When the Dust Settles: Preventing a Mental Health Crisis in COVID-19 Clinicians
Authors: Stephanie B. Kiser, Rachelle E. Bernacki
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions9 June 2020When the Dust Settles: Preventing a Mental Health Crisis in COVID-19 CliniciansFREEStephanie B. Kiser, MD, MPH and Rachelle E. Bernacki, MD, MSStephanie B. Kiser, MD, MPHHarvard Medical School, Boston, Massachusetts (S.B.K.) and Rachelle E. Bernacki, MD, MSDana-Farber Cancer Institute, Boston, Massachusetts (R.E.B.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-3738 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail On 26 April, after spending weeks caring for patients with coronavirus disease 2019 (COVID-19) in New York City, emergency room physician Lorna Breen took her own life. Her grieving family recounts days of helplessness leading up to this as Dr. Breen described how COVID-19 upended her emergency department and left her feeling inadequate despite years of training and expertise.The clinical experience of Dr. Breen during this pandemic has not been unique. During the past 5 months, COVID-19 has caused an upheaval of medical systems around the world, with more than 4 million cases and 300 000 deaths worldwide so far (1). Unfortunately, we've also seen that the experience in caring for patients with the virus may have profound effects on clinicians' mental health (2). A recent study conducted at the center of the outbreak in China reported that more than 70% of frontline health workers had psychological distress after caring for patients with COVID-19 (3).Understanding and addressing these effects starts with naming the problem. Watching patients die alone, constant worry about inadequate resources, and paranoia about our own health are all deeply distressing and unprecedented experiences that cannot be described as anything other than trauma. Much of what we are facing daily is uncharted territory, but history tells us that this trauma, like other types, may have profound implications for the mental health of clinicians. In a study of health care workers involved in the 2003 SARS (severe acute respiratory syndrome) outbreak in Toronto, one third of those surveyed reported posttraumatic stress symptoms at levels similar to those of victims of a large-scale natural disaster (4). Furthermore, the risk for this secondary trauma comes for clinicians who already have a higher burden of mental health disease than the average population (5).Many institutions have established resources, such as employee assistance programs, offering counseling and debriefing groups. These institution-wide approaches are crucial, but from our work in palliative care, where death is experienced daily, we know they will not be enough. We have learned the value of finding meaning in times of intense grief and sorrow—a new skill for many clinicians outside palliative care. As we have struggled to adapt our own coping mechanisms during this time, we have also observed our colleagues throughout the health care system in despair, often without the support, structure, and skills to process these events. With that in mind, we share a foundational set of principles to use as guidance for building internal support for the trauma caused by the pandemic: looking past the illness, fostering community, promoting vulnerability, and establishing boundaries and limitations.Look Past the IllnessThe practice of health care often dehumanizes our patients, reducing them to a list of symptoms and diagnoses. As we grieve over the restrictions currently limiting family members' presence at the bedside in our hospitals, we lose our most valuable connection to remembering who the patient is outside of their illness. During these times, we seek out ways to grasp small pieces of what that family presence often provides us. We spend a few extra minutes on the phone listening to a patient's wife tell us about the time they first met. We ask about an intubated patient's favorite song and play it at their bedside. These humanizing moments are desperately needed now. They sustain us and allow us to process our experiences as part of the complex narrative of illness.Foster CommunityFor many persons, the first response to trauma is self-isolation (4). Although personal processing and reflection are certainly needed, healing requires community. Topics that are challenging to discuss often are not talked about transparently in our work culture. In palliative care, these challenges bring us together and we make time to talk about them in groups; 1 example is weekly Bereavement Rounds to share grief about the death of our patients. These groups promote and honor each other's strengths to further build resiliency and help us process the grief and ensure that we protect ourselves.Promote VulnerabilityThroughout the pandemic, the community has praised health care workers. From posters of support to donated meals, these gestures are a warm embrace. In much of this, health care workers are cast as "superheroes." Although the sentiment is honored, the disconnect it creates cannot be ignored. Many health care workers may not feel they are "flying" but instead barely keeping their heads