of the Society of Hospital Medicine Public Policy Committee.