ASK DEAN DALILI, MD, about the struggles that hospitalists have faced during the pandemic, and he talks about the bravery and resilience of hospitalists and other clinicians on the front lines of covid. As president of hospital medicine for Envision Healthcare, which has more than 27,000 clinicians working in more than 800 hospital medicine and emergency medicine groups around the country, Dr. Dalili is proud.
“We had a group of people who for all intents and purposes were essentially running into the fire not really knowing what was going to happen when they got there,” says Dr. Dalili. “You have to admire their commitment to caring in an environment with elements of uncertainty. The level of resiliency that people demonstrated was awe-inspiring.”
But he’s quick to point out that bravery can come at a high price. Hospitalists, after all, have been storming that metaphorically burning building day after day, not just once or twice, and that can take a toll on their mental health.
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“There’s clinical fatigue,” Dr. Dalili says, “or being tired from the sheer volume of work. But there’s also a sense of emotional fatigue about this ever-present threat.” Needing to be encased in PPE, for example, “clinicians don’t get the same level of emotional connection to patients. And then there are all the things outside of work that our providers are dealing with, from childcare and social isolation to social distancing or quarantining.”
How have hospitalists managed the mental strain of caring for patients during the pandemic? We asked three hospitalists to describe their experiences and the strategies that helped them stay strong during a time of unprecedented stress.
Hitting close to home
When Angelika Koch-Leibmann, MD, a hospitalist at Evergreen Health in Kirkland, Wash., found herself caring for some of the first Americans diagnosed with covid, the biggest challenge was dealing with all the unknowns. In February, she treated one of the patients from the Life Care Center of Kirkland, which ended up being ground zero for covid in the Seattle area.
“It was a lot of death to process.”
~ Angelika Koch-Leibmann, MD Evergreen Health
“In the beginning, we didn’t really know much,” Dr. Koch-Leibmann says, “but we definitely saw that people were getting sicker so much faster than patients with the regular flu.” Couples admitted to the hospital were dying at the same time, and nurses were losing up to one covid patient per shift during the month of March. “It was a lot of death to process,” she says.
Staff quickly realized that patients weren’t the only ones at risk. An ICU nurse at her hospital who had treated some of the earliest covid patients died after becoming infected. (An ED physician and a hospitalist ARNP in her group also got the virus and needed to be hospitalized, but survived.)
Dr. Koch-Leibmann worked many nights with that ICU nurse, and while she wasn’t particularly close to him, his death shook her. “That was really hard on us since we are so close to our nurses,” she says. “It hit home that the virus isn’t a threat only to the patients we’re treating.”
In addition to that anxiety, Dr. Koch-Leibmann felt a profound sense of exhaustion. “It took so much out of you to talk to families without really knowing what to expect and what to tell them and what the course of the disease will be,” she explains.
Despite the clear sense of danger, Dr. Koch-Leibmann also felt a sense of dedication and pride to continue on. “I was scared,” she recalls, “but I was proud that I was able to be there at patients’ and family members’ sides.”
Her hospital and group made her days treating covid less stressful through a couple of initiatives. For one, her group could rely on a “risk system” implemented before covid to help handle sick calls and high patient volumes.
While the pandemic has strained the hospital’s finances, the administration has been “incredibly supportive.” Administrators guaranteed that they wouldn’t make changes to that risk system or to the number of FTEs. Another plus: The hospital’s chief medical officer (CMO) is himself a hospitalist who understands their needs firsthand.
“Having support and reassurance from administration really helped us get through those difficult times,” Dr. Koch-Leibmann says.
And to address the clinical challenges, the hospitalist group held almost daily phone meetings created specifically for the pandemic. Along with the CMO and the director of infection control, hospitalists would review what had happened with patients and come up with strategies to improve care. “Every day, the team would change something about how we approach and treat patients.” Those phone calls helped by providing information that hospitalists could pass onto patients and their families.
While the phone calls took time, they gave hospitalists a forum to talk about their fears—and about what they should be doing at home. A few months into the pandemic, the hospitalist group held a teleconference with a psychologist to give hospitalists a chance to talk about their experiences.
Colleagues who attended said that people opened up about what they were feeling and that the conference was very beneficial. (She wasn’t able to attend herself.) While Dr. Koch-Leibmann isn’t sure she would personally share in such a forum, she believes such sessions have value.
“Just knowing your leadership cares about your physical and mental health is comforting,” she says. “You also have a chance to hear what your peers are going through and to realize that you’re not alone in this.”
As for more personal strategies to cope with the stress, Dr. Koch-Leibmann found it helpful to write, from a blog to letters to her two sons (ages 12 and 17). Writing, she says, helped “really get things out and felt almost cathartic.” She also developed a ritual for leaving the hospital: changing out of her scrubs at the hospital, driving home and getting undressed in the garage, then immediately taking a shower.
One part of the pandemic that no strategy has helped with is the changes in patient care that covid has brought. ”Before covid, we would sit at the patient’s bedside talking eye to eye. We see the patient’s facial expressions and they see ours.”
But with masks and goggles, providers aren’t able to get too close to patients or to hold their hands. “One reason I went into medicine was that personal touch, and it’s largely gone. I’m not sure when it will come back, because now every patient is a potential threat to our own health.”
A way to deal with unknowns
Hospitalist Colleen Poggenburg, MD, saw her first covid patient in mid-March. She works in the Milwaukee area at two hospitals, as well as a nursing home and a hospice. She was working as a hospitalist in 2009 when swine flu was active, and she has seen the hospital fill up with influenza patients. But treating covid patients was different.
