key: cord-1027433-05kcygis authors: Restauri, Nicole; SheridanMD, Alison D. title: Burnout and PTSD in the COVID-19 Pandemic: Intersection, Impact and Interventions date: 2020-05-27 journal: J Am Coll Radiol DOI: 10.1016/j.jacr.2020.05.021 sha: 6c728bc43f345794e38313607be0cb6e1cfab471 doc_id: 1027433 cord_uid: 05kcygis Summary sentence Individual physicians and hospital administration should take proactive steps to minimize the compounding effects of high baseline burnout and the acute stressors of the COVID-19 pandemic in order to promote wellness among health-care providers. The COVID -19 pandemic has posed unprecedented challenges to the healthcare system worldwide while revealing major deficiencies in this country's epidemic preparedness. Individuals have been required to drastically modify their lifestyle in an effort to "flatten the curve" and engage in social distancing in order to allow an overwhelmed healthcare system time to respond to the novel coronavirus. In healthcare, this circumstance is so profound that the COVID-19 pandemic has required an adoption of the language of war. There is talk of physician redeployment to the frontline and sophisticated statistics track daily causalities while military style temporary hospitals are constructed. The Cable News Network (CNN) has compared the epidemic's impact on our civilization to that of WWII (1) . In their personal lives, radiologists are required to adapt to the myriad challenges imposed by the pandemic while also managing the stresses related to caring for patients with COVID-19 and working in a healthcare system with limited resources while evaluating constantly evolving knowledge surrounding containment and management of the COVID-19 illness. This pandemic has exacerbated stressors in a healthcare system in which physician burnout, a response to workplace stress, is already epidemic (2) . Individual physicians and hospital administration should take proactive steps to minimize the compounding effects of high baseline physician burnout with the acute stressors of the COVID-19 pandemic. Although Post Traumatic Stress Disorder (PTSD) is commonly associated with active military conflict, the context and definition of what constitutes a traumatic event is, in fact, much broader and is relevant to the COVID-19 pandemic and it's impact on radiologists. This paper presents a conceptual paradigm for understanding the relationship between burnout, acute stress disorder and PTSD while providing an evidence based review and recommendations for systems based interventions that may reduce provider suffering and stress ensuring a stable, healthy radiology workforce. Mental health providers define "trauma" as a stressful occurrence that is outside the range of the usual human experience and that would be markedly distressing to almost anyone (3) . This type of stressor, according to the DSM IV, involves a perceived intense threat to life, physical integrity, intense fear, helplessness or horror (3) . By this definition, the COVID-19 pandemic and the collective and personal threats and fear that it has produced, meets the definition of a traumatic event. Exposure to such traumatic events can lead to the development of Acute Stress Disorder (ASD) and finally PTSD if symptoms persist. Similarly, burnout is a syndrome driven by increased exposure to workplace stressors that results in emotional exhaustion, depersonalization and a decreased sense of personal accomplishment (4). In a 2014, a study by Shanefelt et al, a survey using the Maslach Burnout Inventory, found the rate of radiologist burnout to be 61% (5) . In this regard, the COVID-19 pandemic presents a sort of perfect storm regarding the intersection of chronic workplace stress resulting in a epidemic physician burnout rates with the acute traumatic stress imposed by the pandemic. Exploring the intersection of these two phenomena is necessary in order to inform interventions. Symptoms related to PTSD fall into three categories that include: reliving the event, a sense of emotional numbness/depersonalization, and symptoms of increased arousal (difficulty sleeping, feeling irritated or easily angered, difficulty concentrating). The diagnosis of PTSD occurs when a person has experienced symptoms for at least 1 month following a traumatic event, although symptoms may be delayed by several years. (3) . In the initial month following exposure to a traumatic event, the diagnosis applied is acute stress disorder (ASD) and includes symptoms of intrusion, dissociation, negative mood, avoidance, and arousal. The prevalence of ASD is 5-20% following a traumatic event (6) . Importantly, intervention in this early phase can reduce the progression to PTSD (6) . Increased exposure to stress and trauma in multiple life domains, including acutely increased workplace stress resulting from the pandemic, when combined with underlying baseline burnout; may result in rising rates of PTSD among physicians. Additionally, as there is significant overlap in drivers of both PTSD and burnout, as well as consequences and comorbidities, the intersection of these entities may have a compounding effect (Table 1) . For example, lack of control over one's schedule is a known driver of burnout that may acutely worsen for individual radiologists as hospital administration responds to changes in imaging volume and economic consequences by redefining work hours, staffing and clinical responsibilities. Many radiologists also face the threat of redeployment to understaffed fields of medicine taxed by the pandemic providing an example of the way in which another known driver of burnoutimbalance between skillset and work demands-may be exacerbated by the pandemic. Theoretically, and in a worse case scenario, if these workplace stressors were combined with the added loss of control and sense of displacement that may arise if a radiologist were exposed to or contracted COVID-19 and chose to quarantine away from home and family, the mental health consequences could be devastating. Large-scale disasters are associated with significant increases in mental health disorders in both the immediate aftermath