Getting Through COVID-19: Keeping Clinicians in the Workforce
Authors: Eileen Barrett, Susan Thompson Hingle, Cynthia D. Smith, Darilyn V. Moyer
Journal: Annals of Internal Medicine (2021)

Ideas and Opinions28 September 2021Getting Through COVID-19: Keeping Clinicians in the WorkforceFREEEileen Barrett, MD, MPH, Susan Thompson Hingle, MD, Cynthia D. Smith, MD, and Darilyn V. Moyer, MDEileen Barrett, MD, MPHUniversity of New Mexico School of Medicine, Albuquerque, New Mexico (E.B.)Search for more papers by this author, Susan Thompson Hingle, MDSouthern Illinois University School of Medicine, Springfield, Illinois (S.T.H.)Search for more papers by this author, Cynthia D. Smith, MDAmerican College of Physicians, Philadelphia, Pennsylvania (C.D.S., D.V.M.).Search for more papers by this author, and Darilyn V. Moyer, MDAmerican College of Physicians, Philadelphia, Pennsylvania (C.D.S., D.V.M.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-3381 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail While the world recognizes that the COVID-19 pandemic is not yet over, physicians and other clinicians continue to wrestle with how to provide safe, high-quality, compassionate care despite ever-changing and potentially dangerous work conditions. The risk for contracting COVID-19, the challenges of caring for medically complex patients, and a polarized political environment compound the workplace hazards and stress that threatened clinicians before the pandemic (1). As physicians, educators, peers, and friends of COVID-19 responders, we are gravely concerned about our colleagues' exhaustion, burnout, and disillusionment. In addition, as physicians experienced in advocacy for clinician well-being, we urge employers and organized medicine to take tangible steps to preserve the clinical workforce.To keep physicians and other clinicians in the workforce, the entities that employ us must move beyond suggesting stress-reduction activities, such as yoga and meditation, to provide the tactical support clinicians need to safely care for patients and support one another. We call upon every health system, hospital, and clinical practice to adopt the following actions.First, ensure physical safety by reducing clinicians' risk for contracting COVID-19 through vaccination mandates, policies and practices that guarantee universal masking and adequate ventilation in work areas, and access to personal protective equipment (PPE). Transparency about PPE supplies and contingency plans when there are shortages are particularly important to restore and maintain trust among clinicians who spent earlier COVID-19 waves without adequate PPE.Second, provide practical support in the areas that clinicians identify as causing emotional stress or moral injury. Professional development should prioritize activities that help increase clinicians' confidence in managing anger, frustration, and grief when caring for patients who have chosen not to be vaccinated. Additional training should focus on addressing vaccine misinformation, holding rapid “goals-of-care” conversations, and providing care that may be outside clinicians' usual scope of practice. Training can be offered during existing team meetings and educational times, such as grand rounds. Transparency about staffing levels, medication availability, and hospital bed capacity with contingency plans during surges is a foundation of pandemic management that can decrease clinicians' moral injury.Third, provide sufficient time during clinical encounters for members of the care team to address COVID-19 and vaccine misinformation. Taking the long view instead of focusing narrowly on productivity metrics includes recognizing that when clinicians have time to address these issues, it can help prevent additional COVID-19 infections and hasten returning to usual operations. Training and empowering all members of the care team on these topics can relieve physicians of the need to respond on their own.Fourth, extend support to clinicians who are parents by offering flexible work schedules and support groups and advocating for policies to reduce SARS-CoV-2 transmission in school settings. Work schedules should be revised using a lens of equity, recognizing that women and those who are primary caregivers for dependents may be penalized by schedule changes that do not account for the “second shift” at home.Fifth, reduce administrative