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Clinicians coping together

Hospitalists find ways to stave off burnout

March 2021

AS INTENSIVIST Hesham Hassaballa, MD, recalls, working the early days of the pandemic last year was fraught with fear—of becoming infected, of bringing the virus home—but also a certain thrill.

“You were part of a global, historic effort,” says Dr. Hassaballa, medical director of the Sound Physicians intensivist group at Rush-Copley Medical Center in Aurora, Ill., “and you were on the front line.”

But that thrill quickly went away. Earlier this year, Dr. Hassaballa described in a blog post how his mindset over the course of the pandemic has changed. He went from having high hopes of curing most covid patients, he wrote, to learning just to “take it day by day and view every patient I discharge as a win.”

Mortality in his ICU this past year rose 50%, mostly due to covid. Many who die linger weeks on a vent, an exhausting process that happens so often that he refers to it as “Lather. Rinse. Repeat.”

“I’m tired of being strong.”

Hesham Hassaballa, MD

~ Hesham Hassaballa, MD
Sound Physicians

“We’re supposed to be strong all the time, but I’m tired of being strong,” says Dr. Hassaballa. “I want somewhere where I don’t have to be strong, and we’re starting to search for that place.” Frequently, over the course of this unrelenting year, “we’re finding it with each other.”

One year in, hospitalists and other inpatient clinicians admit they’re exhausted. Even as covid cases drop, hospitalists are still treating a virus with no cure, on top of a flood of medical patients who delayed care and are now being admitted.

Physicians say the crisis has taken burnout—which was already pervasive—to whole new levels, as providers who faced their first covid patients with adrenaline and passion now find themselves deep in the slog. But while burnout, at least moments of it, has been a given, clinicians acknowledge that several factors have at least helped prevent it from swamping them.

Many of the basics, from revised staffing to daily huddles and sustained communications, have mitigated a very unbalanced burden of inpatient care. Clinicians have accessed mental health and employee assistance resources, while hospitals have expanded their networks of peer responders and buddy systems. And like Dr. Hassaballa, many have learned to lean on both the army of colleagues and health care workers who came to help them—and on one another.

A turning point
Dr. Hassaballa points out that he’s a peer responder, fielding calls from colleagues “who just want to talk.” His ICU team also maintains an informal “battle buddy” network to regularly check in with one another. (See “Making sure everyone stays connected.)

“I got my first dose three days before Christmas, and I couldn’t believe how euphoric I felt.”

Titilola Britto, MBBS, MBA

~ Titilola Britto, MBBS, MBA
Advocate Aurora Health

Clinicians have also found individual ways to cope. For Dr. Hassaballa, that includes writing, an activity that’s been of enormous value to him since his young daughter passed away from cancer in 2009.

Sources also say that the arrival of effective vaccines has been a major turning point. That provided “the biggest boost” to physician morale since the pandemic began, says Titilola Britto, MBBS, MBA, president of hospital medicine for Advocate Aurora Health in Wisconsin.

“I got my first dose three days before Christmas, and I couldn’t believe how euphoric I felt,” says Dr. Britto. She’s continued to take heart from the fact that, as of mid-February, her health system had administered nearly 150,000 doses of the vaccine, covering all front-line and community health care workers.

Gerard Salame, MD, a hospitalist with Denver Health, points to data released in February by an Israeli HMO showing that mass vaccinations have cut covid cases by more than 90%.

“Finally, this may turn around,” says Dr. Salame. “I can at least think that the worst of it may be over.” That couldn’t come soon enough, he says, admitting his year “definitely had moments of burnout.” Like the other hospitalists in his group, he was pulled away from teaching. He also became part of two hospitalist teams that spent half their clinical time this past year in the covid ICU.

Like Dr. Hassaballa, he found covid mortality in the ICU “very depressing,” saying his lowest point was when he lost four out of an eight-patient panel over five days. “I’ve mastered having that conversation with families, but it’s not a skill I really wanted to master.”

