By Benjamin Chesluk PhD, ABIM Senior Researcher for Ethnographic Research | Assessment and Research and Bradley Gray PhD, ABIM Senior Health Services Researcher
The ongoing COVID-19 pandemic has placed enormous pressures on ICU physicians and other health care providers in the US. They have had to learn to fight an unfamiliar and challenging new disease and, at the same time, protect themselves from becoming infected and grapple with health system dysfunction and sociopolitical turmoil.
During the early days of the pandemic in the US, in spring 2020, news reports from New York City and other disease hotspots focused on the brand-new, overwhelming challenges of the disease: Packed hospitals, isolated patients, exhausted care providers and refrigerated trucks for storing bodies of the deceased because morgues had no room. Since those early days, COVID-19 has persisted and spread in the US, ebbing and flowing in different parts of the country, forcing many providers to deal with crisis conditions for month upon month.
How is caring for patients in a pandemic different in month six versus month one? According to what hundreds of critical care physicians told us in a recent survey, many feel more knowledgeable about how to treat COVID-19 and keep themselves safe, but more stressed by the long duration of the crisis, as well as by political leaders spreading disinformation and undermining public health measures.
These data are drawn from a collaboration between researchers from the American Board of Internal Medicine and Harvard University, a large-scale, longitudinal survey of ABIM-certified critical care physicians across the US. The survey, sent out in spring 2020 (4/23/2020-5/3/2020) and fall 2020 (10/23/2020-11/16/2020), asked physicians about their level of physical and/or emotional stress, and about shortages of personal protective equipment (PPE), medication and medical equipment, or staff. 2,375 physicians responded to the spring survey (20% response rate); of these, 1,356 participated again in the fall survey (57.1% response rate).
The fall 2020 survey gave physicians the option to tell us, in their own words, about what changes had contributed to decreases or increases in stress since the spring. 863 physicians (63.6% of respondents) answered that something had changed; of these, 690 (50.9% of respondents) described changes that increased their stress and 683 (50.4%) described changes that decreased stress. (580 [42.8%] answered about both types of change.)
What has gotten better: Knowledge of how to treat patients and stay safe
The responses regarding what had decreased their stress touched on a few primary themes. [Exhibit 1: Changes that decreased stress] The first relates to treating COVID-19. 316 of the ICU physicians said they felt they had better knowledge of how to treat COVID-19 patients. One responded, “Steroids work. Anticoagulation works. Non-invasive ventilation works. Managing patients is much less depressing when you have treatments that help”. Another respondent described the benefit of increased knowledge of the disease: “[We have] more standardized protocols for treatment… [the] pace of new recommendations has slowed, minimizing whiplash from changing guidelines.”
“Managing patients is much less depressing when you have treatments that help”
Ninety-five respondents described decreased stress due to less fear that they would become infected themselves, and in turn risk infecting their families and colleagues. Respondents described having better supplies of PPE, as well as more confidence in their ability to use PPE to keep themselves and others safe. For example, one wrote that their stress had decreased due to “seeing over time that our PPE and isolation practices are very successful at preventing workplace COVID exposure”. Another said stress had been lessened by “knowing I can be around my family after working on the COVID ward, and not need to isolate myself all the time”. A third comment put it bluntly: “I don’t think I’m going to instantly die upon entering a COVID room like I did in April.”
This is not to say that fear of either becoming infected or infecting others disappeared completely, or even mostly – respondents to the fall survey still identified these as a significant factor contributing to emotional distress, only less so than in spring — (37% of fall respondents cited personal risk of infection as a significant contributor to their stress, down from 50.3% in spring; 58% in fall cited risk of infecting family or friends as a significant stress factor, down from 67.1% in spring).
What has gotten worse: exhaustion from dealing with an ongoing, avoidable crisis
The responses about what had increased their stress touched on a number of significant themes, some of which temper or even contradict the more positive responses to the first prompt. [Exhibit 2: Changes that increased stress] 60 respondents noted their still-unsatisfactory ability to treat patients with COVID-19: “Continued lack of anything that really seems to make a difference in mortality – we are starting to get numb to the high mortality rate”. 30 described feeling stressed due to fear of a possible increase in cases as the winter holiday season approached, such as: “The growing realization and dread that things are rapidly deteriorating as cases skyrocket in my state. Wondering if/when we will be overwhelmed.”
