key: cord-0694338-7q0k0yan
authors: Russo, Mark W; Kwok, Ryan; Marina, Serper; Ufere, Nneka; Hameed, Bilal; Chu, Jaime; Goacher, Elizabeth; Lingerfelt, John; Terrault, Norah; Reddy, Rajender K.
title: Impact of the COVID‐19 Pandemic on Hepatology Practice and Provider Burnout
date: 2021-11-16
journal: Hepatol Commun
DOI: 10.1002/hep4.1870
sha: 9190790f1561aa03e33b7454be4ed4110ef38307
doc_id: 694338
cord_uid: 7q0k0yan

BACKGROUND: The COVID‐19 pandemic has had a wide‐ranging impact on the clinical practice of medicine and emotional well‐being of providers. AIM: To determine the impact of the COVID‐19 pandemic on practice and burnout among hepatology providers. METHODS: We conducted an electronic survey of AASLD members from February to March 2021 who were hepatologists, gastroenterologists, and advanced practice providers (APPs). The survey included 26 questions on clinical practice and emotional well‐being derived from validated instruments. RESULTS: A total of 230 eligible members completed the survey;107 (47%) were adult transplant hepatologists, 43 (19%) were adult general hepatologists, 14 (6%) were adult gastroenterologists, 11 (5%) were pediatric hepatologists, 45 (19%) were APPs, and 9 (4%) other. 69 (30%) experienced a reduction in compensation, 92 (40%) experienced a reduction in staff and 9 (4%) closed their practice. 100 (43%) respondents reported experiencing burnout. In univariate analysis, burnout was more frequently reported in those <55 years‐old, OR=2.2 [95% CI 1.2‐4.2], women, OR=2.2 [95%CI 1.3‐3.7], nontransplant hepatology OR= 2.0 [95% CI 1.1‐3.3], APPs OR=2.7 [95% CI 1.4‐5.1], and those less than 10 years in practice OR=1.9 [95 CI 1.1‐3.3]. In multivariable analysis only age<55 was associated with burnout OR=2.3 [95% CI 1.1‐4.8 ]. The most common ways the respondents suggested the AASLD can help was through virtual platforms for networking, mentoring, and coping with the changes in practice due to the COVID‐19 pandemic. CONCLUSION: The COVID‐19 pandemic has had a substantial impact on the clinical practice of hepatology as well as burnout and emotional well‐being. Women, APPs and early and mid‐career clinicians more frequently reported burnout. Identified strategies to cope with burnout include virtual platforms to facilitate networking and mentoring.

The COVID-19 pandemic has had widespread impact on the practice of medicine and on the physical and emotional health of health care professionals (1) (2) . Among gastroenterology practices, 55% and 21% partly or fully closed during the pandemic, respectively (2) .

Gastroenterology and hepatology practices transitioned from 5% of visits via telemedicine prior to the pandemic to 94% of visits via telemedicine during the pandemic (2,3) There has been an emotional toll as well from the pandemic. Among gastroenterologists 40%-50% report burnout and among transplant hepatology fellows and early career transplant hepatologists 35% reported burnout (4) (5) (6) .

A major concern arising from the pandemic is the impact on physician burnout, which can have severe consequences including lower patient care quality, medical errors, physician substance abuse, increased physician turnover, and increased costs for the health care system (1) There are several drivers of burnout including loss of job control, excessive workload, a feeling of a lack of

This article is protected by copyright. All rights reserved control of workload and challenges in balancing personal life. Potential remedial solutions include decreasing clinical demands, better job control, teamwork, shared decision making, physician directed wellness programs and cognitive behavioral therapy (7) . To that end, a joint statement by several societies advocating for clinician health in the post-COVID pandemic has been released and endorses removing barriers to mental health care for clinicians and health care staff (8)

The impact the COVID-19 pandemic has had on hepatology and the prevalence of burnout among hepatologists, gastroenterologists and advanced practice providers (APPs) is unknown.

The goals of our study were to survey American Association for the Study of Liver Diseases members to determine the rates of burnout and to describe the impact of COVID-19 on clinical practice in hepatology. In contrast to a prior survey (6) we included transplant hepatologists at all stages of their career as well as general hepatologists, pediatric hepatologists, gastroenterologists and advanced practice providers.

