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July 23, 2020

'We are human': How Covid-19 is placing unprecedented stress on providers

Daily Briefing

    America's Covid-19 epidemic has placed an unprecedented amount of stress on health care providers, who were already at a high risk of depression and suicide—and it's time for providers to admit "that [they] are human" and get the care they need, Esther Choo, an emergency physician and professor of emergency medicine at Oregon Health & Science University, writes in an opinion piece in the Washington Post.

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    Providers already were at high risk for some mental health conditions

    According to Choo, providers through much of their careers already must deal with high levels of stress and demand, and research has shown than providers are at a relatively high risk for developing mental health conditions. Choo cites JAMA studies showing that around 27% of medical students and 29% of resident physicians have experienced either depression or depressive symptoms during their training, and physicians—especially female physicians—have a higher risk of dying by suicide than the general population. Further, research has found that physicians in the United States face a higher risk of dying by suicide than physicians in other countries, Choo notes.

    However, Choo writes, providers are often reticent to seek mental health care—a challenge that Choo has faced, herself. When herself experienced depression in her final year of residency, she "did what doctors with depression do: [She] hid it." She writes, "I smiled through my shifts until I couldn't, then I would walk into the bathroom outside the trauma hallway, cry, wash my face, and walk out smiling."

    According to Choo, part of the reason why providers are hesitant to seek mental health care is because norms within the profession discourage it. Providers also may be afraid of harming their reputations and losing their practices if they reveal any mental health histories or seek treatment, Choo writes.

    She notes that, although the American Medical Association, the American Psychiatric Association, and a number of other organizations all have argued that mental health diagnoses and treatment shouldn't be used to assess a person's fitness for work, as of 2018, 32 state medical boards and 22 state nursing boards asked mental health questions on their licensing forms for health care providers. Those questions "are inconsistent with Americans with Disabilities Act," but they still can discourage providers from seeking mental health care, according to Choo.

    Covid-19 has exacerbated the mental health crisis among providers

    America's Covid-19 epidemic has only amplified the stress placed on clinicians, Choo writes. Although providers are used to dealing with terminal illnesses and death, "with Covid-19, these tragedies are coming in rapid-fire succession, and in the form of an illness we are still just beginning to understand," she explains. "Loss of control, failure, and helplessness are all part of practicing medicine, though never before, at least in modern medicine, on this magnitude, for this prolonged duration, and with so many confounding uncertainties," Choo writes.

    Further, the Covid-19 epidemic has exponentially increased expectations of and responsibilities for providers. For instance, Choo write that providers often are finding themselves "stand[ing] in for family members barred from hospitals for fear of spreading infection," placing another burden on clinicians' mental state. When those increased loads are compounded with supply and space shortages, as well as anxiety related to the possibility that providers, themselves, could contract the new coronavirus and transmit it to their relatives, "the dangers to mental health should be obvious," Choo writes.

    And for providers who do contract the coronavirus, returning to work too quickly can have a significant impact on their mental health, as well. Choo notes that some recovered Covid-19 patients can experience lingering physical or neuropsychiatric symptoms, which could make it harder for providers to do their jobs. CDC guidelines state that health care workers can return to work after having three consecutive days without fever or respiratory symptoms, which could "toss back some who may not be ready to return to regular duties, let alone the unusually demanding work environment of Covid-era practice," Choo writes.

    Still, efforts to address mental health risks among providers haven't changed to keep up with their evolving situations, Choo argues. "Clinical practice during the [epidemic] has been marked by remarkable adaptation and innovation, but that creativity has not been reflected in the response to health care workers' mental health needs."

    Culture must change—and providers must 'admit' they 'are human'

    Choo writes that it's important for clinicians to seek mental health care at any time when they need it, as she ultimately did. "I eventually received treatment from a therapist, but in doing so, I was an outlier," she writes, adding, "When it comes to mental health, physicians seldom seek the kind of care they recommend to their patients, whether out of shame, fear of being stigmatized, or silent acquiescence to the unwritten stoic norms of the profession." 

    But given the added stress and demand because of Covid-19, it's "clear how vital it is to change this culture," Choo writes. "As the [epidemic] rages on, sustaining this vital workforce …  will depend, in part, on the profession's ability to transform its culture and make it possible to admit despair, defeat, and sorrow: to admit, simply, that we are human" (Choo, Washington Post, 7/20).

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