Before “flattening the curve,” before “avoid touching your face,” before daily updates and dire warnings on ventilator and mask supply, many physicians were already beaten down and burned out – or morally injured, as the increasingly popular term for burnout goes.
Now, physicians on and off the front lines of the COVID-19 pandemic are in uncharted emotional territory.
Yet comparisons with past health crises and traumatic environments come easily for some physicians. For Houston internist Gus Krucke, MD, it’s the AIDS epidemic of the 1980s, when he was a medical student, intern, and resident. Today he’s medical director of an AIDS hospice and a teaching physician at a Houston-area inpatient hospital.
“We were losing all of our AIDS patients. [You’d get] several a night, and many of them never made it out of the hospital,” he recalled. “What I sensed today amongst everybody [on the care team] was just palpable fear. They’re on the verge of tears, but they don’t want to be seen crying. I’ve been on the phone with colleagues in New York and Georgia, some of the areas that have been hit hard, and they’re just shell-shocked. They feel like there’s practically nothing they can do to slow things down.”
Fear for themselves, fear for their families, fear for the future of private practice, but also a desire to lift up others and rise to the occasion: COVID-19 was spreading a lot more than just illness, and physicians in Texas were experiencing it all as the threat emerged.
Houston emergency physician Arlo Weltge, MD, witnessed the ups and the downs in his hospital.
“Times like this actually bring out some of the best in people. The health care workers, particularly the front-line EMS … police, community health care workers who are out there, and that includes the hospital-based departments and the critical care – you’ll see people really going out of their way to be kind, supportive, collegial,” he said. “But you’ll also see sometimes where people are just overwhelmed and stressed, clearly at the point of breaking. And that particularly [comes out] when they consider the very real fear of taking this disease home and infecting their elderly parents or infecting their young children.
“The extended hours and the change in the routine practice gets very stressful and tiring. And … as people get tired, their ability to deal with the stress gets impaired.”
A very personal threat
Rarely in modern times have American physicians had to worry this much about bringing an illness home to their loved ones. For Tyler pediatrician Valerie Borum Smith, MD, who works in a small-practice, outpatient setting, coronavirus necessitated a stringent new home routine.
“I’m a single mom, and I come home from work every day, and I leave my shoes at the door, and I walk straight to the laundry room, because I [can] get there from my back door,” said Dr. Smith, a member of the Texas Medical Association’s COVID-19 Task Force and Task Force on Behavioral Health. “I drop my clothes in the washing machine and I get in the shower. And then when I get out, I wipe down any surface I might have touched on the way in.”
Dallas psychiatrist Leslie Secrest, MD, describes a sobering, somber effect on physicians during his work as a hospital consultant and private-practice psychiatrist whose patients are also doctors. Physicians increasingly realized that it’s impossible to know where the danger lies because it’s impossible to know who has the virus and who doesn’t. So for him, the oft-repeated equations between battling COVID-19 and fighting a war resonate.
“I got in on the very end of the Vietnam War, and I was initially assigned to a combat group, so I was at [the] main headquarters along the demilitarized zone,” Dr. Secrest recalled. “You didn’t know who your enemy was, and periodically you get rocketed or you get periodic attacks, those sorts of things. That’s what this [pandemic] reminded me of, is that you really don’t know what you needed to be afraid of or not afraid of, in general. This is [what] my patients are telling me: You just begin to have to say everybody could be a carrier. You can’t tell the difference.”
While hospital and urgent-care settings had to prepare for more patients than they’re equipped for, many community physicians experienced the opposite. Because “shelter-in-place” or “stay-at-home” orders largely kept people away from the doctor’s office except for emergencies, the impact on practice salaries and staff created uncertainty about the future of their businesses.
“If they don’t furlough [staff], then they really are having to cut salaries by a significant percentage. That’s been something that’s a weight on their minds,” said Dr. Secrest, a member of TMA’s Behavioral Health Task Force. “I’ve heard in the elevator, several physicians say to me, ‘This may be the end of private practice.’”
Also fueling those fears was Gov. Greg Abbott’s executive order temporarily banning surgeries that weren’t “immediately medically necessary,” which put a number of physicians immediately out of work, including Houston-area plastic surgeon Thomas Wiener, MD. On the eve of Governor Abbott’s announcement in April of the state’s strategy to reopen its economy, including relaxing the elective surgery restriction, Dr. Wiener was concerned about how much longer that ban would go, and how it might affect his practice and those of his colleagues.
“I’m holding up OK because I maintain very tight cost control in my practice, and because my office is very small. I’m able to go on a sort of a minimal-functional status for my office,” Dr. Wiener told Texas Medicine. “[Should] this extend for much longer than the end of April, then I would start to worry even for myself.”
Many of his colleagues were struggling and “very scared” for their future, he said, noting the tightrope many practices walk because of decreased payments, electronic health record system costs, and paying employees to process claims.
