Providers across the country face unique mental health challenges, including burnout and suicidal ideation, from the stresses of their work environments. Learn more about these challenges from some of the nation’s leaders in provider health research and advocacy.
Join Kat McDavitt, Chief of External Affairs at Collective Medical and Dr. Enrique Enguidanos, CEO and Founder of Community Based Coordination Solutions as they interview Bernard Chang, MD, PhD, FACEP, Vice Chair of Research and Associate Professor of Emergency Medicine at Columbia University Irving Medical Center and Lisa Wolf, PhD, RN, CEN, FAEN, Director of Emergency Nursing Research at the Emergency Nurses Association.
- Data on burnout among healthcare workers
- The impact of COVID-19 on provider mental health
- Resources for supporting each other and getting help
Enrique: Can you speak a little bit about the data on healthcare worker stress, perhaps around burnout and issues with suicide?
Bernard: Because providers think about burnout in different ways, I think a good working definition of burnout is psychological stress and emotional exhaustion secondary to your work environment. The data that exists is actually quite troubling in terms of our profession.
We see that 50 to 70 percent of physicians report signs of burnout at one point or another and have high degrees of emotional exhaustion. And we see this extending to the most tragic outcome of all: suicide. Annually, approximately 300 physicians die by suicide.
Lisa: There’s not actually a huge amount of data on suicidality in nursing. There’s just a couple of studies that suggests those rates are equally, horrifyingly high. We just finished a mixed method study on secondary traumatic stress. In the focus group, I was really surprised to hear over and over again nurses discussing suicidality in themselves and in their colleagues.
The number of nurses that we spoke to that had a colleague who died by suicide—sometimes without even leaving the hospital after their last shift—was surprisingly high and very disturbing.
Kat: It seems to me that a lot of the burden of stress reduction is put on providers. I don’t see a lot of support coming from the top and I’d love to hear you two speak to that.
Lisa: This is a systemic problem. Things like traumatic stress and moral distress are a result of the environment. These are not individual failings. We prescribe lavender baths and cookies and tell providers to “take some time for yourself.” Who can do that with intrusive thoughts and replaying the last person who died in front of you over and over again? This is a systemic problem. To place the onus for healing on yourself seems not just burdensome, but also impractical and insulting.
Bernard: Especially among the frontline clinicians, you’re beginning to see pushback when people talk about burnout. Because there is this implicit assumption that it’s an individual failing or not being resilient enough.
There are complex factors, both in the environment and the occupational stressors being placed on these individuals. You have to ask at the hospital level, as well as the state and federal level—”what are we really doing to support providers so that they can support patients?”
Enrique: I went to medical school in the early 90s, and prior to that I was a firefighter EMT. At none of those points did I get training around self help. Has that changed? Do you think we’re getting better at it?
Lisa: No. What newer clinicians will tell us is that “this terrible thing happened and I went to my colleague and I was told to suck it up, pull it together, and get back to work.” In order to respond to a colleague, we have to allow ourselves to unpack our own trauma. Yet, we don’t have the time or space to do that in the work environment, so it’s easier to respond by telling someone to pull it together and get back to work.
It’s that dismissal of those moments that compounds the trauma. This goes on and on because we all learn to stuff it down. You have to develop a coping mechanism or you’d be drowning in this tsunami of pain. It causes us to be somewhat divorced from our work. We lose that relational component and we can’t do our jobs. This is the thing that doesn’t get dealt with in training. I suspect that digging into this during pre-license or training would go a long way towards managing it.
Bernard: This is the dark flip side of the heroic narrative is that these people on the front lines are tough and resilient. There’s an implicit assumption that if you’re scared, stressed, or vulnerable—it’s shameful to admit that.
A key thing is to focus on stigmatization of mental illness. It’s going to have to be at an individual and cultural level within the medical community, but also getting support from higher up at the system level. We have to find ways to express and unpack our emotions and the trauma we see everyday on the front lines.
Enrique: Let’s talk about the symptoms. What are the things that we can identify early on?
