Since the practice of medicine began, healers have held a special, almost exalted place in society.
In turn, their obligation to their patients and to society at large was considered “holy” in a very real sense. This dynamic has continued to the present day; doctors and nurses swear an oath pledging their commitment to their patients’ health above all.
The modern practice of medicine has tested this special position. The relationship between doctor and patient is now mediated by multiple external forces, from formulary committees who determine what drugs will and won’t be available, to administrative leads determining the correct number of patients per month a practitioner should be seeing, to “chief experience officers” who review patient satisfaction scores and regulate behaviors.
Prior to the pandemic, doctors were already in a state of quiet crisis. Task overload related to administrative and EHR functions was the norm. Depression, anxiety, and even suicide were reaching dangerous levels, and early retirement, unheard of in previous generations of Western doctors, was on the rise. One neurologist in the UK put it bluntly:
The pandemic arrived against a background of staff demoralisation and fatigue.
UK Neurologist, May 2020
In short, the practice of medicine was at a crossroads—and doctors were caught squarely in the middle. Were doctors the sole guardian of patient health, or were they simply team leads, tasked by administrators to oversee efficient population health?
The pandemic has brought this tension to a head, stripped it down to its basics, and forced us to re-examine the role of doctors in society. And with that comes a clear, simple finding: what motivates doctors, more than anything, is being a doctor.
Early on in the Behind the mask project, doctors noted that as hospitals emptied of all but essential workers, a churchlike atmosphere took hold.
Gone suddenly were the “candy stripers,” social workers, cafeteria workers, various adjunct hospital employees, and importantly, pharmaceutical representatives. It was just patients, providers, and care. While some lamented the lack of energy and activity, one called the absence of unwanted callers and intrusive side meetings “bliss.” Certainly, it was a notable change, and it gave physicians a chance to rethink what hospitals could feel like. Empty emergency rooms were cause for concern, but empty spots in daily agendas were not.
In addition to spaces being transformed by the pandemic, the nature of professional relationships, and specifically the focus of finances versus patient (and doctor) care were also being highlighted. Administration was seen by many clinicians (especially in the US and UK) as unsupportive and too financially focused. One PA in Florida mentioned the irony of having hours cut in a pandemic (“I never imagined…”), and others in Germany noted that financial considerations should not include how to maintain profits when the world was fighting for its metaphorical life.
One German PCP stated she had “very mixed feelings” about her company giving the administrative staff pay raises in April at the same time physician wages were being cut, and had no mixed feelings about a merger going through at a very inopportune time:
Adding stress to frontline workers and paying non-HCPs raises was seen, universally, as evidence that the system had its priorities wrong. And for physicians who spent their own money in good faith early in the pandemic, the relatively slow return of that money is frustrating:
“…we invested huge amounts of money from our own practice pots to get things up and running, changing to video consultations, changing to VOIP technology, creating hot rooms in our surgeries, lifting up carpets so areas were clean, lifting up stair carpet, buying PPE…and yet despite this spend, there has been no money sent back to primary care to pay for the work and changes we have made. We billed our CCG in April and May and are still waiting for the money. The response from the CCG is that they have not received any money from the Treasury COVID fund. Clearly this is not good enough.”GP, UK, April 2020
A strong counterbalance to these stressors was the perceived support and behavior of fellow physicians, who were seen as both helping with patient care and supporting their HCP peers.
In the throes of fighting COVID-19, doctors realized that what they could count on was one another. In all countries where we conducted research, they give high marks to their colleagues for doing everything possible to fight this pandemic (see Figure 1).
Are frontline staff doing
Doctors (and advanced practitioners) everywhere noted that the pandemic was bringing out the best in physicians. The same German PCP who lamented the upcoming merger was equally enthusiastic about doctors stepping up to the plate, including herself, to help where help was needed:
One of my work partners came out of retirement to help out with COVID. I volunteered at COVID urgent care and a lot of patients thanked me for working and helping out.
German PCP, May 2020
The reward in both cases was twofold: the satisfaction of helping, and the thanks from those helped. It seems this is still the essence of being a doctor; one dermatologist in the US stated plainly, “Being a doctor means everything to me. I had no plan B. This is all I ever thought about being.”
Despite the stresses and strains, then, COVID-19 has served to reinforce physician commitment to their profession.
“This profession is what I have signed up for and I will continue to take care of patients to the best of my ability.”US Neurologist, May 2020
At the same time, HCPs are worried that the pressures they face may be unsustainable: while only 19% of payers and administrators worry that HCPs will leave the profession as a result of the pandemic experience, fully 43% of HCPs believe this will be the case. Data like these can be hard to parse, as none of those queried stated they were planning to leave the profession; but clearly, a sense that stress is reaching a breaking point for doctors is a key takeaway. One US oncologist captured both the joy of practice and the stress of finances in May:
As economies and health systems slowly reopen, many physicians are concerned that the pandemic will leave long-term bruises on their profession. Of great concern is disruption to training and impact on junior staff. A UK cardiologist working at a training hospital voiced concerns that the duration of the pandemic is outlasting the ability of junior staff to “muscle through”:
“Juniors were working 3 days on 3 days off ad infinitum and I was working 7 long days in a row with no breaks. It was good to be making a difference, though the good will has now faded and trainees are rightly asking about their specialty work time, and consultants similarly. It’s not sustainable to keep juniors working in such patterns which don’t allow for planned annual leave. One of my colleagues who is a consultant in acute medicine had to take 2 weeks of emergency annual leave last week due to burnout.”UK Cardiologist, May 2020
The tonic for this stress is, again, simply doing their job. When asked about a potential imminent wave of retirements, one US rheumatologist answered simply:
We just need to continue to do our best to help patients.
US Neurologist, June 2020
Anxiety about the next wave
Continuing to do their job is far from easy.
The prospect of a second wave of infections is now seen as nearly inevitable—in the first survey wave, 70% of HCPs were worried about a second wave of infection but listed several other factors as more immediately concerning to them; in July, that number had increased to 79%, and it was the top concern for physicians.
Their concern focuses not on personal ability to handle the ongoing stress, but rather the system’s ability. The same UK clinician who observed the pandemic arrived when doctors were already stressed and depressed feels that “years of underfunding” of the NHS have left the system ill prepared for a second blow. Figure 2 shows that the primary concern of physicians in July was not personal safety, as it had been in the early stages of pandemic, but rather the sustainability of the system:
Implications and opportunity
Doctors have long been viewed as the quintessential professionals, driven by a desire to help their patients and society through the exercise of their art. At least, that is how they view themselves, and the pandemic has reinforced this view. Simply being a doctor is the reward doctors desire. But they don’t want to have to choose between being a good doctor and making a living. And they don’t want anyone else profiting unduly from their work. In this transformed environment, they appreciate having less interference, and likely will try to maintain this level of control in the time ahead. Healthcare stakeholders can find opportunities in supporting this newly direct and unmediated relationship that doctors now have with their patients.
The Behind the Mask Team
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