A Flashlight While Stumbling Around in the Dark: Organized Medicine Meets the COVID-19 Pandemic and Physician Burnout Head On

Jennifer Joiner Bryan, MD

Coronavirus – One word has turned the entire world upside down. As I watched this virus escape Wuhan, China, and spillover quickly to other nations, my mind raced. It was raging like wildfire and moved so quickly that it felt like an alternate reality. As I interacted with the public, I grieved that they did not yet realize the tidal wave was coming– the new normal. We are now living in the new normal. Most physicians realize that we are finding our new normal through this and that the old normal isn’t returning anytime soon… if ever.

Prior to the pandemic, physician burnout was at an all-time high. Physicians, taught to put others first, have been attacked from every direction, and yet remain resilient. Depression, substance abuse, and suicide are serious threats to our workforce, and regulatory issues have become quite a burden. Physicians, who in years past had kept a box of index cards that listed things such as “strep throat, gave penicillin” slowly became data entry clerks. “Click here or don’t get paid…” “Make sure you meet your patient’s ‘quality’ measures even though you just spent a half hour listening to them cry over their divorce.” “Didn’t code that visit right?” Fraud. Did you call in a refill on your neighbor’s blood pressure pill when they ran out while out of town? Well, that might threaten your license. Medical school? Why did you waste all that time and money? Everyone knows you can go online to become a nurse practitioner and do nearly the same thing. Look at your patient and hold their hands as they weep? There’s no time. Type. Click the boxes. Get it done. As the regulatory burdens increased, physicians slowly gave up autonomy. Just before the pandemic, 51% of United States physicians were employed. With Centers for Medicare and Medicaid Services (CMS) requirements and an ever changing regulatory environment, it is not feasible for most to own their own practice. Or it hasn't been feasible until recently when regulations were slashed in the name of easing the burdens of the pandemic crisis.

Over the past 15 years, health administration became big business. Physicians became employees but still held that medical decision making was autonomous. In reality, that autonomy looked like, “You can order what you want, doctor, but we (the insurance company) are just telling you what we’ll pay for. The patient can have the test, but we’ll bill them the thousands of dollars for the test unless you order what we tell you we will pay for.” That same policy goes for prescriptions.

Health systems have grown their own networks of clinics to support their hospitals. To get around Stark Law issues on self-referral, etc., administrators stop short of telling physicians where to refer patients. However, reminders are often given for those clinics that are recommended to use and currently practicing within or financially supporting the system. Many physicians are given little say in their own time management and clinic flow, and there is significant micromanagement (little of which has anything to do with actual medical care and most designed around billing practices). Physicians are deemed “providers” and witness first-hand the death of medical expertise.

As practices shifted to outpatient care separate from inpatient care provided by hospitalists, an even greater disconnect began. It affected medical care, and we all knew it. Doctors in the hospital cared for gravely ill people whom they had never met before. Why didn’t outpatient doctors want to go to the hospital anymore? The answer was simple. Their lifestyle could no longer sustain it. Many could not keep up with the quality measures and charting systems, which were again designed primarily for billing purposes, and still care for their patients in their hours of greatest need. Doctors who had to type and “button click” quality measures began to employ nurse practitioners and physician assistants just to keep up. The scope of practice battles waged and burnout task forces were created across the country to determine what was causing this “mysterious” burnout. At national physician-run meetings, the message was clear. Physicians knew why they were burned out (a hint for the nonphysicians reading this: it is all of the above things and more), but there has been too much money at stake for stakeholders to stop the current processes and rethink what we have been doing in health care. And then the coronavirus pandemic happened.

Despite what some may think, physicians are generally nurturing people who went into medicine to help people. They are peoplepleasers, and somewhere along the way became so wrapped up in trying to juggle all the balls in the air that they gave up a lot of autonomy. They realized they were caught up in a system of prior authorizations, insurance denials, disruption of care between outpatient and inpatient, devalued expertise, and it was all too BIG. It was so big that no one really knew how to change it, and so they quietly burned out. At the dawn of the pandemic, the health care workforce found itself at a critical point of experiencing burnout, and some even have called it moral injury. Physicians who took an oath knew that there were fundamental differences between what drove them and what drove other stakeholders, but never was it so exposed until the pandemic.