We conducted a cross-sectional survey of U.S. AASLD members who practiced hepatology to determine rates of burnout and the impact of the COVID-19 pandemic on hepatology practice. Survey development occurred within a working group that included the authors. The survey consisted of three sections: 1) the impact of COVID-19 on clinical practice 2) assessing work-related well-being, including engagement, burnout and professional satisfaction, and 3) demographics. The section on burnout included questions from validated surveys; Maslach Burnout Model (MBI) and Stanford

This article is protected by copyright. All rights reserved Professional Fulfilment Index (PFI) (9, 10) . The survey also included questions on burnout from a prior survey conducted by the AASLD in 2018 of members who practiced hepatology (11) . members were eligible for the study for a response rate of 9.6% among all those who received the survey and a response rate of 24% for those who opened the survey.

This article is protected by copyright. All rights reserved Means were compared with Students t-test for normally distributed variables and nonparametric test for nonnormally distributed variables. Proportions were compared with Fisher's exact tests.

Multivariable analysis was performed using logistic regression adjusting for age>55 (age 55 was chosen to separate early and midcareer from senior career), gender, profession (MD vs APP), race, practice type (transplant vs nontransplant), and specialty. A p value <0.05 was considered statistically significant.

A total of 230 eligible members responded to the survey between February and March 2021 of which 107 (47%) were adult transplant hepatologists, 43 (19%) were adult general hepatologists, 14 (6%) were adult gastroenterologists, 12 (5%) were pediatric hepatologists, 45 (19%) were APPs, 9 (4%) other (Table 1) . One-hundred six (46%) respondents were female, 45 (20%) Asian and 5 (2%) Black. One-hundred sixty-six (72%) respondents were 55 years-old or younger and 115 (50%) were in practice 10 years or less. In general, geographic areas were well represented except with fewer respondents from the Southeast ( Table 1) .

One-hundred twenty-four (54% ) respondents reported switching to primarily telemedicine sometime during the pandemic (Figure 1 ). Most respondents (93%) wanted to ensure telemedicine was widely available after the pandemic but most agreed that the widespread use of

This article is protected by copyright. All rights reserved telemedicine will not continue unless reimbursement for telemedicine is comparable to in person services. Although 88% of respondents viewed telemedicine favorably and almost all (98%) were increasingly using telemedicine to increase access, only 35% agreed or strongly agreed that most patients preferred telemedicine over in person visits. Other strategies to address access during the pandemic in descending order of frequency included: e-consults, longer hours during weekdays, satellite clinics, weekend clinics and hiring new providers. Sixty-nine (30%) respondents experienced a reduction in compensation, 92 (40%) experienced a reduction in staff and 9% reported closure of practice ( Figure 1 ).

The majority of respondents reported their leadership took appropriate steps to protect them from COVID-19 infection, prepared them to perform duties, and provided timely information to keep them informed ( Figure 2 ). In contrast, the majority of respondents felt their employer did not, honor their dedication and sacrifice, provide tangible needs or provide support for childcare.

Among the 230 respondents, 100 (43%) reported experiencing burnout. 61 (27%), 50 (22%), and 119 (52%) respondents reported that it was somewhat true/not at all true, moderately true, or very true/completely that they felt happy at work, respectively. Respondents reported that it was 'not at all true or somewhat true" that they felt worthwhile at work (21%), work was satisfying (16%), felt in control when dealing with difficult problems at work (27%) or contributed professionally in the ways they valued most (19%).

This article is protected by copyright. All rights reserved Seventy-three (32%) respondents reported that the amount of time they enjoyed work was too little or far too little and 58 (25%) reported rarely or never having control of their workload.

Thirty-five (16%), 37 (16%), and 43 (19%) respondents reported that it was very true or completely true that during the past two weeks before the survey they experienced a sense of dread when they thought about the work they have to do, are physically exhausted at work , or emotionally exhausted at work, respectively. Thirty-eight (17%) respondents reported that it was very true or completely true they felt less connected with colleagues. Fewer than 5% of respondents reported it was very true or completely true that they felt less empathetic with patients or colleagues, less sensitive to others' feelings or emotions, and less interested in talking with patients.

The most common reasons for burnout in descending order of frequency included too many bureaucratic tasks, lack of time to take care of themselves, not enough time to spend with family and friends, spending too many hours at work, irritable at work/home and feeling stressed most of the time. Select comments from the survey are shown in the Table 2 .

Respondents who reported feeling burnout felt less supported by their employer or leadership during the pandemic. The most notable differences among those who did and did not report burnout were feeling their employer or leadership did not listen to their needs and concerns, provide support for tangible needs, childcare or emotional needs, and their dedication and sacrifices were not honored in a meaningful way ( Table 3 ). Factors that were not associated with

This article is protected by copyright. All rights reserved burnout included closing a practice, reduction in staff, reduction in pay, moving jobs, moving from direct patient care and switching to telemedicine.

