This article is the first of a multi-part series on burnout among pulmonary and critical care physicians.

Ongoing demands related to the COVID-19 pandemic have led to increasing rates of burnout among clinicians of various medical specialties.1,2 In pulmonology, many physicians were already experiencing burnout before the pandemic began, and rates have subsequently increased even further. In a survey published in February 2021, 76% of pulmonologists who reported burnout indicated that it started prior to the pandemic, while 24% stated that burnout developed after the pandemic began.3

Despite the high rates of pre-pandemic burnout, most pulmonologists surveyed pre-pandemic (82%) reported that they were somewhat or very happy outside of work, compared to only 47% of those surveyed in 2020; 48% of those surveyed in 2020 also indicated that they were suffering from both burnout and depression.3


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Excessive bureaucratic tasks represented the top contributing factor (58%) to burnout for these physicians, followed by insufficient compensation or reimbursement (39%), too many hours spent working (38%), and lack of respect for employees, colleagues, and staff (37%).3

While many pulmonologists coped with burnout with exercise (54%), sleep (47%), playing or listening to music (45%), and talking with family members or close friends (31%), others reported coping by binge eating (26%), drinking alcohol (20%), and isolating themselves from others (29%).3

Only 18% of pulmonologists with burnout and/or depression are currently seeking or plan to seek professional help, while 62% have never sought professional help and do not plan to currently, for reasons such as being too busy (51%), viewing symptoms as not severe enough (58%), and believing they can deal with their issues without professional help (30%).3

Most pulmonologists surveyed (79%) indicated some level of anxiety about the future in the context of COVID-19, and 6% are considering leaving medicine altogether due to the severe impact of burnout on their lives.3

Among the vast range of challenges pulmonologists and other physicians are facing related to the pandemic, many are dealing with “moral injury” as a result of witnessing high numbers of patient deaths in the context of limited treatment options.4

Experts emphasize that health care providers experience mental health problems like everyone else, and peer support programs offer physicians the opportunity to share painful experiences with colleagues in a safe setting.2,4 In addition, the American Medical Association provides mental health resources for physicians, along with strategies for health system leaders to provide support to physicians and other providers.4

To gain insight into causes and solutions for burnout in the field, Pulmonology Advisor interviewed David G. Hill, MD, a medical spokesperson and board member for the American Lung Association. Dr Hill is also a pulmonary and critical care physician at Waterbury Pulmonary Associates in Connecticut and an assistant clinical professor of medicine at the Yale University School of Medicine in New Haven, Connecticut.

Since the pandemic began, 48% of pulmonologists reported experiencing either burnout or both burnout and depression. Yet pre-pandemic, rates were only somewhat lower, at 41%.3 Why do you believe so many pulmonologists are feeling burned out?

Dr Hill: As a private practice pulmonary and critical care physician, my perspective on burnout may differ from those of my colleagues who are primarily academic- or hospital-based providers. The survey data was published [by Medscape] in February 2021, and I would strongly suspect burnout numbers are significantly higher now than at that time.

Prior to the pandemic, the factors leading to burnout included long work hours [and] caring for complex patients. Many of these patient encounters in the hospital involve complex and/or end-of-life care with difficult discussions with both patients and their family members or guardians. In private practice, additional stress is added by constantly increasing overhead costs, which outrun increases in reimbursement from insurance and government programs. 

In addition, our healthcare system constantly adds unpaid work to providers. Trying to navigate and determine which prescription drugs are on formulary and determine patients’ out-of-pocket costs can be daunting. Time spent performing prior authorizations, peer-to-peer reviews, and completing disability and Family and Medical Leave Act paperwork seems to increase every year.

More and more of our patients are unable to afford care despite having health “insurance,” while insurance industry profits skyrocket. Early in the pandemic, auto insurers rebated policyholders because people were driving less. No health insurers issued rebates when outpatient care utilization plummeted. They simply passed the profits to their executives and shareholders. 

For years our practice has maintained income by increasing volume and adding new services or facility coverage; this model is unsustainable.

Practically speaking, how has the pandemic affected physicians in your field?

Dr Hill: The pandemic has not eliminated any of those issues, has exacerbated many, and has added multiple new stressors.  

In the inpatient setting, pulmonary and critical care physicians are heavily involved in caring for pandemic patients, and the care of these patients is time consuming. Simply entering and exiting COVID-19 isolation rooms can add 10 to 20 minutes to every patient encounter.