“It’s uncanny how this kind of isolation can really hurt you.”

~ Gerard Salame, MD
Denver Health

But what also surprised him was how tough it was to come home, thinking he could put the hospital behind him for a bit, only to find his family wearing masks and worried about him. “You couldn’t get away from it and unwind,” says Dr. Salame, whose “saving grace” has been running and weightlifting. “Your family keeps asking questions, and it’s always on the news. Covid is just ubiquitous.”

Another revelation: “It’s uncanny how this kind of isolation can really hurt you. I have my family, but I know some docs who are single, and I can’t imagine how hard this has been for them.”

New care models and revised schedules
At New York’s Mount Sinai, Krishna Chokshi, MD, the hospital medicine division’s wellness champion and the department of medicine’s interim director for faculty wellness, ticks off the innovations that the hospitalists—who treated at least 75% of the flood of covid patients—could rely on last spring.

The “massive redeployment” of non-medicine lines to the hospitalist service, Dr. Chokshi says, had the entire medical community all in and was very heartening. The division also made the right move in adopting a model where hospitalists would supervise teams consisting of a non-hospitalist attending—a fellow or resident—as well as an NP or PA, either from in or outside medicine.

“Each supervising hospitalist,” she explains, “oversaw a couple of those teams, which really helped with workflow. We were able to take care of a really large volume of covid patients much more effectively.”

“People are saying they need to back down on their work, and they’re willing to take a pay cut.”

Jennifer Ashley, MD

~ Jennifer Ashley, MD
St. Charles Health System

By also adopting a four-on/four-off schedule, “we ended up sometimes working fewer shifts than we would have otherwise”—another “important part of getting through the worst of the pandemic for us. Definitely, burnout was there, but such changes prevented it from getting worse.”

Both the division and the department, says Dr. Chokshi, also figured out the importance of “really consistent messaging.” Frequent town halls were “a source of real comfort,” while transparency about PPE, testing supplies and vaccines “became really important for faculty wellbeing. I never realized before that hearing regularly from leadership is really valuable.”

Plowing through
Mount Sinai last spring launched its Center for Stress, Resilience, and Personal Growth that doctors and nurses—as well as anyone on staff—can access. Hotline numbers were widely publicized, clinicians were given easy access to mental health counseling and group sessions, and divisional town halls were held every two weeks. While the department of medicine also launched a “buddy” system, Dr. Chokshi notes that the hospitalists were already very tight-knit.

But now, while a team of orthopedic PAs is still helping the hospitalists, it’s back to business as usual for the other specialists. Meanwhile, the hospitalists have a census that is considerably larger than usual, and about 30% of those patients have covid.

“We’re now in a different phase of the pandemic where clinicians are just completely tired and disillusioned, and they want this to end,” says Dr. Chokshi. As for offering workshops on resilience skills or mindfulness training, “those require an investment of time and people’s buy-in. The interest may be there, but everyone just wants to get their work done and go home.”

The challenge, now and going forward, is figuring out how to incorporate burnout-prevention skills and training into clinicians’ weekly programming.

“We did have a mindfulness educator come in during grand rounds to talk about stress reduction, and we’re floating the idea of a wellbeing grand rounds as well,” she says. “We need to figure out how to make this part of the culture and not ‘something extra.’ ”

Pitching in across sites
In Wisconsin, Advocate Aurora’s Dr. Britto says that her health system’s big covid surge hit last fall when “we couldn’t use the reinforcements we’d planned on in the spring.” In addition to hiring locums, the group—140 clinicians across 14 hospitals—relied on its size and its physicians’ universal credentialing to support all those sites.

“Group members stratified themselves,” Dr. Britto explains. Those who could stay away from home in a hotel volunteered in sites 200 miles away; others who wanted to travel only 60 miles from where they usually work would do so and then go home in the evenings.

Still others were willing to travel only an additional 30 miles to staff other sites, while some—because of child or elder care—opted to stay at their home site, but take extra shifts to allow colleagues to work elsewhere. Dr. Britto, who typically works only a few clinical shifts a year, tripled that amount in sites around the state.

