DEI, wellness, health equity, burnout
The burgeoning wellness and burnout crises in medicine accelerated during the pandemic, with several pre-existing conditions contributing to the current mental health crisis felt by many medical professionals.
These crises are particularly palpable among physicians on the front line. Emergency physicians receive disaster preparedness and rapid response training for isolated disasters focused on maximizing resources to improve patient outcomes, but they have no readiness training for the physical, psychological, and emotional impact of an ongoing daily global disaster over several years such as the COVID-19 pandemic.
It is imperative as society transitions into the recovery phase of the pandemic that we reflect on its immense impact on emergency physician wellness, especially utilizing a diversity, equity, and inclusion lens to acknowledge the disproportionate impact felt by those from underrepresented and marginalized backgrounds.
Crisis-level Burnout
Burnout is characterized by high emotional exhaustion and depersonalization, with a low sense of personal accomplishment from work. (National Academies of Sciences, Engineering, and Medicine. Oct. 23, 2019; https://bit.ly/3QC21B8.) The National Academy of Medicine described an imbalance in which the demands of the physician’s job were greater than the resources available to complete the job effectively, resulting in crisis-level rates of burnout. These pre-pandemic reports identified substantial burnout in 35 percent to 54 percent of nurses and physicians and 45 percent to 60 percent of medical students and residents.
The U.S. Surgeon General described COVID-19 as a fully and uniquely traumatic experience for the health care workforce. (Addressing Health Worker Burnout. 2022; https://bit.ly/3y7aS6J.) Emergency physicians initially responded swiftly to support the community during the early part of the pandemic, and many are struggling two years later with more than one million American lives lost after countless COVID surges.
We must acknowledge that emergency physicians sacrificed their own lives to treat and support others, including providing direct care to their colleagues and loved ones. Studies examining medical professional wellness during the pandemic reported exceedingly high rates of stress, anxiety, exhaustion, loneliness, and overall burnout. Burnout is costly in the human cost felt by health care professionals, the monetary cost associated with high worker turnover, and the profound impact on the health and safety of society given patient care implications. The direct result of high burnout among medical professionals is evident in the increasing rates of the heart disease, diabetes, substance use disorders, anxiety, depression, insomnia, and unfortunately suicide documented since the pandemic.
The wellness of all front-line health care professionals has been profoundly affected during the pandemic, and groups known to be underrepresented or marginalized in medicine have been disproportionately affected, specifically those belonging to gender and racial/ethnic minorities.
Female professionals have consistently reported higher rates and sequelae of burnout, which was exacerbated during the pandemic. Female colleagues are also more likely to be caretakers of children and older people. School closures and nursing home outbreaks added additional stress on top of an already heavy workload, resulting in significant career disruptions with academic advancement implications and financial consequences for some.
Front-line medical workers from racial and ethnic minority groups have continued to have a higher rate of COVID-19 and negative impact on wellness. People of color are disproportionately represented in roles such as medical aides, personal care workers, direct contact support workers, and nursing home workers. These front-line health care workers were more likely to report inadequate PPE or having to reuse PPE, while these types of jobs placed them at a higher likelihood of being in direct contact with COVID-19 patients and elevated their risk of workplace exposure. (Kaiser Family Foundation. Nov. 11, 2020; https://bit.ly/3xwGwZM; Lancet Public Health. 2020;5[9]:475; https://bit.ly/3QpJlEs; Health Affairs Health Policy Brief. June 4, 2021; https://bit.ly/3xYNlEX.) Health care workers of color were subsequently nearly twice as likely to test positive for COVID-19 and represented the largest percentage of front-line health care worker COVID deaths compared with their white counterparts.
Hate Crimes, Mass Shootings
Many of those from racial and ethnic minorities also faced the realities of systemic racism in this country head-on after the murders of unarmed Black Americans by police officers sparked what many have deemed the largest global civil rights movement in history, all amid the backdrop of the COVID-19 pandemic and local government shutdowns and rises in anti-Asian, anti-Semitic, and anti-immigrant violence, and mass shootings.
The recent mass shootings in a Buffalo, NY, grocery store, a Uvalde, TX, elementary school, and a Tulsa, OK, hospital have redirected national attention toward gun reform. Unfortunately, more than 100 people are killed daily from gun violence, while 200 are shot and wounded every day. (CDC WONDER Database. Underlying Cause of Death [Yearly average: 2016 to 2020].) Emergency physicians are in a unique position because they administer care to perpetrators and victims of violence, with little time to process the enormous emotional and psychological impact that these events have on them.
The impact is particularly profound and deep when racial and ethnic concordance exists between emergency care professionals and victims of hate crimes and targeted attacks. This growing phenomenon warrants attention to acknowledge the cumulative impact of treating patients in these situations, especially when the patients remind medical professionals of their loved ones and amplify the dangers that they themselves face once they leave the hospital.
It is crucial to create an environment and culture that acknowledges the impact of gun violence and to allow for space to have nuanced discussions among health care teams. A degree of compartmentalization is necessary to carry out our duties in the ED, and it is vitally important that we create a culture that allows colleagues to begin to decompress and process this trauma.
Immediate critical debriefing sessions after ED deaths and difficult traumas have been shown to affect patient safety in a positive way, improve compassion fatigue, and promote resiliency and subsequent group healing. (Emerg Med Australas. 2021;33[5]:922; J Trauma Nurs. 2017;24[5]:317.) Recent studies continue to recommend a hot debriefing session immediately after the event in the emergency department. (Emerg Med Australas. 2021;33[5]:922.)
Recovery and Rebuilding
The pandemic has been truly traumatizing for front-line medical professionals. Several opportunities to implement systemic changes aimed at shifting organizational cultures and improving workplace conditions can help promote recovery and healing as we shift toward rebuilding community.
These systemic efforts should be centered around building a commitment to the health and safety of front-line medical professionals into the fabric of the workplace culture. This includes actions to show that front-line medical professionals are valued by offering competitive wages; opposing workplace bias and discrimination; promoting family-friendly policies around caring for children and older people; and building a culture that encourages and normalizes the use of sick leave, family leave, and mental health breaks.
Deliberate efforts should be made to improve access to high-quality mental health and substance use care while creating environments that seek and incorporate explicit input about occupational stress, grief, bias, and mental health challenges into systemic solutions. Front-line workers should be encouraged, not deterred, from seeking mental health care.
The U.S. Surgeon General recommended that professional licensing and credentialing forms be reviewed to ensure that professionals are not discouraged from or reprimanded for disclosing mental health challenges. Recovery from any insult is challenging, and we have a unique opportunity to rebuild with a focus on mindfulness and attention to creating an environment where colleagues are supported in showing up as their authentic selves to do the work that they once loved and ultimately improve the overall health of the community.
Dr. Knightis the director of faculty experience at Zuckerberg San Francisco General Hospital and Trauma Center, the associate chair of diversity and inclusion in the department of emergency medicine, and an emergency medicine diversity, equity, and inclusion endowed professor at the University of California, San Francisco. Follow her on Twitter@StarrKnightMD.