above water. Clinicians are not superheroes. We make mistakes, and we have limits. Leaders of our departments and institutions must broadcast this message. Senior clinicians can acknowledge the reality of the situation and encourage questioning of ourselves and our systems during this period of uncertainty. In palliative care, these thoughts are often shared during structured weekly Reflection Rounds. Although some may worry that this approach promotes weakness, we have seen the strength and support it provides.Establish Boundaries and LimitationsThe calling to the medical profession may feel even stronger during these times of intense need. This comes at the risk of throwing ourselves into the work without considering our own needs and protection. Leaders must protect their clinicians by carefully considering appropriate time off in scheduling and ensuring that colleagues, superiors, and trainees use this time. A need will always exist to do more, but this need cannot be met without ensuring that clinicians are well.For our palliative care department, incorporating all these supports means making dedicated time with intentional activities and, more importantly, fostering a cohesive community of constant reflection. The strength of our program in honoring these principles comes from our leaders, who have made them a priority and have led by example. We do this together and have learned the power of community and how diversity within community can provide perspective.As we offer these thoughts, we remain hopeful. The time for us to do more is now. If we take timely and targeted action, we will provide the support our fellow clinicians desperately need. We challenge leaders to act and make this a priority in the culture of their institutions. Today, we honor Dr. Breen and we grieve with her family. As we continue to mourn the catastrophic mortality from this pandemic, we must recognize that some outcomes can be prevented.References1. Johns Hopkins University of Medicine. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Accessed at https://coronavirus.jhu.edu/map.html on 15 May 2020. Google Scholar2. Chou R, Dana T, Buckley DI, et al. Epidemiology of and risk factors for coronavirus infection in health care workers. Ann Intern Med. 2020;173:120-36. [PMID: 32369541]. doi:10.7326/M20-1632 LinkGoogle Scholar3. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3:e203976. [PMID: 32202646] doi:10.1001/jamanetworkopen.2020.3976 CrossrefMedlineGoogle Scholar4. Maunder R. The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: lessons learned. Philos Trans R Soc Lond B Biol Sci. 2004;359:1117-25. [PMID: 15306398] CrossrefMedlineGoogle Scholar5. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161:2295-302. [PMID: 15569903] CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Laura Carravallah, MD, FACP, FAAPSpeaking for myself16 June 2020 Fix the System " Senior clinicians can acknowledge the reality of the situation and encourage questioning of ourselves and our systems during this period of uncertainty." It is unconscionable that health care workers have been put into this no-win situation of deciding whether to risk their health without necessary equipment vs. abandoning their patients. While the virus was probably not preventable (though that can be debated, as our ongoing depredations on our environment have contributed to the likelihood of this pandemic), the lack of preparation and PPE was. That - and the politicization of the CDC and other public health resources - was completely due to our own society's selfishness, greed and lack of foresight. Clapping for heroes is not enough. We should mobilize and advocate for public health measures and adequate supplies so that we will be able to decrease and mitigate the next wave of the pandemic, which will very likely come in the next few months. This could save many thousands of our patient's lives as well as our own, and diminish the root causes of this tragic mental health crisis. Wynn Bear, Mingzi WuInternational WYNNBEAR Advanced Innovation30 June 2020 National Academies Guidance Should Consider A Top-level Design Change For The Future A given secure channel for a specific crowd is needed, such as a particular community, expert, or vulnerable group. Gain new insights through restudying old material. Although the prevalence of the SARS-CoV-2 has been for half a year, the reported most incubation period of SARS-CoV-2, however, is just 5-6 days; only a few cases can be up to 14 days. This gives us an idea to provide an approach to get adequately both in economic and social benefits and isolating the virus by a novel distributed anti-epidemic social system, in which the whole society is divided into smaller two or more societies, and one is free in the first 14 days, the other one is in lockdown. But in exchange, the first one will be in lockdown in the next 14 days, and the second one will be free. It also is called the grouping model. An instance of the detail of the grouping definition has shown (3). The processing of the distributed anti-epidemic social system for stopping the pandemic is also compatible with many existing solutions or measures and creates significant benefits