Colleagues were “most reassured” by frequent and transparent communications from the top and from daily huddles during the surge. “Everyone felt they knew what was going on and that things weren’t out of control.”

She also tasked each site director to pull each group member “out of the fray for a coffee-cup chat,” she says, to check in and ask about their families, parents and siblings.

“They also asked each doctor if they needed to just get away for a weekend, and we’d fill those slots with locums,” says Dr. Britto. “Those check-ins were really important.”

Pulling more shifts
Advocate Aurora also offers a robust employee assistance program and a childcare credit. Hospital administrators found additional workspace so the hospitalists could continue to get together in the hospital while staying physically distanced.

And while the health system adjusted compensation because of revenue losses, that didn’t apply to hospital-based specialties. While some hospitalists, particularly those with children being homeschooled, were “really challenged” with work-life balance, Dr. Britto believes no one suffered serious burnout. Out of a staff of 140 hospitalists, only three, she notes, have asked to reduce their hours.

But in Bend, Ore., Jennifer Ashley, MD, the hospitalist director for St. Charles Health System, says her doctors were hard-hit. “Right around Thanksgiving, we were absolutely flooded,” she says. While covid cases have since dropped, they remain “a steady burn.”

Dr. Ashley hired locums and cross-trained anesthesiologists to help the hospitalist service. But while she typically schedules six rounding teams, she had to staff eight during the surge, with additional providers coming in as well.

“Everyone worked between 10% and 15% more shifts than they usually do,” she says, including herself. They are paid per shift, “and there was a little premium on top of that. But that wasn’t what motivated them. We all knew how difficult it was, and we wanted to help each other. It didn’t take begging.”

With locums on board, the group this January began offering vacations to those hospitalists who pulled the most extra shifts. Still, says Dr. Ashley, five out of her group of 31 hospitalists have asked to cut their time back to a 0.8 FTE this year. That translates to 138 shifts a year vs. the full-time load of 172.

“It’s across all ages,” she points out. “People are saying they need to back down on their work, and they’re willing to take a pay cut.” Dr. Ashley has already gotten the OK to hire several hospitalists to help cover those requests. But it’s still, she says, “a huge number of people. It’s also a marker of burnout.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Bouncing back?

TITILOA BRITTO, MBBS, MBA, president of hospital medicine for Advocate Aurora Health in Wisconsin, was asked at a recent meeting to reflect on resilience.

“I looked up the meaning, and I found one I really liked,” Dr. Britto notes. “It talked about how resilience isn’t just the ability to cope and survive, but to adapt to and be energized by challenges.” The idea behind resilience, she says, is to “actually absorb a type of energy from going through adversity.”

How are doctors and nurses going to come out of this? In Illinois, Hesham Hassaballa, MD, an intensivist and medical director with Sound Physicians, believes “at the end of this, I’ll be a better doctor. I’ll certainly have a new appreciation for evidence-based medicine.” He also will never take PPE for granted, and he looks forward to having family members back at the bedside again.

“It’s been a great honor for us to help other New Yorkers.”

Krishna Chokshi, MD

~ Krishna Chokshi, MD
Mount Sinai

A hospitalist with Denver Health, Gerard Salame, MD, plans to take his family camping in the mountains this spring. He is also looking forward to being able to teach again after being pulled away from being with residents to treat covid patients.

Dr. Salame admits he’s “terrified” of another pandemic, saying this one proved “how far we are from understanding the human immunologic response, and just how much research and data it takes before we can actually use it clinically.”

He’s definitely staying in medicine for the long haul and couldn’t imagine working in any other profession. He’s also grateful that, at least in his city, he and his colleagues don’t have to deal with anti-maskers or anti-vaxxers.

But he worries that morale among health care workers may be low nationwide. He’s heard about attacks in hospitals in other states where patients refuse to wear masks or insist the virus is a hoax and that providers are poisoning them to make money.