“I know what PPE to put on, I know how to get it on and off, and I know how to get out of the room.”
~ Colleen Poggenburg, MD
“It wasn’t like we had never treated something similar before,” Dr. Poggenburg says. “It’s just that you’re facing the unknown. We didn’t know how contagious it would be and what we had to do differently to avoid getting infected.”
For her, one of the toughest parts of working during the pandemic was how much attention everyone both in and out of the hospital was paying to the risk of getting infected.
“During bad influenza seasons,” Dr. Poggenburg said, “families aren’t worried about their kids going to school. Usually we’re the ones that can just say, ‘OK, let’s get to work.’ But if you’re surrounded by it all the time and it’s everywhere you go, whether at the hospital or the grocery store, your life changes. It’s not just us as physicians in contact with potentially sick people. There are lots of jobs where you make contact with other people who can make you sick.”
One irony is that despite the anxiety she felt about covid, Dr. Poggenburg often felt the most comfortable being in the hospital. “I have been trained over and over how to cover up and put on PPE,” she says. “I’m more comfortable when I know someone’s status, like with influenza, as long as you’re not trying to intubate them or do an aerosolized procedure. I know what PPE to put on, I know how to get it on and off, and I know how to get out of the room. I’ve been doing it for many years.”
Her hospital and hospitalist group also took certain steps to make treating covid patients more doable. Her group’s schedule, for example, allows some hospitalists to leave a little early if the day’s census is light.
“We have ways of backing each other up so that some people are covering and others can go home,” Dr. Poggenburg says. “Having already established that schedule made a big difference. If you don’t have that kind of freedom, you can never get home, particularly when you’re seeing coronavirus patients.”
Another step that made a big difference to the hospitalists: The ED reduced unnecessary admissions as much as possible. “The ED physicians were very aggressive about sending patients home who didn’t need to be hospitalized,” she says. “The patients were motivated to go home and the emergency department was motivated to get them home.”
That helped assure her that the hospital and the other physicians there were looking out for her. “There were things already in place that seemed to insulate us a little more than other groups,” Dr. Poggenburg says.
On a personal level, she found that reading blogs by other hospitalists treating covid patients helped reduce her anxiety. “I watched what was going on in New York,” she says. “It was like watching coverage of a snowstorm that’s about to hit. Because we’re in the Midwest, we had the advantage of learning from peoples’ experiences. ”
Reading blogs was also a way to deal with some of the unknowns. “It was a way to say, ‘What am I doing personally?’ and an added layer of routine, regardless of whether it was going to protect me and my family.”
She also set up a quarantine zone upstairs in her house in case she became sick and needed to physically separate herself. (She never did contract the virus.) And she set up a “clean zone” in her car to store used work clothes. Because she works at more than one facility, she didn’t want to leave clothing or anything else that might have been infected at any of the hospitals. “I had to have a way to become mobile but still stay clean.”
As a physician, she also felt compelled to take some action on her own. “I wasn’t trained to sit back and do nothing,” Dr. Poggenburg says. “I had a nurse at one facility say she was waiting for the administration to help. I remember thinking, ‘You’re going to wait for the nonmedical people to tell you what to do to protect yourself?’ That doesn’t make any sense to me.”
An interconnected community
Hospitalist Sima Pendharkar, MD, MPH, experienced the pandemic from several perspectives. On a personal level, Dr. Pendharkar, who was living in New York City at the time, knows people like her friend whose 51-year-old husband died of covid. “People around me were losing their friends and family,” she says. “You would be walking down the street and see a picture of someone with candles. It’s something I’ve never experienced before.”
“You have people dying in the hospital, but then you have people outside showing solidarity. That meant a lot.”
~ Sima Pendharkar, MD, MPH
To take care of herself personally, Dr. Pendharkar put together a small group of physicians to stay in touch via Zoom. That group included an ICU doctor, a primary care physician and a psychologist, all of whom were friends before the pandemic. “We set up weekly calls just to check in with each other,” she says.
On a professional level, she helped staff overworked programs through a small hospitalist staffing company she had created a few years ago. That company sent members of its pool of about 20 hospitalists to several hospitals in CarePoint Health in northern New Jersey.
Dr. Pendharkar and other group members covered wards and ICU units. “The physicians were really stressed because they were working lots of shifts and going in every night,” she says. “They were intubating patients and under a lot of pressure.” Physicians aren’t used to practicing under those types of really intense situations, she adds. “We tried to make sure people had a little bit of a break, so they weren’t always just working.”
Her group also brought lunch to the programs where members were working, and she reached out to some of the physicians. “I would personally text or call some of them just to check in on them,” she recalls. “Sometimes just having a real person check in on you can go a long way. Oftentimes in health care, those things can be missing.”
And Dr. Pendharkar was struck by the support she felt from the community. “When I’d walk into the hospital for my shift each night,” she says, “people in the surrounding buildings would be whistling and shouting ‘thank you.’ ” It was a much-appreciated reminder that she was part of an interconnected community.
“You have people dying in the hospital, but then you have people outside showing solidarity. That meant a lot, because it was hard going into some of those shifts knowing that your best is not going to help some patients.”
Edward Doyle is Editor of Today’s Hospitalist.
Published in the October/November 2020 issue of Today’s Hospitalist