In 2005, President George W. Bush devised the National Strategy for Pandemic Influenza, followed by an implementation plan the next year in 2006. It was updated in 2009 following H1N1 influenza and again in 2017, and these plans outlined what would be needed in a time of a pandemic. President Bush famously said, “If we wait for a pandemic to appear, it will be too late to prepare.” These plans included a robust stockpile of supplies, and after a strong initial effort, the plans were abandoned. Just five short years ago, in April 2015, in the Clinical Infectious Diseases publication, a scientific assessment was published. This was the background of the article titled “Potential Demand for Respirators and Surgical Masks During a Hypothetical Influenza Pandemic in the United States,” which stated, “To inform planning for an influenza pandemic, we estimated the United States demand for N95 filtering facepiece respirators (respirators) by health care and emergency services personnel and need for surgical masks by pandemic patients seeking care.” It outlined how much personal protection equipment (PPE) would be needed for a pandemic. Bill Gates promoted our lack of preparedness often, and his TED talk from 2015 titled “The next outbreak? We’re not ready” is eerily telling. Others increasingly sounded alarms to be prepared for a pandemic, but most stakeholders operated on a “just enough to get through a few days” supply. Our only real defense against a pandemic was to hope one didn’t happen.

As the virus spread earlier this year, physicians across the United States began to voice concerns to many of the hospital systems and other healthcare stakeholders about the fact that COVID-19 was coming to the United States based on the early available science and the R0 (“R naught”), which indicates how easily a disease spreads. They spoke to their business-minded colleagues and tried to teach and to advocate. They attempted to keep themselves, their staff, and the public as safe as possible. If they were not terminated, they were ridiculed. Across the country, it was the same story. “Don’t talk about it.” “Here is the new policy.” “Wear a surgical mask for a week or until it is visibly soiled.” Physicians were communicating in real time with colleagues in other countries. From their own scientific backgrounds, many assessed that this would be a significant event and that testing and PPE would be critical. These physicians watched in shock as they heard messages that the virus would not be a big deal or would be contained. When they tried to explain the early science to others, they were chastised for fear-mongering or being political. The psychology was obvious and detrimental. People did not want to believe that something horrible was actually happening.

Physicians attempted to educate, but that depended on the approval of their public relations department to approve educational posters. Common-sense suggestions such as baby monitors to monitor COVID-19 patients to preserve the PPE for frequent staff checks were shot down or lost in red tape. Many clinic staff could work remotely while performing telemedicine, but this decision was not left to the physicians. Despite physician warnings that many already suspected COVID-19 was present and replicating in our country, the lack of testing caused physicians across the United States to be “flying blind” as to what the true disease prevalence actually was, and day to day business rolled on. There was no focus on education or prevention. Many took to social media to try to forewarn the public, while the early public messages they heard indicated that the virus would be contained were incongruent with reality. They knew health care workers were dying at a greater rate overseas and that it was likely due to increased exposure to high viral loads and increased length of time around the sickest people. They also knew that health care workers were getting sick and succumbing to the illness due to the lack of PPE and that the PPE acquired overseas was faulty many times. While publicly called heroes, physicians were being silenced and left unprotected. Many said they felt stabbed in the back, and indeed, in ways, they had been.

Plenty of physicians were proactive and bought PPE for themselves, but were not allowed to wear it because institutions or employers told them that it would scare the patients. One Mississippi physician stated he was terminated because of trying to discuss proper infection control with his hospital administration and that he had his mask pulled from his face by an infectious disease nurse. Perhaps, if asked, many physicians would have shared their individual PPE supplies if they had been more included in the various task forces, run primarily by executives. Perhaps they could have developed a network to ensure that PPEs never stopped flowing until production ramped up or re-use protocols were found to be safe. Our national lowering of safety standards would never have occurred. As physicians began to change their collective management of COVID-19, utilizing ventilating as a method of last resort, the American Hospital Association and their executives across the nation were working closely with Washington, D.C., on ventilator production and distribution. While ventilators were definitely needed then, and are still needed going forward, many doctors were scratching their heads as the need for PPE remained dire. Without PPE, health care workers would either get sick, die, or spread the disease to others, including their own families or their community.

On April 25, the Prime Minister of Canada, Justin Trudeau stated, “I don’t think we should be reopening any sector of the economy until there is enough personal protective equipment for businesses to fight the coronavirus.” He alluded to “planeloads” of PPE being delivered soon and domestic production being ramped up. Where is this conversation in the United States, and where is the focus on the American health care worker? While the timeline for the economy to be opened up is one that can be debated, the fact is, that at the time the ventilators were being mass-produced, PPE could have been produced as well in anticipation of reopening the economy. Yet, it was not, and in fact, our PPE was still being shipped to countries overseas. This was alarming to many American physicians.

Everyone wanted to help, but organizations and governments were left to compete with people all over the globe for the PPE they did not have. Our United States health care structure was such that physicians had a difficult time leading medical decision making as well as public messaging, as politicians and hospitals primarily generated the verbiage regarding our nation’s COVID-19 response. It is hard to convince the public that this is a deadly virus, and they need to take it seriously and change their behaviors when they hear constant mixed messaging. Currently, personal liberties are of concern, and protests are ongoing, and most physicians who also value freedom and a thriving economy also see the continued spread of disease. A graduated return of the economy will come, but it will be a return to a new normal. There is currently not enough PPE to protect the United States health care workforce, to take care of all the people who would fall sick from an immediate return to prepandemic activity without safeguards in place, and this would likely lead to catastrophic economic failure and subsequent secondary health effects. Effective re-use strategies are gaining steam, and production is finally increasing. We are currently at what has been dubbed by the health department as “modified crisis level PPE” in our daily jobs using single-use PPE for a week or longer, etc. Once properly protected to fight COVID-19, which will unfortunately and undoubtedly occur once we are in a plateau phase and not before any peak, contact tracing and testing will be an important piece in managing outbreaks. This will allow us to get by until there is a reasonable therapy and/or vaccine.