Fifty-eight physicians wrote about the need to keep operating under crisis conditions for a long period of time. Some used the image of running a marathon to capture their feeling of long-term exhaustion: one wrote that what had changed since the earlier survey was the “[d]uration of the pandemic. As I think we expected (but did not really understand) this is a marathon”; another said, “[It’s] seeming like there is no end in sight. I’ve had more and more COVID + ICU patients lately and the marathon is very draining.”
Adding to the marathon-level exertion of caring for patients in an enduring pandemic was the need to combine care for COVID-19 patients with more routine work/life obligations, noted by 54 respondents. Whereas in the early days of the pandemic many hospitals and health systems postponed elective surgeries and other care for non-COVID patients, by November 2020 respondents faced the need to somehow manage the continuing pandemic as part of a more “normal” routine, seeing other patients too, as well as dealing with the organizational repercussions of the lack of normal revenue. One reported, “all of the regular clinical work has returned. There is a compounding effect of having both the stresses of COVID-19 and its ongoing burden as well as all of the usual busyness.” Another described being newly stressed by “[f]inancial stress of the institutions I work for and worrying about the stability of my employment.” Others described the stress of dealing with non-work obligations, such as helping children manage distance learning.
Summing up this sense of exhaustion and stress, a respondent wrote, “I’m not sure why, but I am much more bothered by it when I have to care for these patients than I was in April. Probably multiple factors. I’m just so sick of it.” Another, responding to the prompt about whether anything had changed to decrease their stress, simply entered: “Hah!”
“Initially we felt supported that we are all in this together not just as staff in the hospital but as a wider community…
When people don’t care, infections rise and we deal with… sick patients and deaths that were avoidable.”
Alongside these themes, some ICU physicians said their stress had increased due to lack of social support from the public and disinformation from political leaders. While these were present to an extent in the results of the spring survey, by fall, 168 respondents expressed feeling frustrated and angry at how much of what they had experienced over the last few months (and would continue to grapple with for the foreseeable future) had been made needlessly worse by the politicization and drowning out of necessary, common-sense public health measures. One physician wrote, “Initially we felt supported that we are all in this together not just as staff in the hospital but as a wider community… When people don’t care, infections rise and we deal with… sick patients and deaths that were avoidable.” Another described feeling increased stress due to “people thinking or believing that COVID is a hoax or overblown. People not engaged in a social contract to protect all.” 27 respondents directly attributed this needless worsening and prolonging of the pandemic to then-President Trump, such as one who said their stress was increased by their “increased annoyance about the public refusing to wear masks [and] Donald Trump contradicting expert opinions thereby making the pandemic uncontrollable.”
Of course, this study has limitations – we rely on physicians’ self-reported perceptions of what contributed to their stress both at the time of the October-November survey and the April-May survey 6 months earlier; our sample might not be representative of the larger population of all critical care physicians; and we do not have similar data on the perspectives of other healthcare providers who might have different experiences, such as ICU-trained nurses and respiratory therapists. In addition, just as conditions changed between the spring and fall 2020 surveys (and the fall survey was completed before surges linked to the winter holidays), other current and future changes will certainly change physicians’ experiences, most notably the rollout of nationwide vaccination, which is already helping improve providers’ security about their personal safety – but not their dismay about seeing patients who are needlessly sick or dying, with families and communities in needless turmoil.
In sum, these ICU physicians’ words show that, compared with the early days of the COVID-19 pandemic in the US, when physicians struggled not to be overwhelmed by a new and poorly-understood disease and by the fear of infecting themselves and their families and communities, by November 2020, many had experienced a transition. They felt more confident in being able to care for their patients and protect themselves. Now, however, they grappled instead with stresses arising from several sources: the long-term nature of the pandemic; the need to maintain at least some aspects of “business as usual” alongside caring for COVID-19 patients; and, making these stresses worse, the conviction that much of what they were experiencing could have been avoided but for disorganization of the public health response and disinformation spread from the Trump White House and its allies. Our findings align with journalistic reports of US providers traumatized by the experience of dealing with the COVID-19 pandemic. How different would reports have been if we had instead surveyed ICU physicians in Canada, Australia or South Korea?
Articles linked in text:
“Critical care physicians treating COVID-19 report high stress levels”, published by ABIM.org on 9/3/2020