of the trauma and over longer periods of time with increased rates of PTSD, depression and substance abuse disorders reported (7) . Similarly, burnout is associated with higher rates of substance abuse, depression and suicide (5) . Those studies that specifically Before addressing appropriate systems based responses to such stressors, it is important to also consider the role that racism may play with regard to increased PTSD susceptibility among minority healthcare providers in response to the COVID- Colleges (AAMC) found that 17.1% of physicians in the United States self-identified as ethnic Asian (12) . Many minority groups experience higher rates of PTSD when compared with white populations and one theory for this vulnerability focuses on the traumatic nature of racism (13) . On May 8, 2020, the United Nations Secretary General warned against xenophobia and anti-Asian sentiment, stating, "the pandemic continues to unleash a tsunami of hate and xenophobia, scapegoating and scare-mongering" and advised governments to "act now to strengthen the immunity of our societies against the virus of hate" (14) . There is, unfortunately, an abundance of historical precedent for minority discrimination related to epidemics and pandemics. Examples include violent pogroms against the Jewish community during the Black Death (1347-51) and, in recent history, discrimination in response to HIV/AIDS pandemic (15) . Historians cite "the newness and mysteriousness of a disease" as a predisposing factor for igniting racial violence and minority scapegoating and these elements certainly apply to the current state of the COVID-19 pandemic underscoring the potential of this pandemic to incite racism (15) . It is critical that radiology leadership maintain a zero tolerance policy regarding workplace discrimination while also committing to support strong diversity training programs and efforts that focus on humanism and tolerance. The impact of PTSD among healthcare workers on patient care has not been widely studied in radiologists. However, there is evidence that among those with symptoms of PTSD, burnout is also highly prevalent and a recent meta-analysis identified physician burnout as significantly and positively correlated with increased medical error (16, 2) . Physician burnout is costly, and not only in terms of the risk of medical error. The syndrome of burnout is associated with increased risk of physician suicide as well as substance abuse and may contribute to healthcare infrastructure instability by fostering increased turnover, early retirement and decrease in percent of professional effort; consequences certainly undesirable in the setting of a pandemic requiring increased healthcare resources and reserves (2, 17) . Previous conceptual models related to mitigating physician burnout focus on individual as well as systems based interventions and suggest that responsibility for maintaining a healthy physician work force lies, not only with individual physicians, but with hospital administration and department leadership (18) . Therefore both individual strategies and systems based interventions should be adopted in these challenging times (18) . Recent recommendations to improve individual radiologists well-being in the setting of the COVID-19 pandemic have suggested "micropractices", or strategies requiring just a few seconds that are readily available to individual physicians in order to manage stress. These practices focus on managing the emotional aspects of stress and fear and leverage positive psychology, mindfulness practices and embodiment to combat the fight or flight response as well as emotional exhaustion and depersonalization (19) . Similar interventions, including mindfulness and gratitude practices, have been successful in the setting of PTSD (19, 20, 21) . The American College of Radiology (ACR) Radiology Well-being Program has compiled an on-line collection of resources to promote radiologist wellness during the COVID-19 pandemic and site contains direct links to resources focusing on the arts, mindfulness, fitness and sleep (22) . An additional important and potentially overlooked well-being practice involves limiting ones exposure to media coverage of the pandemic. One study found that those individuals with repeated related medial exposure following the Boston Marathon bombing reported experiencing higher levels of acute stress than those present during the actual event (23) . While individual action steps are certainly required to promote resilience and well-being during this time of crisis, an appropriate and informed response from the healthcare system and radiology leadership will also be required. Interestingly, the incidence of PTSD in healthcare workers following the SARS pandemic positively correlated with the perceived risk of exposure and was negatively associated with provider identification with their work as altruistic (8) . These are important factors that may be considered in informing the allocation of department resources and efforts to minimize physician burnout and PTSD. A frame work of suggested interventions to prevent burnout and treat PTSD in the radiology workforce are outlined below and in Table 2 and Figure 1 . In addition to promoting those individual based interventions discussed above, radiology leadership should direct departmental resources toward creating a physically safe work environment and support the development of an infrastructure that allows radiologists and staff to work from home. This specific strategy is in line with many public health policies promoting containment and individual well-being such as the "Safer at Home" policy, advocated by the government of the State of Colorado (24) . The capacity to work from home is an advantage of the digital era and may have a positive impact on radiologist mental as well as physical health. For example, a workplace centered at home mitigates several previously outlined sources of physician anxieties related to the pandemic, including concerns about bringing the virus home to family, stress regarding the impact that contracting the virus may have on family resources, while