Lisa: Part of it is self recognition. One thing our study participants told us is that feeling of being disconnected from your work and even at home. Somebody said they felt like they were a dimmer switch that kept getting lower and lower until all they could do after work was sit on their bed and stare at the wall. I think the first thing is noticing that sense of disconnection if you can.
Kat: The burden of identifying your symptoms and doing something about it is still on the clinicians. What is it going to take to change that? Is this a policy level change? What can we do to take some of the burden off providers?
Bernard: I think as an initial concrete step, it goes back to de-stigmatization. It goes beyond platitudes and is embedded culturally with some of the medical licensing and credentials. We still have a number of states where providers have to click on a specific box whether or not they have a history of mental illness.
I’ve had a number of colleagues who’ve had depressive or anxiety symptoms that will find a psychiatrist or psychologist and pay out of pocket because they don’t want this to be on their medical record for fear of impacting their professional licensure. That’s a step we have to address at the highest level.
At the systems level within the hospital, there’s a lot of the occupational stresses of the acute care environment that can be changed—from clinical scheduling to crowding to patient ratios. With EHRs, there’s a tremendous amount of documentation burden placed on our nurses and physicians that can only contribute to and exacerbate the stress.
Lisa: These are situationally appropriate responses for what we see everyday. It is not in any way pathological that you would be traumatized and depressed working in an ER. That seems to be an absolutely reasonable response. So, the idea that it’s an inappropriate response—such that nurses and physicians would seek out-of-pocket care because of the stigma—seems really wrong. Clinically inaccurate and also wrong.
Bernard: Perhaps there are two challenges we’re encountering. The first is that by nature of our occupational environment, we’re going to see extraordinary stressful things at times. It’s a normal, expected reaction to feel exhausted, stressed, and anxious at times. We want to normalize the ability to express that and de-stigmatize that sense of feeling “weak.”
The second thing is that there will be a small number of our colleagues who will, as a result of this occupational stress, go on to develop more clinically concerning behavioral or mental health challenges. We need to be able to identify those individuals and support them. We have to be able to provide the emotional and occupation support for those frontline providers.
Enrique: All of what you’ve said so far has been exacerbated in the last few months with COVID. What are your thoughts on that?
Lisa: What is troubling to me and exacerbates the stress of the nurses I’ve spoken to on the east coast is that you have these providers that are working so hard and putting their lives, quite literally, on the line every day to take care of people in a pandemic. And watching the inadequate response sparks a very profound moral injury in these providers who, due to external factors, are unable to provide the care they know their patients need.
Bernard: Our traditional means of social support for one another are ruptured. For example, you’d usually be able to see your friends and family members. Because of good public health guidance, it’s more challenging now.
Additionally, for a lot of providers, especially those on the front lines witnessing tragedy day in and day out, it’s been a challenge at the highest levels of the federal government where they feel the science is being undermined. Clinicians almost feel pushed into a corner because we’re considered heroes but we’re also out on our own, risking our lives for our patients without broad-level support.
Kat: We’ve seen some articles circulating that suggest a mass exodus of healthcare providers post-COVID. Do you two have any thoughts on that? Do you agree with that potential fallout?
Lisa: Oh absolutely. But I’m hoping that we can have a revolution instead of an exodus. At this moment, we see the value and the necessity of clinical providers. The work that they do is intellectual, it’s relational, it’s ethical, as well as clinical. All of those pieces need to be supported in order for us to appropriately care for the population.
The Band-Aid has been ripped off, we see all the inequity. We see all the bad things about how the healthcare system is set up and who it serves. You cannot cover that up anymore. So, the opportunity to change it as a result of a groundswell of both public opinion and providers pushing back. The vast majority of this system is predicated on the ethical stand of providers to never abandon their patients.
Bernard: I agree completely. An unhappy clinician is also a poorly-cared for patient. This is really a public health issue. There’s already a mountain of evidence and research showing that clinicians who have increased psychological stress are prone to more medical errors and poor patient care.
This impacts not just clinicians, but everyone. We need this imperative to be resonating not just in hospitals, but to the government level to recognize that we need to support our providers so they can provide care to everyone.
