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Dual fatigue syndrome

Pandemic fatigue piles on to burnout

December 2020

WE HAVE SPENT the past nine months fighting this pandemic, and there seems to be no end in sight. With vaccines likely months away and (often) conflicting research on therapeutics coming out daily, health care providers have been tested and tried. Going through one surge after another has been motivating, but exhausting.

Fortunately (or not), hospitalists are conditioned to work while fatigued or even burned out. But now, many of us might be suffering from a dual fatigue syndrome: pandemic and physician fatigue combined.

Burnout on top of burnout
The World Health Organization defines pandemic fatigue as “demotivation to follow recommended protective behaviors, emerging gradually over time and affected by a number of emotions, experiences, and perceptions.1

Physician fatigue, on the other hand, is the inability or unwillingness to continue to perform effectively, caused by excessive workload, stress, sleep loss and circadian disruption.2 According to a 2019 Medscape survey, both hospitalists and nonhospitalists reported burnout levels of about 45%.3 Among hospitalists, major causes of burnout included too many administrative tasks and a lack of respect from administrators, employers, colleagues or staff.4

If news and social media are stirring our distress, we should limit our intake.

Then there’s the pandemic, with its backdrop of exhaustion or burnout as well as extra or changed work patterns, ever-evolving guidelines and the need for precautionary measures. Those come on top of the tremendous pressure of uncertainty, homeschooling and lack of control.

But acknowledging pandemic fatigue can lead front-line physicians to feel stigmatized and judged. Leaders, wellness champions and physicians themselves may fail to implement coping strategies when pandemic fatigue goes unrecognized or is wrongly labeled as something else.

Signs of fatigue
Some signs specific to pandemic fatigue: being less diligent with mask-wearing or hand-washing, taking less care to physically distance, an unwillingness to follow guidelines and recommendations, decreased efforts to remain informed, or having lower risk perceptions related to the virus. Providers now may also feel stressed out, impatient and irritable carrying out mitigation strategies that came easily during the pandemic’s early days.

Other manifestations of fatigue include performance changes; impaired learning and thought processes; memory defaults; interpersonal dysfunction; careless errors in judgment, diagnosis or therapeutics; drug or alcohol abuse; marital disharmony; and even suicidal ideation.5,6 One 2018 study suggested that physician burnout, fatigue and work unit safety grades were independently associated with major medical errors.

And hospitalists are not the only ones to feel the impact of pandemic fatigue. It can have a ripple effect on provider and patient safety—and on our families. Subconscious emotions may also be adding to the stress and fatigue. It’s emotionally taxing to lose, or even be afraid to lose, patients, colleagues or loved ones.

The fact that close to 800 health care workers have died while more than 200,000 have been infected certainly provokes anxiety.7 Most of us are also frustrated over how scientific and public health measures have come under scrutiny, while thousands of health care workers have been laid off or furloughed or seen their pay cut.

And news that some administrators are giving themselves bonuses while they work remotely and refuse to give physicians hazard pay has caused outrage.8 Both providers and public health officials have quit during this pandemic due to health risks, disagreements over how to handle the crisis, and severe political or public backlash.9,10

Coping tips and strategies
The American Medical Association 11 and other institutions have provided much needed coping strategies for physicians. Here are some tips to prevent burnout that could come handy, particularly at work.

• Take strategic breaks during the workday.

• Plan your day to improve the late-afternoon slump.

• Communicate effectively and keep handoffs strong.

• Catch up with coworkers while following physical distancing.

• Give yourself accurate information.

• Take a break from PPE gear while following guidelines.

• Keep work-life balance in mind when taking on additional optional work.

• Seek professional help within or outside your program when needed.

• Practice physician advocacy and become part of the solution.

• Revisit the perks of being a hospitalist.

As for administrators and leaders, they can do a lot as well. They can ensure adequate PPE and rapid testing turnaround, while opening up access to personal leave for front-line providers and allowing shorter shifts. In addition to maintaining robust wellness programs, they should also share victories—like decreases in length of stay and mortality—with staff.

Coping strategies at home
Coping at home starts with recognizing and accepting fatigue. Acknowledging that we have little control over the pandemic’s trajectory and vaccine or therapeutic discovery can focus us on what is within our control.