helping those who may be vulnerable, such as single parents or households where both parents work, cope with child-care requirements (11) . Additionally, maintaining a healthy radiologist workforce in the setting of a pandemic requires the type of social distancing that can only be maximized with home quarantine. Therefore, developing an infrastructure whereby radiologists may care for patients directly from home is an asset that will support radiologist personal and family needs in myriad unforeseen ways in the era of COVID-19 and should be a key component of future pandemic preparedness. Creating a work environment and culture where mental illness is not stigmatized may be challenging, but it is a critical step in establishing policies and practices whereby physicians are enabled to Cura te ipsum, "heal themselves" (25) Developing psycho-educational seminars on the symptoms of PTSD and burnout with direction to the appropriate resources may be an essential first-step for those who are affected but might not recognize the illness or symptoms in themselves. Additional efforts that may contribute to a culture where burnout and mental illness is not stigmatized may involve coordinating expert panel discussions on stress and PTSD, allowing dedicated time away from work to attend to mental health appointments and, in unprecedented times, considering non-traditional methods of physician engagement. For example, the field of narrative medicine leverages the arts and humanities as well as reflective writing exercises that allow healthcare providers the time and space necessary to access emotions and process experiences in a structured manner (26) . This contemplative environment facilitates cognitive reframing and self-compassion while helping to solidify professional identity and reinforce a sense of altruism at work, a factor previously shown to be protective from PTSD following a pandemic (6) . and this should be a conversation with both value and time given to the voice of those with "boots on the ground" knowledge. In order to optimize high performing teams in the workplace, a culture of psychological safety is a pre-requisite and key components of psychological safety include trusting that one will not be punished for making a mistake or speaking one's mind (27) . Finally, responding to the COVID-19 pandemic may be a time to recognize diverse personnel as a resource in the department. Radiology leadership may ask to hear from voices of those that may have worked through prior natural disasters, such as Hurricane Katrina or the World Trade Center terrorist attacks, when creating policy and procedure. These perspectives may add elements of both wisdom and hope to those of us navigating the complex uncharted territory of this pandemic. As much as social distancing is being leveraged as a critical method of COVID-19 disease containment, both individual and system based practices will be required to reduce workplace stress and burnout and minimize the acute stress response and risk of subsequent PTSD. The mental health consequences for physicians related to this pandemic may be significant given the common drivers of burnout and PTSD and the high rate of underlying burnout among radiologists (17) . As the COVID-19 pandemic has highlighted, the healthcare system in the United States is marred by imperfections. Taking good care of the physical as well as mental wellbeing of physicians on the frontline of the COVID-19 pandemic should not be among them. Support an infrastructure that allows radiologists and staff to work from home Decrease exposure and mitigate concerns about contracting the virus and promotes schedule flexibility Increase education treatment about burnout, ASD, and PTSD, via expert panel discussions and access to mental health Increase awareness and early intervention, reduce stigma Employ non-traditional methods of physician engagement (eg narrative medicine) Facilitates cognitive reframing and self-compassion, reinforce a sense of altruism in work Clear Communication from Leadership Increase sense of safety and stability, increase team work Engage Radiologists in scheduling Increase engagement and prevent burnout, promotes schedule flexibility Virus Confronts Leader's with one of Modern History's Gravest Challenges Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis Post Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population UpToDate: Acute stress disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk Center for Disease Control and Prevention (CDC): Severe Acute Respiratory Syndrome(SARS). SARS Basic Fact Sheet Case of Coronavirus (COVID-19) in the U Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic Association of American Medical Colleges: Diversity in Facts and Figures Assessing racial trauma within a DSM-5 framework: The UConn Racial/Ethnic Stress & Trauma Survey National Action Plans Needed to Counter Intolerance Pandemics: Waves of Disease, Waves of Hate from the Plague of Athens to AIDS The prevalence and impact of post -traumatic stress disorder and burnout syndrome in nurses Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Enagement and Reduce Burnout Coronavirus Disease 2019 (COVID-19) and Beyond: Micropractices for Burnout Prevention and Emotional Wellness Fessell Gratitude and PTSD symptoms among Israeli youth exposed to missile attacks: examining the mediation of positive and negative affect and life satisfaction A meta-analytic investigation of the impact of mindfulness-based interventions on Post Traumatic Stress The American College of Radiology (ACR) Radiology Well-Being Program: Combatting the COVID-19 Pandemic: A Collection of Well-Being Resources for Radiologists Boston Marathon Bombings, Media, and Acute Sress Physician Heal Thyself: Meaning and Origin Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust High Performing Teams Need Psychological Safety. Here's How to Create It FIGURE 1: A System based model for minimizing physician workplace stress and promoting policies that simultaneously minimize burnout and acute stress disorder (ASD) while decreasing the risk of subsequent post-traumatic stress disorder