Enrique: As we wrap up, I want to give each of you an opportunity to share any resources you’d like to share.
Lisa: The American Nurses Association and the Emergency Nurses Association have partnered to have discussion groups calling the Well-being Initiative.
Overall, I know this sounds doom-and-gloom and heavy, but this is a huge opportunity for us to really uncover this part of our work—the part that makes us human—to de-stigmatize this and help people work through what it is to care for people on the worst day of their lives and to still maintain their own psychological integrity.
This is a great opportunity for us because you can’t solve a problem until you have uncovered it. The more work that we do around moral distress and secondary traumatic stress, the more tools we have to help people through it. So, in that sense, I’m pretty optimistic that all this work will bear fruit and allow our providers to continue to provide care in a way that’s healthy for them as well as for their patients.
Bernard: For all the nurses and physicians out there, please know that you’re not alone with the stress you’re experiencing. Please feel comfortable enough to share it with your friends and family. I think we all need to, step-by-step, try to change this culture of stoicism in our profession.
But it starts day-to-day, on your shifts, talking with your friends and colleagues. Really normalizing all of the emotions that we’re feeling. This has been a challenging, historic time. But I believe that it has shown a spotlight on the importance of the frontline, as well as the need to support the frontline. I’m hopeful and optimistic that the last few months will be the touchstone and foundation for us to move forward in a positive way.
About the Speakers
Bernard Chang, MD, PhD, FACEP and Vice Chair of Research and Associate Professor of Emergency Medicine at Columbia University Irving Medical Center
Bernard Chang is Vice Chair of Research and Associate Professor in the Department of Emergency Medicine at Columbia University. He has research interests in clinician psychological and physiological health. He has received grant funding at the institutional, state, and federal level for his work on burnout and is currently one of the leading NIH-funded Emergency Medicine Principal Investigators in the United States with 2 active large (R01) federal grants looking at long term cardiovascular and psychological development of burnout in Emergency physicians and nurses.
Chang received his PhD from Harvard in psychology, his MD from Stanford and completed his Emergency Medicine residency training at the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women’s Hospital. Prior to going to medical school he served as a professional sailboat captain doing yacht deliveries internationally.
Lisa Wolf, PhD, RN, CEN, FAEN, and Director, Emergency Nursing Research at the Emergency Nurses Association.
Dr. Lisa Adams Wolf is the director for Emergency Nursing Research at the Emergency Nurses Association. Her work has focused on the intersection of workplace environment, moral agency, and clinical decision-making in the healthcare setting, as well as workplace violence, mental health and suicide in care teams.
Wolf is an adjunct professor of nursing at several area colleges and Universities, and maintains a clinical practice in a local ED. She holds a bachelor’s degree in anthropology from Amherst College, master’s degrees in fine arts (Emerson College) and nursing (Molloy College), and a PhD in nursing from Boston College.
About the Podcast
The Collective Conscious is a monthly podcast aimed at addressing gaps in healthcare for some of our nation’s most vulnerable patients. Each month, we’ll meet with healthcare leaders to discuss what care teams, communities, and government agencies are doing to better support individuals with unique care needs—this includes mental and behavioral diagnoses, substance use disorder, homelessness and social determinants of health, and other complexities of care.
About the Hosts
Enrique Enguidanos, MD, MBA has over 20 years of clinical experience in emergency medicine—much of which has been spent also serving in organizational and systems management roles. As CEO and founder of Community Based Coordination Solutions and a practicing ED physician, he has spent over a decade developing and fine-tuning systems of care and community management systems that have proven very effective for frequent utilizers. He has organized these systems in a manner that allows CBCS to continuously reproduce care results across varying communities and healthcare systems.
Kat McDavitt is Chief of External Affairs at Collective Medical. With over ten years of experience in healthcare marketing, communications, corporate, and government strategy, she has positioned healthcare companies from small angel-funded start-ups to multi-vertical public corporations. Her knowledge of the healthcare industry spans both clinical and administrative innovations—as well as professional services—in the patient, physician, institutional and payer markets.