key: cord-0942016-tobn3nh9
authors: Barrett, Eileen; Hingle, Susan Thompson; Smith, Cynthia D.; Moyer, Darilyn V.
title: Getting Through COVID-19: Keeping Clinicians in the Workforce
date: 2021-09-28
journal: Ann Intern Med
DOI: 10.7326/m21-3381
sha: f486b385037c528189b153918de78121036b40e7
doc_id: 942016
cord_uid: tobn3nh9

Physicians and other clinicians continue to wrestle with how to provide safe, high-quality, compassionate care despite ever-changing and potentially dangerous work conditions in the setting of the ongoing COVID-19 pandemic. The risk for contracting COVID-19, the challenges of caring for medically complex patients, and a polarized political environment compound workplace hazards and stress. The authors urge employers and organized medicine to take tangible steps to preserve the clinical workforce.

W hile the world recognizes that the COVID-19 pandemic is not yet over, physicians and other clinicians continue to wrestle with how to provide safe, high-quality, compassionate care despite ever-changing and potentially dangerous work conditions. The risk for contracting COVID-19, the challenges of caring for medically complex patients, and a polarized political environment compound the workplace hazards and stress that threatened clinicians before the pandemic (1) . As physicians, educators, peers, and friends of COVID-19 responders, we are gravely concerned about our colleagues' exhaustion, burnout, and disillusionment. In addition, as physicians experienced in advocacy for clinician well-being, we urge employers and organized medicine to take tangible steps to preserve the clinical workforce.

To keep physicians and other clinicians in the workforce, the entities that employ us must move beyond suggesting stress-reduction activities, such as yoga and meditation, to provide the tactical support clinicians need to safely care for patients and support one another. We call upon every health system, hospital, and clinical practice to adopt the following actions.

First, ensure physical safety by reducing clinicians' risk for contracting COVID-19 through vaccination mandates, policies and practices that guarantee universal masking and adequate ventilation in work areas, and access to personal protective equipment (PPE). Transparency about PPE supplies and contingency plans when there are shortages are particularly important to restore and maintain trust among clinicians who spent earlier COVID-19 waves without adequate PPE.

Second, provide practical support in the areas that clinicians identify as causing emotional stress or moral injury. Professional development should prioritize activities that help increase clinicians' confidence in managing anger, frustration, and grief when caring for patients who have chosen not to be vaccinated. Additional training should focus on addressing vaccine misinformation, holding rapid "goals-ofcare" conversations, and providing care that may be outside clinicians' usual scope of practice. Training can be offered during existing team meetings and educational times, such as grand rounds. Transparency about staffing levels, medication availability, and hospital bed capacity with contingency plans during surges is a foundation of pandemic management that can decrease clinicians' moral injury.

Third, provide sufficient time during clinical encounters for members of the care team to address COVID-19 and vaccine misinformation. Taking the long view instead of focusing narrowly on productivity metrics includes recognizing that when clinicians have time to address these issues, it can help prevent additional COVID-19 infections and hasten returning to usual operations. Training and empowering all members of the care team on these topics can relieve physicians of the need to respond on their own. Fourth, extend support to clinicians who are parents by offering flexible work schedules and support groups and advocating for policies to reduce SARS-CoV-2 transmission in school settings. Work schedules should be revised using a lens of equity, recognizing that women and those who are primary caregivers for dependents may be penalized by schedule changes that do not account for the "second shift" at home.

Fifth, reduce administrative tasks that are not mission-critical, such as lengthy online mandatory trainings that have not been shown to improve patient outcomes, burdensome promotion and tenure reporting requirements that do not allow creativity and innovation during the pandemic to count, and unnecessary meetings.

Sixth, health care institutions should adopt robust antidiscrimination and antiharassment policies to acknowledge and mitigate harm, particularly against minoritized persons (2) . There should be zero tolerance for discrimination, harassment, or retaliation against those who voice concerns about patient or clinician safety.

Seventh, offer free and confidential resources to support clinicians' mental health. Easy access to crisis hotlines, counseling, and peer support groups should supplement readily available medical care appointments (3). Many of these resources already exist; it is important to make clinicians aware of them.

Eighth, update credentialing and employment applications to remove unnecessary questions about mental and physical health diagnoses that may deter care-seeking, violate the Americans With Disabilities Act, and stigmatize clinicians (4).

Ninth, actively encourage clinicians to use available vacation and professional development days to nurture a mentally healthy workplace. Leaders should role-model taking time off and setting and defending work boundaries during that time, as well as advocate that others do the same.

Finally, implement suicide prevention strategies. This includes instituting "wellness check-ins" for clinicians in hardhit areas so that they can express concerns and receive coaching on coping skills (5) . In addition, offer explicit suicide prevention programming on reducing access to lethal means (6) .

Adopting these actionable steps heeds calls by the media, academia, the Joint Commission, the National Academy of Medicine, and medical professional societies to reduce barriers to clinicians' accessing care (7, 8) .

This article was published at Annals.org on 28 September 2021.

Annals of Internal Medicine © 2021 American College of Physicians 1

These recommendations should be considered by organizations in conjunction with their frontline clinicians to decide which would be most impactful and feasible in their current environments. Overcoming institutional inertia and personal exhaustion is a challenge when implementing any change, as are valid concerns about burdens on small practices and clinics and hospitals practicing in the safety net. However, because clinicians in these settings often have fewer resources available to support their well-being, acting swiftly on as many of these steps as possible is even more pressing. If a small practice is unable to provide mental health resources, they can avail themselves of existing free resources and share them with their staff. Examples of such resources are highlighted through the American College of Physicians' I.M. Emotional Support Hub (www. acponline.org/practice-resources/physician-well-beingand-professional-fulfillment/im-emotional-support-hub), which includes links to relevant materials from the American Psychological Association, the Center for the Study of Traumatic Stress, the Physician Support Line, and other resources. Individuals and practices that have unstable PPE supply chains can take advantage of the American College of Physicians' collaboration with Project N95 to ensure they have sufficient supplies (www. acponline.org/featured-products/ppe-materials/project-n95-collaboration-faqs).

Sharing and spotlighting best practices can provide incentives to reluctant adopters. The entire health care system can benefit when clinicians receive material, logistic, and tactical support, and foundational themes have long been recommended (9, 10) . The adage that no crisis should go to waste presents us with many opportunities to do better-and the ongoing waves of the pandemic create a new urgency to do so. Financial Support: None.

Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M21-3381.

Work related post traumatic stress disorder in medicine residents

Addressing patient bias toward health care workers: recommendations for medical centers

Addressing the psychological impact of COVID-19 on healthcare workers: learning from a systematic review of early interventions for frontline responders

Improving how state medical boards ask physicians about mental health diagnoses: a case study from New Mexico

Implementing a universal well-being assessment to mitigate barriers to resident utilization of mental health resources

Workplace Suicide Prevention. 2021. Accessed at www. workplacesuicideprevention.com on 16

Accessed at www.jointcommission.org/-/media/tjc/documents /covid19/statement-on-removing-barriers-to-mental-health-care-forclinicians-and-health-care-staff

Preventing a parallel pandemic-a national strategy to protect clinicians' well-being

Supporting clinicians during the COVID-19 pandemic

Annals for Hospitalists Inpatient Notes-Preparing for battle: how hospitalists can manage the stress of COVID-19

Analysis and interpretation of the data: C.D. Smith. Drafting of the article