Amid new surges of COVID-19 patients across the country, the battle against caregiver fatigue and burnout has become harder than ever.
It's not just run-of-the-mill burnout—which was a well-documented problem before the pandemic—but a different level some have labeled as moral injury as clinicians risk their lives in hospitals overrun with patients, including some who continue to deny the dangers posted by the pandemic. Meanwhile, medical practices face financial stress and logistical challenges that threaten to shutter their businesses.
Despite the scope of the problem, there is plenty organizations can do to help healthcare workers, said Alexa Kimball, M.D., CEO and president of Harvard Medical Faculty Physicians (HMFP) at Beth Israel Deaconess Medical Center and president of Physician Performance LLC.
That was her primary lesson from leading a program over the last year at HMFP, which employs just under 2,000 physicians, advanced practice providers and researchers, aimed at alleviating stress in the era of COVID. The project was funded by the American Medical Association.
The latest perks they've offered docs? Home restaurant deliveries, laundry and dry cleaning service, personal concierge services and free Peloton app access for on-demand workouts.
"You really can move the dial," Kimball said. "I will say I was concerned when I started this work that it was going to be really hard to effect change to make a difference. Again, this is a pernicious problem that evolved but you can make interventions that make a difference. So I encourage institutions to take a look at it and make a run at it and have an open mind about what's going to be effective."
Using different strategies
The program is the extension of pre-COVID pilot program in which Kimball led efforts to develop a standardized survey tool that organizations can use to identify stressors and develop strategies to improve the work-life experience for physicians.
"We were seeing that physicians were really stretched on all fronts, which was not, maybe, surprising. But it was particularly concerning because people who have meaning in their work tend to be more protected from burnout than others."
The group began the process of coming to physicians to ask them about what benefits would be most helpful in addressing their pressures. The answers helped them develop a program where individuals could sign up for one of six different options with everything from meditation resources to Uber passes at the time.
It wasn't really about the perks, but listening to what clinicians said they really needed instead.
"What we discovered early on is that everyone had different needs and you couldn't necessarily predict what they would be. We had to allow for people to customize and tailor things that were helpful to them," Kimball said.
Those offerings came alongside changes inside the work environment, such as reducing required clicks in the electronic health record and giving people CME credit for mandatory training. They focused on taking out redundant aspects of documenting, where possible, and increased the ability to use voice dictation in real time.
"We had a whole list of things physicians helped us prioritize," Kimball said. She said they were able to see burnout shrink by 20%. "That was incredibly gratifying."
Early in the crisis, Kimball said the group didn't have time to survey, assess and be programmatic about what the exact right options might be.
"We just threw everything we could at the problem. We had free food delivery. We got people hotel rooms when they needed them. We searched through every corner to get people PPE. We increased our childcare resources for them. We developed an identity theft protection program because there's been all sorts of fraudulent unemployment claims out there. We just recently created other insurance programs for illness," she said. "We went out there and said: 'What do you need?' And then we tried to provide opportunities for people wherever we could."
Kimball said the team knew it needed to adjust quickly.
"Uber isn't so important right now, but Uber Eats may be more useful," she said. "People are struggling with child care resources. People are anxious to connect and share both what their own needs are but also connect with others to try to help solve problems. How do you create a pod for carpooling? Maybe someone down the block lives near you and could help you, but you just haven't identified that connection yet. We're tailoring it to the next step."
For those working from home and providing care via telehealth, they found some young parents preferred offering sessions from 10 a.m. to 2 p.m., rather than the standard 8 a.m. to noon. "We're trying to find ways to offer that for people that allows them to leverage flexibility to help them. It's a multi-pronged approach."
Kimball said HMFP was able to later take the time to conduct surveys, asking specific questions around feelings of burnout and feelings of engagement. They just launched their new burnout efforts and in the next couple of months, they'll be measuring the impact again.
"In this next phase, we're going to be more deliberate and planned. But we learned a lot from that process," she said.
Her advice: Act first even before you survey workers about what might help their work-life balance.
"A mistake people make is they get their survey data, they wait, analyze it and come up with a plan six months later," Kimball said. "But you know you're going to do something. So, what we did instead is, we had a plan we were going to adjust when we got the data. But it was pretty robust and ready to go and that allowed us to react much more quickly when the data came in."
Understanding the uneven nature of burnout
When COVID first hit, it didn't cause an uptick in burnout among caregivers at work immediately.
"In the beginning in Boston, we looked at March and April and we thought, 'Wow, look what's coming down the pike.' There was a lot of very legitimate concern about personal protection given that we had PPE shortages and so much was unknown about the transmission," Kimball said. "But the incredible thing was that, in that process, people had an incredible focus on their work and there was a lot of adrenaline about managing the process and managing it well. We saw this huge burst of energy and coming together which was very satisfying for people, even as everyone was wrestling with what this meant to their own personal lives and professional lives."
But that didn't hold true as the months wore on.
"We definitely saw increased burnout at home. People couldn't be working when they wanted to. People had kids who weren't thriving. So it was really a mix of very charged and intense experiences," she said. "Now, I think people are kind of tired. As we look down the pike, the intensity of both of those things still being true, things like the vaccine give us hope it might not be so hard the second time around."
Not all providers were equally impacted by certain stressors.
For instance, women in healthcare—particularly those who have children or are caregivers for their own parents—are more likely to shoulder increased burdens at home. Studies have found a notable decline in the amount of research submitted by women to academic journals compared to men since the start of the pandemic. As The Guardian reported in May, many female academics said "juggling their career with coronavirus and childcare is overwhelming." These disparities were even starker among Black and other non-white scientists, researchers found.
"We're seeing that not only in their stress levels but in their research careers," Kimball said. "So when we survey people around their concerns about child care, they were worried about their time seeing patients, but also about their scholarly productivity. That's something we're going to have to keep a close eye on."
The power of a gesture
The most important piece of finding ways to combat burnout is to tap into a sense of empathy, Kimball said.
"You can't necessarily predict what people need. You have to let them tell you and sometimes it will surprise you and you have to be prepared for that," she said.
During the group's first pilot, one of the options was a meditation app but there wasn't much uptake. "But when we came to the end of the program, we did get an email that said: 'Please don't take away the app. It was the thing that was working for me,'" Kimball said. "Part of our strategy in our programming is to remove barriers so people can experiment with things they'd never thought of before."
The point is not to create permanent benefits, she said, but to make it easier to find and incorporate good ideas for individuals, she said. That helps make the cost of the program more manageable, Kimball said. And while the group is not focused on return on investment, she said, there's a fair amount of data that suggests when physicians are either less engaged or reduce their hours, or are unhappy in their work, there are a lot of downstream financial consequences.
It's also good to remember that some of the most powerful tools are actually free.
"Little notes and gestures of kindness make a difference in a really tough day," Kimball said. "I'm lucky enough that maybe once a week, someone reached out with some gesture of niceness and kindness that is just so powerful. So I try to do that for others on a regular basis as well. But this is a time where what seems like a little gesture might make a big impact. Encouraging others to do that would be great."