But home lines have blurred with “work from home” and with having everyone at home all the time. Prioritizing self-care and relaxation with small achievable goals—eating a little healthier, exercising, reading, catching up on a show or a movie, extra sleep—can turn a bad day around.

And quarantine has a tremendous psychological impact. In one study, hospital staff quarantined due to suspected contact with SARS were significantly more likely to report exhaustion, detachment from others, irritability, and insomnia, along with a host of other problems.12

To ward off isolation, whether or not we need to quarantine, we should pursue creative solutions such as outdoor visits or phone or Zoom calls that provide social interaction without transmission risk. Forming a pandemic pod or bubbles has also become popular.

And according to a paper in Health Psychology, increased consumption of news or media may increase our perceptions of threat, which in turn can foster problems with physical and mental health.13 If news and social media are stirring our distress, we should limit our intake.

Lessons learned
There’s too much suffering in this pandemic to talk about “silver linings.” But the pandemic has driven important changes. A big one: Front-line hospitalists have redefined our roles in health care. We have treated, taught, supervised, volunteered, learned—and led. Too often perceived as “glorified residents” or a “dumping ground” for other services, our specialty has gained newfound respect.

But it’s come at a price. While many specialties have been able to stay away from the hospital, we—and other front-liners—have taken ownership of covid patients. All those long, in-person meetings and conferences are now virtual, making us wonder why we weren’t holding them that way before.

We’ve polished, learned and implemented new skills. We’ve stretched our roles and services to become volunteers, ICU doctors and advocates for science. We’ve designed protocols for clinical care and disaster management, and we’ve made our voices heard in the ethical rationing of resources. We’ve helped develop telemedicine and pushed physician well-being like never before.

We’re now entering the pandemic’s third wave, with the holiday and flu season also upon us. We have to be ready for the long race while keeping ourselves sound in body and mind. To do so, let’s take heart in what we’ve achieved and remind ourselves that we are all in this together.

Taru SaigelTaru Saigal, MD, is a hospitalist and assistant professor at Ohio State University in Columbus, Ohio.






1. https://apps.who.int/iris/bitstream/handle/10665/335820/WHO-EURO-2020-1160-40906-55390-eng.pdf (Last accessed on Saturday, October 31st)

2. Parker JB. The effects of fatigue on physician performance—an underestimated cause of physician impairment and increased patient risk. Can J Anaesth. 1987;34:489–495

3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012 Jan;27(1):28-36. doi: 10.1007/s11606-011-1780-z. Epub 2011 Jul 20. PMID: 21773849; PMCID: PMC3250553.

4. https://www.medscape.com/slideshow/2019-lifestyle-hospitalist-6011430 (last accessed on October 28, 2020)

5. Tawfik DS, Profit J, Morgenthaler TI, Satele DV, Sinsky CA, Dyrbye LN, Tutty MA, West CP, Shanafelt TD. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clin Proc. 2018 Nov;93(11):1571-1580. doi: 10.1016/j.mayocp.2018.05.014. Epub 2018 Jul 9. PMID: 30001832; PMCID: PMC6258067.

6. Ramsay MA. Physician fatigue. Proc (Bayl Univ Med Cent). 2000;13(2):148-150. doi:10.1080/08998280.2000.11927659

7. https://covid.cdc.gov/covid-data-tracker/#health-care-personnel (last accessed on October 29th, 2020)

8. https://www.medicaleconomics.com/view/coronavirus-pandemic-demonstrates-disconnect-between-executives-and-doctors

9. https://www.cnn.com/2020/06/22/us/health-officials-threats-coronavirus/index.html

10. https://medicalrepublic.com.au/doctors-quitting-because-of-covid-19-survey/35419

11. https://www.ama-assn.org/delivering-care/public-health/managing-mental-health-during-covid-19?gclid=CjwKCAjw0On8BRAgEiwAincsHD80tIADdti2aU9NiC3rb-jTE8Ln8I6e5GvcVtBKj0g0cg_D6RVS1BoCNwwQAvD_BwE (last accessed on October 28th, 2020)

12. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004; 55: 1055-1057

13. Garfin, D. R., Silver, R. C., & Holman, E. A. (2020). The novel coronavirus (COVID-2019) outbreak: Amplification of public health consequences by media exposure. Health Psychology, 39(5), 355-357

Published in the December 2020 issue of Today’s Hospitalist
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