“Nurses more than doctors have been exposed to that kind of brutality when they’re already exhausted,” Dr. Salame says. “That’s going to take a long time to recover from.”

Jennifer Ashley, MD, the hospitalist director for St. Charles Health System in Bend, Ore., also wonders about long-term retention. Physicians couldn’t help but notice, she points out, that while they had to head off every day to work (in a building crammed with infected patients, no less), many of their friends could work from home—and may continue to do so post-pandemic.

“That flexibility right now has a lot of appeal,” Dr. Ashley says. “I bet we see a lot of physicians including hospitalists move into non-traditional careers to be able to do the same.”

“Very positive experience”
While she admits that last year was the hardest in her career, Dr. Ashley also underscores the positive developments that have come out of a year of struggle.

The pandemic has certainly cemented hospitalists’ place in clinical practice and earned goodwill with administration. And she has been able to appoint what she calls her “leadership council,” with site leads named for staffing, education and research.

“These are all folks who stepped up to fill these slots last year,” she says. “We’re now rewarding them with dedicated administrative time. We’re going to get through this tunnel, and we’re going to come out of it bigger.”

At Manhattan’s Mount Sinai, Krishna Chokshi, MD, the hospital medicine division’s wellness champion, also highlights ways in which the pandemic has been “a very positive experience for us.”

“The gratitude we get from the community has been uplifting,” she points out. “It’s been a great honor for us to help other New Yorkers.”

Colleagues during the pandemic also forged new career paths they’ll expand on going forward in research, leadership, public health and advocacy. And individually, “it’s changed us, very fundamentally,” Dr. Chokshi says. That’s been true as clinicians, with hospitalists caring for very sick, complex patients and becoming adept at having challenging conversations with patients and families about the end of life.

“It’s also made a lot of us introspect about happiness and our priorities,” she says. “All of us have now cared for patients our own age or younger, and we’ve seen them succumb. We’re really talking through it to try to make meaning out of what we’re seeing. It’s opened up all our emotional lives, and it’s given us license to be more human.”

Promoting resilience

Hospitalists struggling to keep their heads above water during the pandemic may not have had the time or capacity to avail themselves of wellness resources already in place, let alone launch new ones.

But some programs were able to implement new initiatives. The University of Minnesota, for instance, developed an ambitious battle buddy system, designed to leave no front-line clinician feeling unconnected. (See “Making sure everyone stays connected.“)

And in Denver, Denver Health—just a month or two before the pandemic hit— had the good fortune to implement a RISE (Resilience In Stressful Events) program, based on one developed at Johns Hopkins to help clinicians with traumatic events such as medical errors and patient safety events. The Denver program features a call line, a peer-responder network, and a clinician drop-in center for both one-on-one and group sessions.

During the pandemic, that center has been stocked with snacks and beverages for any staff member to drop by. It has also had, according to a health system spokesperson, the highest start volumes among all the hospitals nationwide that have adopted the program. Over the course of this year, in a health system with 7,000 employees, the program as of mid-February this year has had more than 60,000 “touches” in terms of phone calls or visits—all while half the staff has worked at home and isn’t even onsite.

Gerard Salame, MD, one of Denver Health’s hospitalists, is among those who have visited over the past year. After rounds, he and his colleagues would often grab what he calls “a RISE moment,” heading to the center for free coffee and snacks.

“Even something that simple acknowledges and values your efforts,” Dr. Salame says. “And just spending 10 minutes there with colleagues and not talking about work was a bit of breathing room.”

He also, he says, attended a group RISE session on one of his worst days last year: A native of Lebanon, he didn’t know on the day of the massive Beirut explosion if his family was OK. While it eventually turned out that they were safe, he learned that he lost two friends in the blast.

“Physicians promote a culture of stoicism, but I felt very comfortable going to that group session and divulging what I was going through,” says Dr. Salame. “Everyone was very supportive, and I hope the program can continue after the pandemic is past.”

Published in the March/April 2021 issue of Today’s Hospitalist

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