tasks that are not mission-critical, such as lengthy online mandatory trainings that have not been shown to improve patient outcomes, burdensome promotion and tenure reporting requirements that do not allow creativity and innovation during the pandemic to count, and unnecessary meetings.Sixth, health care institutions should adopt robust antidiscrimination and antiharassment policies to acknowledge and mitigate harm, particularly against minoritized persons (2). There should be zero tolerance for discrimination, harassment, or retaliation against those who voice concerns about patient or clinician safety.Seventh, offer free and confidential resources to support clinicians' mental health. Easy access to crisis hotlines, counseling, and peer support groups should supplement readily available medical care appointments (3). Many of these resources already exist; it is important to make clinicians aware of them.Eighth, update credentialing and employment applications to remove unnecessary questions about mental and physical health diagnoses that may deter care-seeking, violate the Americans With Disabilities Act, and stigmatize clinicians (4).Ninth, actively encourage clinicians to use available vacation and professional development days to nurture a mentally healthy workplace. Leaders should role-model taking time off and setting and defending work boundaries during that time, as well as advocate that others do the same.Finally, implement suicide prevention strategies. This includes instituting “wellness check-ins” for clinicians in hard-hit areas so that they can express concerns and receive coaching on coping skills (5). In addition, offer explicit suicide prevention programming on reducing access to lethal means (6).Adopting these actionable steps heeds calls by the media, academia, the Joint Commission, the National Academy of Medicine, and medical professional societies to reduce barriers to clinicians' accessing care (7, 8). These recommendations should be considered by organizations in conjunction with their frontline clinicians to decide which would be most impactful and feasible in their current environments. Overcoming institutional inertia and personal exhaustion is a challenge when implementing any change, as are valid concerns about burdens on small practices and clinics and hospitals practicing in the safety net. However, because clinicians in these settings often have fewer resources available to support their well-being, acting swiftly on as many of these steps as possible is even more pressing.If a small practice is unable to provide mental health resources, they can avail themselves of existing free resources and share them with their staff. Examples of such resources are highlighted through the American College of Physicians' I.M. Emotional Support Hub (www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/im-emotional-support-hub), which includes links to relevant materials from the American Psychological Association, the Center for the Study of Traumatic Stress, the Physician Support Line, and other resources. Individuals and practices that have unstable PPE supply chains can take advantage of the American College of Physicians' collaboration with Project N95 to ensure they have sufficient supplies (www.acponline.org/featured-products/ppe-materials/project-n95-collaboration-faqs).Sharing and spotlighting best practices can provide incentives to reluctant adopters. The entire health care system can benefit when clinicians receive material, logistic, and tactical support, and foundational themes have long been recommended (9, 10). The adage that no crisis should go to waste presents us with many opportunities to do better—and the ongoing waves of the pandemic create a new urgency to do so.References1. Kannan L, Wheeler DS, Blumhof S, et al. Work related post traumatic stress disorder in medicine residents. Acad Psychiatry. 