The power of physician foresight is important in realizing this is a marathon and not a sprint. We should stop stumbling around in the dark and turn on the flashlight of organized medicine. We are taught to put ourselves last, but now we must evaluate our priorities. First, identify who you are and what is important to you. What is going to happen next? What do we, the physicians, want the new normal to be? Your family and your health are important. It is not now and has never been ok for anyone to ask you to work in an unsafe environment or to do something that endangers your health and wellbeing or that of your family. We should make sure we know what we are comfortable with and what our boundaries are ahead of time, and then respect them. As things are shifting, practice saying, “No” and setting personal boundaries. It is good medical decision making and absolutely acceptable to say, “No” to unsafe practices. Even if we as health care workers contract the virus and are asymptomatic, we can infect. We should study the things we thought were necessary in life versus what really is.

We all recognize the economic crisis is real and will affect us in many ways. Many physicians are concerned about the Relative Value Unit (RVU) model of pay and coding. While these are extremely important concerns, telemedicine is here to stay in some capacity and will be an important social distancing tool in dealing with COVID-19. We know there is surgery that has to happen, and we need to decide what that will look like and how we will serve our patients first. The economics of medicine is important to public health but cannot be the primary driver during an infectious health crisis. Financial times will be tight, and hospitals and other employers will be significantly strained. The government is trying to mitigate that impact as much as possible by opening up as much as they can and as safely as they can, but we know that the virus will still be around, and people will not be spending money like they were for a long time. There will be significant financial difficulty, and we need to start now deciding how we will move medicine forward and stand up for our profession and redefine it. Now is the time to work on getting rid of what was negatively affecting medicine and add back the things that make it better. We have a golden opportunity to make medicine better for all involved parties but, most importantly, for the patients. As we attempt to return to some semblance of normal with a graduated return and a heavy focus on social distancing, masks, public health expertise, technology, etc., we should be thinking about what makes us happier people and better physicians. Then we should be working to improve and expound on that. There will always be a role for physicians, but what do we want the practice of medicine to be?

Never again will physicians wear garbage bags and bandanas to fight such a horrible virus. Never again will we wear masks meant for a single use for a week or until they are visibly soiled. Never again will our altruism be used against us. We will lead. We lost precious time in our nation’s response because the health care experts at the table, in most instances, were not physicians. The CDC published crisis regulations based on available supplies and not standard regulations based on safety. This caused many to lose trust that anyone cared about their safety or the safety of their families. It was a defining moment in modern medicine. In the eye of the storm, we face a moment of clarity right now. Physicians, I encourage you to think about who and what is important, and then to go after those things! While we advocate against the negatives, it is up to us to make a joyful, functional return to the basics of a doctor/patient relationship where physician expertise is respected, and burnout is nonexistent.

In closing, I urge you to take the time to proactively determine what your boundaries are in taking care of COVID-19. Will you treat without proper PPE? Think through what it means to code a COVID-19 patient, or to perform an aerosol-generating procedure without PPE and how infectious that is to yourself and surrounding staff without standard protection. Assess the situation beforehand and make sure you have appropriate protection and that you will wear it before rushing in because you can help no one if you are quarantined or sick. Please decide before that emotional moment happens what your plan will be and stick to it. All of that is practicing good and ethical medicine for the benefit of the patient and others. If antibody testing rolls out without evidence as a purported means for those infected to return to work, how will you respond? We cannot abandon our evidence-based medicine approach to disease as we simultaneously attempt to restart the economy with a cautious and measured approach following the advice of our public health experts and our elected officials. We cannot rush forward without proper PPE and turn our backs on the safety of the entire health care team and the public. This is the time for physicians to LEAD. I look forward to being with you on the journey as we seek the new normal of the physician-led team who not only leads through a pandemic, but is healthy, happy, and professionally fulfilled on the other side of it. A healthy physician is one who makes good medical decisions. We CAN stop the culture of burnout. Keeping patients first, we must find a way to forge a new normal that makes sense. You are so cherished as an individual and as a physician. Society needs you, and we need the BEST you. Our crystal balls are dark. We cannot see the future, BUT we can turn on the flashlight of organized medicine and take a much-needed look around as we move forward together. I invite you to join us as we stand up for physicians and patients. Organized medicine has your back. n