The Burdens Grow Heavier for COVID-19 Health Care Providers

Dr. Christine Choi, a second year medical resident at Harbor-UCLA Medical Center
Dr. Christine Choi, 32, a medical resident at Harbor-UCLA Medical Center in Torrance, prepares to enter an isolation area for COVID-19 inpatients. Health care providers must face daily patient death and suffering.

Soon after the COVID-19 pandemic began last spring, Christine Choi, DO, a second-year medical resident at Harbor-UCLA Medical Center, volunteered to enter COVID-19 patient rooms. Since then, she has worked countless nights in the intensive care unit in full protective gear, often tasked with giving the sickest patients and their families the grim choice between intubation or near-certain death.

Essential Coverage

I’m offering this guy two terrible options, and that’s how I feel about work: I can’t fix this for you and it sucks, and I’m sorry that the choices I’m giving you are both terrible,” Choi told the Los Angeles Times’ Soumya Karlamangla about one patient encounter.

While Choi exhibits an “almost startlingly positive attitude” in her work, it’s no match for the psychological burdens placed on her shoulders by the global pandemic, Karlamangla wrote. When an older female COVID-19 patient died in the hospital recently, her husband — in the same hospital with the same diagnosis — soon began struggling to breathe. Sensing that he had little time left, Choi held a mobile phone at his bedside so that each of his children could come on screen to tell him they loved him. “I was just bawling in my [personal protective equipment],” Choi said. “The sound of the family members crying — I probably will never forget that,” she said.

It was not the first time the young doctor helped family members say goodbye to a loved one, and it would not be the last. Health care providers like Choi have had to work through unimaginable tragedies and unprecedented circumstances because of COVID-19, with little time to dedicate to their own mental health or well-being.

It has been nearly a year since the US reported what was believed at the time to be its first coronavirus death in Washington State. Since then, the pandemic death toll has mushroomed to nearly 500,000 nationwide, including 49,000 Californians. These numbers are shocking, and yet they do not capture the immeasurable emotional weight that falls on the health care providers with the most intimate view of COVID-19’s deadly progression. “The horror of the pandemic has unfolded largely outside public view and inside hospitals, piling a disproportionate share of the trauma on the people whose work takes them inside their walls,” Karlamangla wrote.

Experts are deeply concerned about the psychological and physical burdens that providers must bear, and the fact that there is still no end in sight. “At least with a natural disaster, it happens, people get scattered all over the place, property gets damaged or flooded, but then we begin to rebuild,” Lawrence Palinkas, PhD, MA, a medical anthropologist at USC, told Karlamangla. “We’re not there yet, and we don’t know when that will actually occur.”

Burned Out and Exhausted

A new CHCF survey of 1,202 California doctors, nurses, nurse practitioners, physician assistants, and behavioral health specialists confirms that levels of burnout and exhaustion are rising as the pandemic wears on. The survey, conducted January 4 to 14, 2021, is the second in a three-part series assessing COVID-19-related effects on health care providers.

Sixty-eight percent of providers said they feel emotionally drained from their work, 59% feel burned out, 57% feel overworked, and 50% feel frustrated. The poll asked providers who say they feel burned out what contributes most to that viewpoint. One doctor from the Central Valley wrote:

“Short staffed due to people out with COVID. I’m seeing three times as many patients, with no time to chart or catch up. Little appreciation or contact from my bosses. I have never had an N95 [mask]. The emotional toll this pandemic is taking. Being sick myself and spreading it to my wife and young kids. Still not fully recovered but needing to be at work due to physician shortages. Lack of professional growth, and a sense of lack of appreciation at work and feeling overworked. The sadness of the COVID-related deaths and the stories that go along with the disease. That’s a lot of stuff to unpack.”

Safety-net providers and health care workers with larger populations of patients of color are more likely to experience emotional hardships at work. As we know well by now, COVID-19 exacerbates the health disparities that have long burdened people of color and disproportionately harms communities with fewer health care and economic resources.