for asymptomatic transmission and vaccination, etc. We should do such the public health intervention measures of distributed social systems seven days in advance since there has always been one keep the society in operation by such the swappable anti-epidemic models. Earlier non-pharmaceutical interventions play a key role in most cases, sooner rather than later. From the considerations of economics, politics, and cost, most governments don't do what they should do often. By such the distributed social system and anti-epidemic intervention measures, however, there is no heavy burden on the main aspects of society no matter how early you made such the decision. It will be a global good omen to mitigate the spread of the coronavirus if the decision is made by the authorities of the city where the initial case is found or diagnosed. (1, 2) The outbreak spread widely in other countries by SARS-CoV-2 put a substantial burden on local health systems and society in every way. Nonpharmaceutical interventions are often the main immediate means to stop virus transmission since vaccines and miracle drugs are often too late. Pushing such the distributed anti-epidemic systems with earlier isolation without any chaos and shifts in strategy (3), not only will it lead to reduce and stop transmission in the area, but also reassuring the people around the world in all respects. It will avoid critical care capacity from being exceeded (4, 5), and become the solutions for the future unexpected outbreak of epidemics, or second, third COVID-19 waves in a pandemic, and several infectious diseases overlap and peaks around the same time or even several disasters are overlapping with infectious diseases and natural disasters, such as meteorological disasters, geological disasters, and marine disasters, etc. The distributed anti-epidemic social system provides powerful psychological support and strategic decision for pharmaceutical treatments and vaccination with difficulty and uncertainty in earlier stages. By such the distributed anti-epidemic social system, there are no great pressures for individuals, such as the pressure of as ideological, moral, mental, employment and financial, etc., since it short-term days of 7-14 (it is allowable to adjust in the future). This is a general mechanism for infectious disease and natural disasters, whether the virus is known, unknown, current, or future, etc. For the global happiness, health, and welfare, an agreement needs to be born that such the decision must be made first by the authorities of the city around the world where the initial case is found or diagnosed, all the same. There is no very gloomy outlook for the world economy if such the general intervention mechanism happening at its very early stages at present and in the future. It is easier to be a smooth implementation with a scientific grouping method, advanced information technologies and terminals, and appropriate incentives. A rewards need to be set up for the authorities that make the decision with such the novel isolation to stifle the disease in its earliest stages. References Hsiang, S., Allen, D., Annan-Phan, S. et al. The effect of large-scale anti-contagion policies on the COVID-19 pandemic. Nature (2020). https://doi.org/10.1038/s41586-020-2404-8 Jeanine Condo, Learn from Rwanda's success in tackling COVID-19. Nature 581, 384 (2020). http://doi.org/10.1038/d41586-020-01563-7 Wu Mingzi, et al. Always Swapping Isolation will be alternative approaches for maintaining physical distancing and minimize the risk. https://science.sciencemag.org/content/368/6496/1163/tab-e-letters. Stephen M. Kissler, et al. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science 22 May 2020. DOI: 10.1126/science.abb5793. Eric J. Rubin, Lindsey R. Baden and Stephen Morrissey, Audio Interview: The Challenges of Safe Reopening, Editorial, June 25, 2020. N Engl J Med 2020; 382:e113. DOI: 10.1056/NEJMe2023276. Joan Stephenson, National Academies Offers Guidance to Decision-Makers on Evaluating COVID-19 Data. JAMA, June 26, 2020. Author, Article, and Disclosure InformationAuthors: Stephanie B. Kiser, MD, MPH; Rachelle E. Bernacki, MD, MSAffiliations: Harvard Medical School, Boston, Massachusetts (S.B.K.)Dana-Farber Cancer Institute, Boston, Massachusetts (R.E.B.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-3738.Corresponding Author: Stephanie Kiser, MD, MPH, 450 Brookline Avenue, Jimmy Fund 8, Boston, MA 02215; e-mail, stephanie_kiser@dfci.harvard.edu.Current Author Addresses: Dr. Kiser: 450 Brookline Avenue, Jimmy Fund 8, Boston, MA 02215.Dr. Bernacki: Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Avenue, JF 821, Boston, MA 02215.Author Contributions: Conception and design: S.B. Kiser.Analysis and interpretation of the data: R.E. Bernacki.Drafting of the article: S.B. Kiser, R.E. Bernacki.Critical revision for important intellectual content: S.B. Kiser, R.E. Bernacki.Final approval of the article: S.B. Kiser, R.E. Bernacki.Provision of study materials or patients: R.E. Bernacki.Administrative, technical, or logistic support: R.E. Bernacki.This article was published at Annals.org on 9 June 2020. 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