Significant differences were found in burnout by age, gender, APP (compared to hepatologist), and practice setting.

Among those younger than 56 years-old compared to those who were older, 82 (49%) and 19 (30%) reported feeling burnout, respectively, OR=2.2 [95% CI 1.2-4.2] p=0.011 ( Figure 3 ).

Compared to respondents >55 years of age, those 55 years-old and younger were less likely to feel in control at work when dealing with difficult problems (38% vs 64%, p=0.004), as well as a loss of empathy with patients ( p=0.049) and more likely to be very dissatisfied or dissatisfied with their annual salary (30% vs 13%, p=0.017 ). Among respondents <55 years-old 33%

reported it was moderately to completely true they experienced emotional exhaustion at work compared to 19% of those >55 years old (p=0.059). Sixteen percent of participants <55 years-old reported it was moderately to completely true they felt less empathetic with colleagues compared 5% of those >55 years-old (p=0.057).

Rates of burnout for those in practice 5-10 years, 11-15 years, 16-20 years, 21-25 years and >25 years were 53%, 53%. 33%. 30%, 23%, respectively. Those in practice less than 10 years were

This article is protected by copyright. All rights reserved more likely to report burnout compared to those in practice more than 20 years, OR=1.9 [95% CI 1.1-3.3], p=0.016.

Women were more likely than men to report experiencing burnout, OR=2.2 [95% CI 1.3-3.7], p=0.005 (Figure 3) . A lower proportion of women compared to men reported that their program leadership had provided support for childcare needs (30% vs 55%, p=0.007), tangible needs such as food, lodging, or transportation (37% vs 59%, p=0.006), and emotional needs (46% vs 61%, p=0.014). Women were less likely to report that their program leadership honored their dedication and sacrifices during COVID-19 pandemic (39% vs 60%, p=0.004).

Women were less likely to report than men that "quite a bit or very much" of the work they did was worthwhile (53% vs 68%, p=0.032) (Figure 4 ). There were no significant differences in overall job satisfaction between men and women, with the majority reporting that they felt "satisfied" or "very satisfied" with their work (86% vs. 87%, p=0.84).

Characteristics of APPs are shown in Table 4 . APPs more frequently reported burnout compared to hepatologists, 29 (71%) and 67 (40%), respectively, OR=2.7 [95% CI 1.4-5.1], p=0.002.

Compared to hepatologists, APPs were less likely to report 'feeling happy at work quite a bit or very much of the time' 32% vs 59% p=0.002. APPs were more likely to report feeling less in

This article is protected by copyright. All rights reserved control at work with difficult issues (42% vs 24%, p=0.049), and physically exhausted at work (26% vs 13%, p=0.007).

Respondents were stratified into those practicing either within or outside a transplant center.

Transplant hepatologists were less likely to report experiencing burnout, OR=0.5 [95% CI 0.3-0.9], p=0.013. Those practicing within a transplant center reported significantly more happiness (p< 0.001), satisfaction (p=0.015), and making a valuable professional contribution (p=0.042) at work when compared to those practicing outside a transplant setting. Respondents working in a transplant center reported more control over their workload compared to those who did not work at a transplant center, 77% and 57%, respectively (p=0.057).

Transplant hepatologists when compared to the rest reported more frequently that they felt happy at work quite a bit or very much of the time (65% vs 39%, p<0.001), that their work was satisfying (70% vs 53%, p=0.015), they were more satisfied with their benefits (92% vs 81% p=0.037) and job security (93% vs 83% p=0.037).

In multivariable analysis only age<55 was associated with burnout OR=2.3 [95% CI 1.1-4.8 ], p=0.019. (Figure 3 ).

This article is protected by copyright. All rights reserved The most common responses to "rank the importance of the following existing or potential AASLD products or services as they support you in your role in hepatology" in descending order of frequency were: expanding mentoring and networking through virtual platforms, facilitate virtual discussions among colleagues on solutions to address challenges in clinical practice resulting from the COVID-19 pandemic, facilitate virtual support groups to address ways to cope with burnout, and expanded eligibility for bridge awards. The ranking of products or services to support their role in hepatology were similar for APPs, women, and those <55 years-old.

The previously published workforce survey included 152 adult transplant hepatologists, 84 adult general hepatologists, 86 adult gastroenterologists, 108 APPs, and 44% were >55 years-old (11) .

39% of respondents reported feeling burnout (unpublished data) vs 43% in the current survey.

39% of respondents in the workforce survey intended to reduce their workload over the next 5 years compared to 26% in the current survey.