Women Bear the Brunt

The pandemic has been especially challenging for female health providers, who compose 77% of health care workers with direct patient contact. “The pandemic exacerbated gender inequities in formal and informal work, and in the distribution of home responsibilities, and increased the risk of unemployment and domestic violence,” an international group of experts wrote in the Lancet. “While trying to fulfill their professional responsibilities, women had to meet their families’ needs, including childcare, home schooling, care for older people, and home care.”

For one female doctor from the Bay Area who responded to the CHCF survey, the extra burdens of the pandemic have been unrelenting: “Having to work more, lack of safe, affordable, available childcare while I’m working. As a single mother, working 15 hours straight, then having to care for my daughter when I get home. Just exhausted with no days off. So many Zoom meetings all day long. Miss my family and friends.”

It is unclear how the pandemic will affect the health care workforce in the long term. For now, the damage “can be measured in part by a surge of early retirements and the desperation of community hospitals struggling to hire enough workers to keep their emergency rooms running,” Andrew Jacobs reported in the New York Times.

One of the early retirements Jacobs cited was Sheetal Khedkar Rao, MD, a 42-year-old internist in suburban Chicago. Last October, she decided to stop practicing medicine after “the emotional burden and moral injury became too much to bear,” she said. Two of the main factors driving her decision were a 30% pay cut to compensate for the decline in revenue from primary care visits and the need to spend more time at home after her two preteen children switched to remote learning.

“Everyone says doctors are heroes and they put us on a pedestal, but we also have kids and aging parents to worry about,” Rao said.

Working Through Unremitting Sickness and Death

In addition to the psychological burden, health care providers must cope with a harsh physical toll. People of color account for most COVID-19 cases and deaths among health care workers, according to a KFF issue brief. Some studies show that health care workers of color “are more likely to report reuse of or inadequate access to [personal protective equipment] and to work in clinical settings with greater exposure to patients with COVID-19.”

“Lost on the Frontline,” a collaboration of Kaiser Health News and the Guardian, has counted more than 3,400 deaths among US health care workers from COVID-19. Eighty-six percent of the workers who died were under age 60, and nurses accounted for roughly one-third of the deaths.

“Lost on the Frontline” provides the most comprehensive picture available of health care worker deaths, because the US still lacks a uniform system to collect COVID-19 morbidity and mortality data among health care workers. A year into the project, the federal government has decided to take action. Officials at the US Department of Health and Human Services cited the project when asking the National Academies of Sciences, Engineering, and Medicine for a rapid expert consultation to understand the causes of deaths among health care workers during the pandemic.

The National Academies’ report, published December 10, recommends the “adoption and use of a uniform national framework for collecting, recording, and reporting mortality and morbidity data” along with the development of national reporting standards for a core set of morbidity impacts, including mental well-being and psychological effects related to working through public health crises. Some health care experts said the data gathering could be modeled on the federal government’s World Trade Center Health Program, which provides no-cost medical monitoring and treatment for workers who responded to the 9/11 terrorist attacks 20 years ago.

“We have a great obligation to people who put their lives on the line for the nation,” Victor J. Dzau, MD, president of the National Academy of Medicine, told Jacobs.

Into the COVID fray again, or for the first time

https://mailchi.mp/45f15de483b9/the-weekly-gist-october-9-2020?e=d1e747d2d8

Addressing Workforce Needs for COVID-19 | University at Albany

While it sometimes seems like the coronavirus has been with us forever, it’s worth remembering that there are still parts of the country that are only now experiencing their first big spike in cases—that’s the nature of a “patchwork” pandemic working its way across a vast country.

One of our health system members in the Midwest, with whom we recently spent time, is in just this situation: they’re seeing their highest inpatient COVID census to date, just this month. As they shared with us, there are advantages and drawbacks to being a “late follower” on the epidemic curve. The good news is that they’re ready.

Back in March, like most systems, they stood up an “incident command center”, and began preparing for a wave of COVID patients, designating a floor of the hospital as a “hot zone”, creating negative pressure rooms, cross-training staff, developing treatment protocols, stockpiling protective equipment, and securing a pipeline of critical therapeutics and testing supplies. There was a moderate but manageable number of cases across the late spring and summer, but never to an extent that stressed the system.
 
