In April 2020, Lorna M. Breen, a top emergency physician in New York City, committed suicide. Breen had no history of mental illness, but prior to her death, according to The New York Times, she described to her father “an onslaught of patients who were dying before they could even be taken out of ambulances.” As Breen’s father told the Times, “She tried to do her job, and it killed her.”

COVID-19 has blanketed the world in an unrelenting fog of stress, anxiety, fear, fatigue and grief. At the same time, the U.S. has faced months of civil unrest, an unprecedented election season and natural disasters ranging from hurricanes to fires.

As Breen’s tragic story exemplifies, though, doctors and other healthcare professionals have had to deal with a myriad of additional stressors stemming from their work on the pandemic’s frontlines. If left unaddressed, these stressors have long-term ramifications for both individuals and the profession. Fortunately, though, more and more hospitals are recognizing this threat and are taking steps to curb it.

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“This is a profession, like the military, where there has historically been stigma attached to mental health,” says Nigel Girgrah, the medical director of the liver transplant program at Ochsner Medical Center and chief wellness officer of Ochsner Health in New Orleans. “We have to make it OK to come forward if you’re not OK.”

Even before the pandemic, physicians faced a unique set of stressors, including long hours, life-or-death decisions, regular encounters with grief, a tendency to skip breaks and vacations, and a culture that pressures doctors to always be fine. “In the past, if you engaged in treating mental health, it was often seen as a weakness,” says Amy Locke, a professor of family and preventive medicine and chief wellness officer at the University of Utah Health. As a result, physicians often suppressed their feelings and problems. With COVID-19, however, “the stress became too big,” Locke says. “Really, nobody can be just fine.”

While the stressors have changed over the course of the pandemic, they remain relentless. In the beginning, there was the uncertainty of treating a novel, deadly disease and the emotional toll of dealing with a high loss of lives. Doctors faced concerns about lack of PPE, ventilators and other equipment and worried about their personal safety and the risk of bringing COVID-19 home to their families and loved ones. The impacts to mental health were immediate. A study conducted last spring of 3,360 frontline healthcare workers at Mount Sinai Hospital in New York City revealed that 39% met criteria for symptoms of post-traumatic stress disorder (PTSD), depression or anxiety. Those who had been burnt out prior to the pandemic were most at risk, whereas those who perceived higher levels of support from hospital leadership were least at risk.

Now, a year into the pandemic, fear has largely been replaced with frustration and exhaustion. “Most of us can run on adrenaline for three to six months, but we just had the one-year anniversary of our first COVID patient,” Girgrah says. “People are just profoundly fatigued, just so over this.”

There is also an ever-present sense of endless uncertainty, says Eve Poczatek, director of strategic initiatives in the Rush Wellness initiative at Rush University Medical Center. “No one has any clear idea of when life will return to normal, if it will return to normal and how this pandemic will impact our lives going forward.”

If stress levels continue to remain high and are not addressed, Locke expects to see “an exodus from the profession.” In October, a Medscape survey of more than 7,400 physicians revealed that 25% are considering an early retirement, and 12% to 14% are considering a career change away from medicine, patient care or their current work environment. Physicians who leave the practice of medicine, even temporarily, may find it difficult to return, Locke says, because of credentialing and licensing requirements.

Two key challenges in addressing physician stress have been breaking through the mental health stigma barrier and ensuring that physicians know that their licenses will not be impacted if they do seek help, says Gail Basch, a psychiatrist and associate professor who leads the internal mental health crisis response at Rush University Medical Center. Often, that work falls to chief wellness officers—professionals whose job it is to ensure the well-being of physicians and other healthcare employees. Efforts to combat pandemic-related stress and improve well-being have included newsletters, web-based seminars, toolkits, free wellness classes, assistance with childcare, crisis lines, counseling and support groups. In many places, the work does seem to be paying off, with an increase in doctors making appointments for counseling and, in general, a greater willingness to engage with mental health.

“COVID generated quite a bit more conversation about what it means to not be OK, to acknowledge that,” Locke says. “What we see is when people show a bit of vulnerability and talk about their experiences and emotions with their teams, it builds connections and actually strengthens relationships with colleagues.”

There is concern that some of these gains could be lost in the coming months and years, as vaccinations become more widespread and the world returns to some semblance of normalcy. Locke, for example, is already seeing this happen among some physicians. “It’s very easy to slip out of that vulnerability and just go back to ‘Oh yeah, I’m totally fine,’” she says.

Holding on to the lessons learned in the pandemic, though, will help with tackling preexisting problems like burnout, which affected 44% of U.S. physicians prior to the pandemic and is not going away. “What people don’t realize is that high burnout contributes to increased depression, anxiety, suicidal ideation and, honestly, turnover from an organizational sense,” Poczatek says. Girgrah also warns of a potential surge in PTSD in frontline healthcare workers as life begins to return to normal.

“It’s not going to get easier for physicians after this, and if anything, they will have residual trauma from what’s happened,” Poczatek says. “I hope the pandemic has shone a light on an issue that already existed and will draw attention to identifying solutions that will contribute to the well-being of physicians in the long term.”

Encouragingly, many hospitals that did not have chief wellness officers prior to the pandemic are now looking into adding them, Locke says. “I would say that everybody is thinking about how to support their physicians, because they don’t really have a choice.”