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The current study is the first survey of hepatologists and advanced practice providers on the impact of COVID-19 pandemic on clinical practice and burnout. Key findings from our study indicate that burnout was common as reported by 43% of respondents. Further, burnout was more common in younger clinicians and women. Importantly we also surveyed advanced practice providers who experienced more burnout, reported feeling less happy at work and increased physical exhaustion compared to physicians. In addition, the COVID-19 pandemic has had a significant impact on hepatology practice with greater use of telemedicine, a reduction in compensation and staff or closure of practice.

Appropriations Act on March 27, 2020 (12). Telemedicine in gastroenterology increased by 4000% during the pandemic and 94% of gastroenterology/hepatology visits were virtual telemedicine visits compared to 5% two weeks before the onset of the COVID-19 pandemic (13, 14) . Utilizing video technology for healthcare is not new to hepatology and has been successfully deployed in improving access to help manage patients with chronic hepatitis through the Extension of Community Healthcare Outcomes (ECHO) project (15) . In our survey almost all providers had a favorable opinion of telemedicine although they believed patients preferred in person visits. However, this is contrary to results from other studies that have found most patients had a favorable opinion of telemedicine (16) . It is likely telemedicine will become a permanent part of clinical hepatology although this is partly dependent on reimbursement.

This article is protected by copyright. All rights reserved A unique finding of our study was there were substantial decreases in compensation and staffing reported by 30%-40% of respondents.. This is consistent with a prior study in gastroenterology that noted a decline in mean number of patients visits, although the economic impact from this decline in visits was not reported (16) . In a survey of North American gastroenterology practices, 65% of centers reported they were operating at less than 10% of normal endoscopy volume during the pandemic (2) . Neither of these studies reported the impact the reduction in patient volume or endoscopy had on compensation or burnout nor were either specific to hepatology. In the current study changes in practice such as reduction in staffing or compensation were not associated with burnout.

Burnout is pervasive in medicine and hepatology is not spared. Prior to the pandemic, a workforce survey conducted by the AASLD found that burnout was reported among 39% of the 367 hepatologists and 108 advanced practice providers surveyed, similar to the rate reported in the current study (11) . In contrast to the prior survey, the current study asked more detail about domains of burnout, such as workload and job satisfaction, which are important to identify so appropriate remedies can be developed. Those who reported burnout felt less supported and appreciated by their employer or leadership, which are potentially easily remedied. Burnout was more common among women, APPs, those in practice less than 10 years and younger hepatology providers, although the association between burnout and women, APPs and years in practice was confounded by age. Similar to our study, a survey of hepatology trainees and junior faculty found that job satisfaction was associated with burnout, but their study was limited to hepatology trainees as well as hepatologists within seven years of fellowship and did not include APPs (6).

This article is protected by copyright. All rights reserved Our survey excluded trainees, included a broader range of hepatologists and included physician assistants and nurse practitioners.

Our study is the first to our knowledge to survey burnout among hepatology APPs who constitute a major group of the hepatology workforce constituting 13% of the current hepatology workforce which is estimated to increase to 22% over the next decade (11) . After adjusting for age, the association was no longer significant, and it may be that APPs who responded to the survey were younger as a whole compared to the physicians who responded. Nevertheless, the care provided by APPs is associated with improved quality in patients with cirrhosis, and their role will become increasingly important as the population ages and the prevalence of liver disease, especially cirrhosis from NAFLD increases (17) . Identifying factors associated with burnout is important in attracting and retaining APPs in the workforce. Specific areas identified among APPs in our survey that should be targeted for improvement include feeling lack of control and physical exhaustion at work. Strategies to reduce burnout include mindfulness-based stress-reduction exercises, participation in meaningful hospital committee work or national societies, and mentorship (18) . However, these methods are not necessarily specific to APPs nor is it known if they specifically address the reported issues of lack of control and physical exhaustion. Other interventions should include strategies developed at a local or division level, control of schedule and job description. Further studies are needed on interventions to reduce APP burnout in hepatology.

The most common ways respondents identified that the AASLD can provide support are through expanded mentoring and networking through virtual platforms and to facilitate virtual

This article is protected by copyright. All rights reserved discussions among colleagues on solutions to address challenges in clinical practice resulting from the COVID pandemic. The priority of potential services that the AASLD could offer to provide support members was the same among hepatologists, APPs, women and those younger than 56 years of age. In addition, organization-directed interventions that introduce changes in the resources, the working environment, and/or work tasks to decrease stress or change intensity of workload are more effective in reducing burnout than physician led interventions that focus on individuals, such as cognitive behavioral therapy or mindfulness techniques (7) .

