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Behind the Mask

Heroes under stress

How HCPs are faring in the COVID-19 pandemic

Healthcare professionals (HCPs) deal with COVID-19 on multiple levels. In addition to worrying about their patients’ health, they must also take care of their own health, their practices, and the overall stability of the healthcare system. Doctors who already faced burnout and depression before the pandemic have been pushed to the breaking point.

As we continue to study the impact of COVID-19 from clinicians’ point of view, the Behind the mask team is finding strong evidence that doctors find themselves caught between powerful forces—their desire and oath to help patients and their communities, a healthcare system that has placed them in a position of maximum accountability without commensurate responsibility, governments that were woefully unprepared (and sometimes unwilling) to address a pandemic, and the anxiety about a second wave of infections.

All this compels us to ask a critical question:

How are they managing, these healthcare heroes who are so lauded, but who receive so little tangible support?

In short, they are surviving, and in some ways thriving, despite great adversity.

The pandemic prelude:
An opportunity wasted

Looking back to the initial surge of COVID-19 in their countries, many of these same physicians see this time as a squandered opportunity. National pandemic plans existed but were ignored; PPE were not stockpiled or were allocated incorrectly, and as the danger mounted, the world at large ignored the call for immediate action. Physicians in the UK in particular cited Operation Cygnus, a recent pandemic war game run by the NHS, as a planning exercise whose lessons went unheeded. This may account for the fact that only half (54%) of HCPs in our quantitative arm felt that the government was doing all they could to counter the pandemic,

with the lowest scores coming specifically from the UK. But anger at lack of preparation is not confined to one country, as the following quotes show:

Over the winter, we saw cases of COVID-19 grow exponentially in China, throughout Asia, and then Italy.  At first, the United States did not think that COVID-19 would hit us hard.  We did not ramp up production of ventilators early on… Hospital systems had to quickly ramp up capacity and accommodate those who were critically ill. This was a huge crack in the system. 

Why were we so underprepared when we saw this happening to the rest of the world?

US Rheumatologist, June 2020

The lockdown:
Shaking the foundations

As the lockdown took hold globally, HCPs felt increasingly isolated and unsupported by both healthcare systems and governments. Many were worried that furloughs would harm patient care, and those who remained active in practice were left without even basic tools to protect themselves and their patients.   

In the early phase of the pandemic, those physicians who were able to participate in research noted clearly that lockdowns, self-quarantine, the transition to remote care, and long hours of consult time were taking their toll. They were left to function despite misinformation, lack of resources, and absence of a clear roadmap. They adopted telehealth wholesale, in spite of financial disincentives for remote-vs-live visits. This variability in reimbursement was a universal theme from all participants, who cited a large number of reasons why telehealth reimbursement was both capricious and illogical:

“One of the most frustrating parts of telehealth is the reimbursement process.  Doctors have not been adequately informed on the amounts that we are being reimbursed. It is also very frustrating that telephone visits are not reimbursed in the same way as video visits…  Why is the reimbursement so much higher for video visits when it is the exact same level of service?”
US Rheumatologist

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Recently, it seems that the reimbursement issue is being addressed to clarify and realign payment schedules, which has come as a relief. But nothing stands out to HCPs nearly as much as the lack of PPE, which seemed both irresponsible and antithetical to basic standards of care. In the face of shortages, HCPs across Germany, the UK, and the US spent out of pocket to buy PPE for themselves and their staff, even as hours were being cut and revenues were shrinking:

When the pandemic started to break in February and March we had no PPE. As primary care, the CCGs decided that they could not supply us with enough PPE, so we were told to buy it from wherever we could and we would be reimbursed.  We are waiting still to have the money reimbursed to us.
UK GP, May 2020

The lack of support was distressing, not simply because of the obvious risks, but because it undermined the sense of confidence in their healthcare systems.

..

My personal view is that this pandemic has exposed the gradual but precipitous decline in the function of the NHS,
starting from a decade ago.

UK Rheumatologist, June 2020

The present moment:
Anxiety and anger

As autumn and flu season approach, fear and anxiety mingle with exhaustion in many HCPs’ minds. Frustration is mounting that early government missteps are having lasting consequences about things like the efficacy of masks; politicization of basic preventive measures is also a source of enormous frustration. Nearly half of HCPs queried believe that their governments don’t fully understand the situation in “hospitals, clinics, and other care situations,” leading to missteps. Early on in the pandemic, the lack of consistent guidance (and in some cases, any guidance at all) regarding masks and social distancing has sown the seeds of ongoing doubt, according to HCPs.

The governors and county health officials could not uniformly agree about whether the use of masks was appropriate and effective. Then there was the concept about infringement on personal rights if everyone was told to wear a mask to help prevent the spread… We were assimilating all this information on the fly.
US Neurologist

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More important than government uncertainty, perhaps, is the belief that the media have not done their job properly and have at best been a neutral party to disseminating information that is useful and correct. Of HCPs surveyed, 66% believe that “misleading reporting” has had a directly negative impact on patient care since the beginning of the pandemic, affecting everything from adherence to social distancing protocols to overall mistrust of the healthcare system that is preventing patients from returning for routine care and screening.

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This dovetails with the almost universal concern that the public are still not taking the pandemic seriously enough. Physicians are becoming increasingly pessimistic that the general public are observing isolation measures to slow the pandemic—63% were concerned that this was the case in Wave 1 of the survey, and in the repeat in June we found 76% were now concerned. In addition, only 1/3 of clinicians believe the people who are wearing masks wear them properly, and numerous physicians have asked the question, “why can’t the government simply mandate masks for everyone?”

This lack of trust in both media and governments is leading to a dim view of our ability to handle a second wave of pandemic infections, which by now 79% of clinicians feel is almost inevitable.

And what would a second wave bring?

Many clinicians fear that the financial implications of an ongoing disruption to routine and elective care will “break the system.” They feel that the goodwill shown to them early in the pandemic (eg, free coffee and public applause) are not sufficient for an ongoing crisis that is approaching its 7th month. “You cannot eat a clap,” as one German PCP stated flatly. Or, as the above-quoted UK cardiologist put it in late July:

“There is only so much goodwill. If there is a second wave, then I think that consultants will be needed doing nights and this will have to be paid for eventually — having a few free meals or coffees provided by the hospital (now largely taken away) is not a substitute for paying staff according to the hours they work.”

German PCP, July 2020

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Stoically moving forward

HCPs feel the burden of care falling squarely on their shoulders. Many have expressed the belief that they did what they had to, hoping that their sacrifices would be recognized and rewarded. Mostly, however, they did this because it’s simply what doctors do. As one clinician in the US said, “This profession is what I have signed up for and I will continue to take care of patients to the best of my ability.”

This perhaps is the real finding. No matter how much medicine changes, how acutely doctors feel the stress of competing mandates of efficiency and outcomes, and how frustrated they are with EHRs and administrative tasks, they will endure. An HCP will stay true to his or her calling of caring for patients and communities, because this is fundamentally who they are. 

For those who are not practicing physicians, the implications are perhaps less obvious, but still critical. Doctors can go it alone, but they don’t want to. They need help and want their allies to stand and offer meaningful support. They need advocates asserting that “masks save lives,” that the healthcare inequalities are being addressed, that they themselves are being seen and heard.

Clapping was never enough. It’s time for all healthcare stakeholders to do more for the physicians who serve us.

The Behind the Mask Team

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