Eventually, recognizing that they couldn’t ask their doctors, nurses, and administrators to stay on high alert indefinitely, they “stood down” to a more normal operational tempo, only to watch with dismay as the surrounding community seemingly forgot about the virus, and lessened precautions (masking, distancing, and so forth), wanting life to return to “normal”. And now, the post-Labor Day, post-return-to-school spike has arrived.

The challenge now is getting everyone, inside and outside the system, to stop talking about COVID in the past tense, as though they’ve already “gotten through it.” The preparations they’ve made are paying off now. Hospital operations continue to run smoothly even with a high COVID census, but the workforce is exhausted, and citizens aren’t stepping outside to bang gratefully on pots every night anymore.

Asking the team to return to war footing is no easy task, given the fatigue of the past seven months. A question looms: what is the trigger to restart “incident command”? As cases begin to increase again in some of the original COVID hot spots—New York, New England, the Pacific Northwest—healthcare leaders there will need to learn from the experiences of their colleagues in the newly-hit Midwest, about how to take an already virus-weary clinical workforce back onto the battlefield.

Melinda Gates: US coronavirus response ‘lacking leadership at the federal level’

https://finance.yahoo.com/news/us-coronavirus-response-lacks-leadership-at-the-federal-level-melinda-gates-151610533.html

Melinda Gates: US coronavirus response “lacks leadership at the ...

Philanthropist Melinda Gates on Thursday sharply criticized the U.S. response to the coronavirus outbreak, telling Yahoo Finance that the country is “lacking leadership at the federal level” and as a result has endured unnecessary deaths and economic pain.

“It’s highly distressing and disappointing,” says Gates, co-chair of the Bill and Melinda Gates Foundation, which she said has donated $300 million to organizations involved in the coronavirus response.

“To have 50 state-grown solutions is inefficient, it makes no sense, and it’s costing people their lives,” she adds.

President Donald Trump said on Tuesday “there’ll be more death” as states lift stay-at-home measures but has urged a path toward reopening the economy in order to blunt job loss and other damaging effects caused by the mandates.

The Trump administration has drawn criticism for what some consider a failure to adequately address the coronavirus outbreak in its early stages. Trump has repeatedly said “nobody” could have foreseen the pandemic though he reportedly received dire warnings as early as February.

“The lack of action is really causing harm and hurt unnecessarily in this country,” Gates says. “I’m incredibly disappointed to see that.”

The White House recently declined to take up guidelines written by the Centers for Disease Control and Prevention for how schools, restaurants, and other institutions can safely reopen, the Associated Press reported on Thursday.

The Trump administration did release a set of conditions for coronavirus containment that it recommends states meet before they reopen, including a 14-day downward trajectory in new cases or positive test rates. However, many states that remain short of that benchmark have started to reopen or will do it soon, among them Kentucky, Ohio, and Utah, the AP reported on Thursday.

On Friday, the monthly jobs report showed the U.S. economy cut 20.5 million payrolls in April, and the unemployment rate jumped to 14.7%.

The severity of economic pain is a direct result of inaction from the federal government, Gates said.

“It is impacting families now, because if we had a good testing and tracing system like Germany has, we would have started to reopen slowly more places in the economy, people wouldn’t be struggling so much to put a meal on their table,” says Gates, who released a book last year entitled “The Moment of Lift: How Empowering Women Changes the World.”

‘Difficult tension’ faced by parents at home

She said the U.S. must bolster its benefits for paid sick, medical, and family leave in order to mitigate some of the economic pain and reopen the economy, since some workers will return to their jobs while others will need to remain home to care for sick family members or children educated remotely.

Speaking with Yahoo Finance, she called on Congress to improve the paid sick and family leave expansion passed in March, which excluded many companies from the benefits requirements.

“Congress made a first step that is in one of the stimulus packages, they really did put in sick days and paid leave,” she says. “The problem is, it doesn’t go far enough.”

Moreover, she advocated for a nationwide paid medical and family leave plan — a proposal backed in part by both parties, though they differ sharply on the details.

The Republican-controlled Senate and Democrat-controlled House remain divided over an additional stimulus measure, while President Donald Trump has sought likely-polarizing tax cuts to be included in the bill, the New York Times reported on Wednesday.