A limitation of our survey includes a low response rate but our response rate of 9.6% is similar to other published surveys of physicians on burnout (19, 20) . There were few respondents who were Black, Hispanic, or pediatric hepatologists/APPs While the response rates for these groups is similar to the composition of the AASLD membership, this highlights the need to increase efforts towards improving diversity within our workforce. We were not able to compare specific domains of burnout to the previously published workforce survey because burnout was not a focus of that survey (11) . An unexpected finding was that burnout was not higher in our survey compared to the workforce survey. One explanation is sampling error and that different populations responded to the workforce survey and the current survey. Lastly, we did not survey the members on specific research related challenges. Yet, the strength of this survey is that it provides insights into the career and burnout challenges faced by members of AASLD and thus provides an opportunity to take a deeper dive into how some of these issues could be addresses at various levels.

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In conclusion, the COVID-19 pandemic has had a substantial impact on the practice of hepatology and the well-being of hepatology providers. A third to 40% of hepatology practices saw a reduction in compensation or staff and almost all providers have used telemedicine.

Burnout is common and reported more frequently by women, APPs and early and midcareer hepatologists. Common issues included feeling a lack of control of workload and feeling physically exhausted at work. Uniformly, across gender, age, and profession, respondents identified that the most common ways the AASLD can help are by providing virtual platforms for networking and mentoring and virtual platforms for discussions on how members have developed strategies to cope with changes due to the pandemic. There were some troubling comments from respondents on the survey regarding dread "sometimes wish for a car accident for extended break' and humiliation "I have been disrespected, insulted, humiliated". As a professional society the AASLD can support its membership through the pandemic and beyond by enhancing or developing virtual platforms for networking, mentoring, and coping with the pandemic. Some of the necessary interventions should continue beyond the pandemic to serve to effectively combat the reported issues, so that Hepatology, as a discipline, remains attractive and that we can maintain an adequate workforce. This article is protected by copyright. All rights reserved 

Physician burnout: contributors, consequences, and solutions

Changes in gastroenterology and endoscopy practices in response to the coronavirus disease 2019 pandemic: Results from a North American survey

Positive early patient and clinician experience with telemedicine in an academic gastroenterology practice during the COVID-19 pandemic

Scope of Burnout Among Young Gastroenterologists and Practical Solutions from Gastroenterology and Other Disciplines

National Early Career Transplant Hepatologist Survey: Compensation, Burnout, and Job Satisfaction

Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis

Maslach Burnout Inventory

A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians

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Successful Distancing: Telemedicine in Gastroenterology and Hepatology during the COVID-19

Accepted Article This article is protected by copyright. All rights reserved

Telemedicine in liver disease and beyond: Can the COVID-19 crisis lead to action?

Expanding access to hepatitis C virus treatment-Extension for Community Healthcare Outcomes (ECHO) proj-ect: disruptive innovation in specialty care

Telehealth utilization in gastroenterology clinics amid the COVID-19 pandemic: Impact on clinical practice and gastroenterology training

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Burnout in gastroenterologists and how to prevent it

Association of physician burnout with suicidal ideation and medical errors

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We would like to thank members of the AASLD COVID-19 Clinical Oversight & Education Subcommittee for their input on study development and thoughtful review of the manuscript. 

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This article is protected by copyright. All rights reserved Table 2 Selected comments from survey Comment Write in statement regarding burnout and workload "I am falling behind with work/research tasks because of increased family needs due to the pandemic" "I sometimes wish for a car accident just to be able to have an extended break" "I love my work but I have been disrespected, insulted, humiliated. I am too old to start again and I am trying to concentrate on what I love, my patients and my clinical research but its hard to believe that we are in 2021 and a woman a be treated poorly by an institution. just hope my daughter who are in med school will have a different experience…" "The problem is not so much time to do things that are enjoyable, but the ability to do them at all. Cannot travel, haven't seen family in >1 year, cannot do any of the things that used to provide enjoyment. If I travel, I lose access to childcare f or a week, which is not an option." Write in statement regarding how AASLD can help "Provide guidance for being better patient advocates, help us educate patients to preventing liver disease, research and communicate efforts to improve disparities" "more awards/recognitions f or APPs: consider "low hanging fruit" ie. modest awards for DNP projects or mentorship stipends, podcast updates (5-10min snippets), better access to liverlearning modules (was difficult to find/register a new employee for fundamentals course).Consider regional "chapters" on engage platform"

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This article is protected by copyright. All rights reserved Accepted Article This article is protected by copyright. All rights reserved 

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