2019;43:167-70. [PMID: 29644602] doi:10.1007/s40596-018-0911-9 CrossrefMedlineGoogle Scholar2. Paul-Emile K, Critchfield JM, Wheeler M, et al. Addressing patient bias toward health care workers: recommendations for medical centers. Ann Intern Med. 2020;173:468-73. [PMID: 32658573] doi:10.7326/M20-0176 LinkGoogle Scholar3. Hooper JJ, Saulsman L, Hall T, et al. Addressing the psychological impact of COVID-19 on healthcare workers: learning from a systematic review of early interventions for frontline responders. BMJ Open. 2021;11:e044134. [PMID: 34020974] doi:10.1136/bmjopen-2020-044134 CrossrefMedlineGoogle Scholar4. Barrett E, Lawrence E, Waldman D, et al. Improving how state medical boards ask physicians about mental health diagnoses: a case study from New Mexico. Ann Intern Med. 2020;172:617-8. [PMID: 32203976] doi:10.7326/M19-3681 LinkGoogle Scholar5. Sofka S, Grey C, Lerfald N, et al. Implementing a universal well-being assessment to mitigate barriers to resident utilization of mental health resources. J Grad Med Educ. 2018;10:63-6. [PMID: 29467975] doi:10.4300/JGME-D-17-00405.1 CrossrefMedlineGoogle Scholar6. Workplace Suicide Prevention. 2021. Accessed at www.workplacesuicideprevention.com on 16 August 2021. Google Scholar7. The Joint Commission. Joint Commission statement on removing barriers to mental health care for clinicians and health care staff. 12 May 2021. Accessed at www.jointcommission.org/-/media/tjc/documents/covid19/statement-on-removing-barriers-to-mental-health-care-for-clinicians-and-health-care-staff.pdf on 10 September 2021. Google Scholar8. Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic—a national strategy to protect clinicians' well-being. N Engl J Med. 2020;383:513-5. [PMID: 32402153] doi:10.1056/NEJMp2011027 CrossrefMedlineGoogle Scholar9. Dewey C, Hingle S, Goelz E, et al. Supporting clinicians during the COVID-19 pandemic [Editorial]. Ann Intern Med. 2020;172:752-3. [PMID: 32196544] doi:10.7326/M20-1033 LinkGoogle Scholar10. Morganstein JC. Annals for Hospitalists Inpatient Notes—Preparing for battle: how hospitalists can manage the stress of COVID-19. Ann Intern Med. 2020;172:HO2-3. [PMID: 32315380] doi:10.7326/M20-1897 LinkGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Alan BarkerProfessor of Medicine, Oregon Health and Science University, Portland, Oregon28 September 2021 Another stress reducer I might suggest you consider another stress reducer: VOLUNTEER at a VACCINATION CLINIC. This thoughtful article addressed mainly a hugely involved, overworked, and wonderful Hospitalist and ICU caregivers whose time is limited, but below reasoning, opportunity, and consideration might be helpful to many physicians. Oregon Health Science University has had an employee and community vaccination program since February 2021. Vaccination sites include a hospital ambulatory vacant infusion area, Portland Convention center, the airport parking lot, community centers in the Portland area, general medicine clinics/offices, vans to rural areas, and homeless camps. We have vaccinated over 375,000 arms over this time period, the largest single program in Oregon. I and other (partly retired) faculty physicians have been volunteers as lead clinician, monitor, and/or vaccinator. This effort has yielded enormous satisfaction providing a life-saving prevention, relief from some of usual hospital work pressures, and a new way to use and broaden my skills learned throughout a career. Most importantly almost every vaccinated patient (young and old) has been so appreciative giving verbal thanks, a chuckle (hard to see a smile through a mask), and just feeling so much better that they are caring for themselves and others. Marvin BittnerCreighton University School of Medicine29 September 2021 Is ACP itself willing to make hard decisions to support clinicians by cutting "trainng"? Among the recommendations was reduction in "lengthy online mandatory trainings that have not been shown to improve patient outcomes." Many of these trainings, I am told, are mandated by the Joint Commission. Is this accurate? If so, is ACP (as a Joint Commission sponsor) willing to make hard decisions to insist that the Joint Commission expunge requirements for these mandatory trainings from its requirements? Is ACP willing to use its limited advocacy resources to insist that NIH fund studies of the value of mandatory trainings? To use its limited resources to develop modules of training that are indeed of value and which can be used by multiple hospitals (instead of requiring an internist with privileges at three hospitals to take three different versions of fire training)? To use its influence on the AMA, ACGME, and the like to reduce these mandatory trainings? To stand up to purveyors of poorly designed training modules just as ACP has confronted third-party payers and pharmaceutical manufacturers who have engaged in undesirable