In the early days of the pandemic, concerns over exposure to the virus and either becoming infected or transmitting infection to our own families was a significant concern. That has lessened with experience and increased knowledge about COVID-19 transmission.

The frustration levels in caring for recurrent waves of COVID patients are contributing to burnout. It is disheartening that a segment of the population, including political and media organizations, are denying science or actively sowing uncertainty, which leads to continued high disease rates. There is a group of patients who do not want to listen to health care providers regarding vaccination or public health measures to reduce risk of viral infection, but they turn to us when they become acutely ill with the virus. Wave after wave of viral infection including new variants have caused surges in outpatient and inpatient acute care. 

Resilience diminishes with time. There are only so many waves a provider or health care system can be hit by before they fall down. Pulmonary and critical care physicians are closely involved in triage decisions and bed availability. Usually there is no shortage of physical beds. As the pandemic continues to rage, there is an increasing shortage of skilled experienced health care providers, particularly critical care nurses and respiratory therapists, but [this is] occurring across all groups of health care professionals.

Experienced nurses are retiring or leaving critical care. Health care systems respond by hiring traveling nurses, many of whom are excellent, but they are not members of an established team and have no organizational loyalty or systems knowledge, and this adds stress to the system.  

In the outpatient private practice setting, we face the same pandemic stresses that any small business does. During the early days, outpatient volumes and income plummeted. In pulmonary medicine we had to implement multiple safety protocols, particularly to restart our outpatient pulmonary function labs as safely as possible. Protocols for screening and testing patients for COVID-19 to protect both staff and our patients had to be created and implemented. These measures slow patient flow and disrupt the workday.

Despite precautions, sick patients or staff can still enter our office and lead to additional workflow disruptions and stress. There is a noticeable lack of patience amongst our providers and staff due to the ongoing stress all of this adds to our already challenging jobs. 

What measures are most needed to address burnout among health care providers? 

Dr Hill: There are no simple solutions to provider burnout. Good communications within health care systems are important. Creating a team atmosphere and a culture that prides itself on delivering excellent care while promoting systems change rather than blame for problems diminishes burnout. Providing resources and increasing reimbursement to diminish workloads is a solution that will require societal change and a reprioritization of economic resources.

Our economy, which favors quarterly profits over long-term solutions, exacerbates the stress on health care workers. Workplace benefits, paid time off, and quality of life are frequently more robust in financial or technology industries than they are for highly trained and skilled health care providers. The expectation that physicians, nurses, and other health care workers will continue to take on increased patient care burdens in an overloaded health care system is unrealistic. Public health and health care workers need to be prioritized.

What are some steps that have personally helped you in this regard?

Dr Hill: Personally, dealing with workplace stress and burnout has at times been a challenge, particularly in the last 20 month. I have learned to prioritize exercising regularly, getting adequate sleep, and spending quality time with family and friends to help maintain my resiliency. Spending some of my valuable free time doing rewarding volunteer work makes me feel better about myself and more able to deal with some of the day-to-day challenges of my career. 

Learning to say “no” to some volunteer or professional requests has been challenging but also important. There are times when taking time for yourself outweighs professional advancement or the desire to do good. Sharing my experiences in the pandemic on the frontlines and being a voice promoting trust in science and public health has also helped me to counter burnout. 

I continue to hope that the majority of people are listening and that we will eventually emerge from this pandemic with a stronger and more resilient health care system. If we don’t successfully address the issues leading to burnout in health care workers, it is a danger to all of us.

References

1. Sasangohar F, Jones SL, Masud FN, Vahidy FS, Kash BA. Provider burnout and fatigue during the COVID-19 pandemic: lessons learned from a high-volume intensive care unit. Anesth Analg. 2020;131(1):106-111. doi:10.1213/ANE.0000000000004866

2. Taylor WD, Blackford JU. Mental health treatment for front-line clinicians during and after the coronavirus disease 2019 (COVID-19) pandemic: a plea to the medical community. Ann Intern Med. 2020;173(7):574-575. doi:10.7326/M20-2440

3. Martin KL, Koval ML. Medscape pulmonologist lifestyle, happiness and burnout report 2021. Published online February 19, 2021. Medscape. Accessed December 21, 2021.

4. Lubell J. How pandemic’s toll adds up to “moral injury” for physicians. American Medical Association. Published online November 11, 2021. Accessed December 21, 2021.

This article originally appeared on Pulmonology Advisor