Nevertheless, Gates said she is optimistic that Congress will enact paid medical and family leave.

“Congress is hearing about this difficult tension moms and dads — but particularly moms — are facing at home,” she says.

 

 

 

Truth dies in silence. Sadly, so do people.

Truth dies in silence. Sadly, so do people.

UNESCO launches “Truth Never Dies” campaign to tackle crimes ...

I have been writing columns for physicians for twenty years.  And year after year, I have had physicians say this: “I’m glad you said what you did. If I said it, I’d be fired.” There are variations on the theme, but they’re much the same.  Twenty years, and far more than 20 years, during which the alleged health care leaders in America have been routinely muzzled because they aren’t supposed to speak the truth.  Open discussions shut down because they might embarrass someone or upset an administrator. Because it might, heaven forbid, shine a light on a genuine problem.

Some years ago, as the mental health crisis was gathering steam across the emergency departments of the land, I was contacted by a news show in France.  The producers wanted to come to South Carolina and follow me on some shifts in my ED. They wanted to see how mental health was working out here. “We have socialized care, but mental health is also a huge problem in our country,” the producer said.

I dutifully, and appropriately, went to administration. “No, we can’t do that,” I was informed. I was given this explanation when everyone knew the mental health system was at the breaking point: “What if they uncover a problem?” Here was a chance for publicity, for potential grant money or to demonstrate that a political solution was in order.  How dare we let in fresh air? How dare we suggest that things were not perfect?

The same thing is happening in the midst of the pandemic.  Physicians, nurses, and other assorted health care professionals are being threatened for wearing masks.  Administrators say, “They make the patients nervous.” Also likely, administrators have realized they don’t have adequate equipment.  Facilities and systems with enormous budgets caught unprepared in a pandemic.

I see the stories of these professionals as I follow online forums.  Physicians, nurses, and others, threatened with firing because they dared to speak out on the issue of PPE (personal protective equipment).

Like police officers without ballistic vests, these physicians don’t want to go into the rooms of COVID-19 patients without the masks and respirators, gloves, gowns, and face shields that will keep them safe. The equipment that will allow them to return home to their loved ones and prevent them from infecting their families.  This isn’t a good look.  A hospital that refuses to acknowledge the concerns and safety of its professionals is a hospital that ultimately doesn’t deserve them.

The same veil of silence pervades dialogue on the treatment of coronavirus.  When I follow discussions, I see a lot of shaming. “There just isn’t enough evidence to try hydroxychloroquine, Zithromax, convalescent plasma, an untried vaccine, HIV drugs, etc.” Those who suggest we might try are considered reckless or ignorant.  As the battle rages and lives are lost, innovation and risk are viewed with disdain.  And our medical establishment is locked into the paradigm of double-blinded, placebo-controlled studies involving tens of thousands of people and lasting years. Here’s a view of the same from the U.K. Unfortunately, to suggest that we may need to react faster is only met with ridicule, and often tied to political views instead of expediency. Worse,  it ignores the deep, fundamental need to offer hope, any hope, to hundreds of millions of professionals and citizens who are living in fear.

There is a tragic irony here; a painful coincidence.  Physicians silenced. Let’s see.  Where did we see that sort of thing resulting in a worldwide pandemic?  Does China come to mind? The Chinese Communist Party threatened (and who knows what else) physicians who dared to speak out about coronavirus, even when they knew its danger.  Even when they knew how easily and widely it spread.

They continued to soft-peddle numbers about total cases and case fatality.  The party continued to allow travel to and from China long after the problem was known. They even suggested that Italians have a “hug a Chinese person” campaign to combat alleged racism; a charge delightfully accepted and repeated by gullible Western journalists in pursuit of a narrative.

Truth dies in silence.  Sadly, so do people.  And certainly when we tell dedicated health care professionals to keep their mouths shut when they have identified problems, offered solutions and simply asked for help.  Whether it’s a private business, a totalitarian government, or anything in between, we should insist that the truth be spoken; freely and without fear of punishment.

Because, for the foreseeable future, lives will depend on it.