practices? It's one thing to recognize how these trainings sap morale. But . .. is ACP willing to act on these words? Drs. Eileen Barrett, Susan Hingle, Darilyn Moyer and Cynthia SmithUniversity of New Mexico, Southern Illinois University, American College of Physicians30 September 2021 Reply to Dr. Bittner Thanks for your thoughtful comment about the burden of mandatory online trainings on practicing physicians. In fact, ACP is already advocating for decreasing unnecessary administrative burdens on practicing physicians through the Patients Before Paperwork initiative. Here is a link to the initiative https://www.acponline.org/advocacy/where-we-stand/patients-before-paperwork. Mandatory online trainings required by hospital systems and other stakeholders are a perfect example of a burden that should be submitted via the data collection tool https://acp1.survey.fm/administrative-tasks-best-practices-survey. We rely on our members to let us know what they are finding most burdensome in their practices and adjust our policy and advocacy accordingly. Additional ACP policy actions are guided by the voice of ACP membership, spoken through our Board of Governors. We encourage all ACP members to work with their Chapters and governors to formulate proposals for advocacy positions using our Resolutions processes. ACP is also actively engaged with several state medical boards to assure that our high quality online educational modules are aligned with state CME requirements wherever possible. We have recently added a state CME filter to the ACP Online Learning Center https://www.acponline.org/cme-moc/online-learning-center to make it easier to connect physicians with high quality CME on state mandated topics. Thanks again for your feedback and suggestion! Disclosures: Drs. Darilyn Moyer and Cynthia Smith are employed by the ACP. Author, Article, and Disclosure InformationAuthors: Eileen Barrett, MD, MPH; Susan Thompson Hingle, MD; Cynthia D. Smith, MD; Darilyn V. Moyer, MDAffiliations: University of New Mexico School of Medicine, Albuquerque, New Mexico (E.B.)Southern Illinois University School of Medicine, Springfield, Illinois (S.T.H.)American College of Physicians, Philadelphia, Pennsylvania (C.D.S., D.V.M.).Financial Support: None.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3381.Corresponding Author: Eileen Barrett, MD, MPH, Division of Hospital Medicine, Department of Internal Medicine, MSC 10-5550, 1 University of New Mexico, Albuquerque, NM 87131-0001; e-mail, barrett.eileen@gmail.com.Current Author Addresses: Dr. Barrett: Division of Hospital Medicine, Department of Internal Medicine, MSC 10-5550, 1 University of New Mexico, Albuquerque, NM 87131-0001.Dr. Hingle: Southern Illinois University School of Medicine, 913 North Rutledge cHOP, Mailcode 9623, Springfield, IL 62794-9623.Drs. Smith and Moyer: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.Author Contributions: Conception and design: E. Barrett, S.T. Hingle, C.D. Smith, D.V. Moyer.Analysis and interpretation of the data: C.D. Smith.Drafting of the article: E. Barrett, S.T. Hingle, C.D. Smith, D.V. Moyer.Critical revision of the article for important intellectual content: E. Barrett, S.T. Hingle, C.D. Smith, D.V. Moyer.Final approval of the article: E. Barrett, S.T. Hingle, C.D. Smith, D.V. Moyer.Administrative, technical, or logistic support: E. Barrett, C.D. Smith.Collection and assembly of data: C.D. Smith.This article was published at Annals.org on 28 September 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoYou Don't Ever Let Go of the Thread Rana Lee Adawi Awdish Getting Through COVID-19: Keeping Clinicians in the Workforce Marvin J. Bittner Getting Through COVID-19: Keeping Clinicians in the Workforce Cynthia D. Smith , Darilyn V. Moyer , Susan Thompson Hingle , Eileen Barrett Annals On Call - Keeping Physicians in the Workforce Robert M. Centor , and Eileen Barrett Metrics Cited byThe impact of COVID ‐19 on chronic disease management in primary care: lessons for Australia from the international experienceGetting Through COVID-19: Keeping Clinicians in the WorkforceMarvin J. Bittner, MD November 2021Volume 174, Issue 11 Page: 1614-1615 Keywords COVID-19 Health care providers Health promotion Personal protective equipment Psychiatry and mental health Safety ePublished: 28 September 2021 Issue Published: November 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...