“So if you then suddenly take away all income because the office is shut down, and many of those expenses continue, then it can potentially be a crisis” for private practices, Dr. Wiener said.
At the time of this writing, shortages of personal protective equipment (PPE) and other supplies to fight COVID-19 were a legitimate concern in certain parts of the Lone Star State, which TMA advocated strongly to remedy. (See “Paying the Price for PPE,” page 22.)
Despite adequate supplies in his hospital, Dr. Krucke said there was plenty of concern about the prospect of rationing care amid a surge of sick patients.
“I know that’s been a really big thing on people’s minds: ‘What am I going to do? Who am I going to choose if I got a 34-year-old who needs a ventilator versus an 84-year-old?’ Most physicians in this country have never been faced with those challenges before,” Dr. Krucke said.
Three North Texas physicians addressed how overwhelmed hospitals should approach that question in an April editorial in the Dallas Morning News (tma.tips/dmnmasscriticalcare).
“There’s a lot of soul-searching going on, and I think that if a physician tells you they’re not worried, they’re not telling the truth,” Dr. Krucke said.
Physicians have had to come to terms with their own fragility and mortality as well.
“I’m embarrassed as a physician to admit this, but I didn’t have an advance directive and a medical power of attorney [before the COVID-19 pandemic]. I do now,” Dr. Smith said. “I know that … if I haven’t already seen someone with COVID, at some point in time I will in the near future.”
Atlanta child psychiatrist Patrice Harris, MD, president of the American Medical Association, adds that some physicians are writing their wills as a result of coronavirus.
“Anytime [there’s] a crisis, we all try to make sense of it,” Dr. Harris told Texas Medicine. “And it does make sense to compare it to other crises, and in some ways, we can look at that and say, ‘Hey, we got through this.’ We can say, ‘We learned the lessons from the Vietnam War,’ if that’s your locus. ‘We can learn lessons from 9/11, we got through that. We’ll get through this again.’ I think those comparisons are normal and certainly personal for each physician.”
A voice of reassurance
Physicians are doing their best to reassure each other and their patients.
When Dr. Krucke spoke to Texas Medicine, he had just returned to the hospital from a leave of absence to refresh for the thick of the threat.
“I’ve never seen my colleagues so frightened, so I did something interesting today,” he said. “I went down to the ER, I said, ‘Hey guys, I’m back, and I just want you to know I’m real proud of you for being on these front lines. Here’s what might happen when you intubate these patients, and here are some ideas. You can call me anytime you want.’
“You could just see a wave of relief that they felt that somebody had their backs. I’m so glad I did. I thought, ‘Aw, it’s going to be corny to go down there and give them a pat on the back.’ But as it turned out, I think it was a boost for them.”
In the emergency department, Dr. Weltge has seen fewer people who’ve been clearly exposed to COVID-19, and more who are worried about unexplained symptoms.
But when there is a risk of exposure, “there are appropriate precautions. We’re not having family members visit, we’re limiting the number of people who can get in the hospital. They don’t have the emotional support, the patients don’t, of family and loved ones.”
Tyler pediatrician Dr. Smith often has provided that support to parents worried about their children’s mental health.
“I actually talked to a mom of a patient yesterday for a visit, and [found out that] my patient’s older brother had a heart transplant 10 years ago,” Dr. Smith said. “And there is a huge amount of concern and fear within their family about how to keep him safe during this time, because he’s definitely a high-risk kid. That family was expressing a lot of that concern and holding onto that weight, and almost responsibility for [his] well-being and safety.”
Dr. Smith said she emphasized “reassuring that mom, and helping that mom to reassure her daughter, that everyone is working on keeping him safe and healthy and that they’re doing all of the right stuff.”
Dr. Secrest anticipates TMA’s Behavioral Health Task Force will have much to study once the crisis point passes.
“There will be lots of opportunity for the behavioral health committee to really look at [the effects], because we’ve been focused on particular areas, and one of the areas that I think we’ll be able to see is, does this sort of stress bring out reactions to people who have had early childhood adverse events?” he said. “Does [that sort] of exposure put them at more risk, or do they become much more adaptable than some of the rest of us who haven’t had that?”
Dr. Krucke believes the crisis could present a chance to make people realize that medicine has been “operating on the margins,” with full hospitals and intensive care units, and resource levels that weren’t built to sustain a pandemic.
“This has been an eye-opener for stakeholders in medicine,” he said, “and also an opportunity for people like me with a lot of clinical experience, decades of experience, to say, ‘You have to have a buffer. You have to staff not only for variable volumes of patients, but potential acuity.’ We were not prepared for this in the U.S. because everybody is always operating at the edge of their efficiency. … The whole landscape of medicine’s going to change because of this crisis.”
Tex Med. 2020;116(6):12-15
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