The COVID-19 pandemic will be seared into the minds of a generation of clinicians as one of the most trying times of their careers. Health professionals have been forced to make life and death decisions in a way they had not previously, while grappling with scarce resources, and fearing for both their own health and their families’ health.
Amidst these challenges, many sensed an increased alignment between clinicians and health care organizations to overcome a common enemy. Within weeks, health professionals and their organizations creatively devised operational changes to adapt to evolving knowledge, ensure safety, and serve patients and communities in need. Clinicians have spoken up about their needs for personal protective equipment (PPE), mental health services, and safety. In some ways, clinicians have felt more heard, empowered, and celebrated than they had in a long time.
Nevertheless, many health care workers have struggled deeply during the pandemic, and as the pandemic stretches on, they continue to struggle. Both individual accounts and population studies point to an increased burden of mental health symptoms associated with the pandemic. These challenges are layered on top of the existing burden of clinician burnout resulting from heavy workloads, moral distress, administrative burdens, poorly designed technologies, and other factors that preceded the current crisis.
To ensure the well-being of our colleagues going forward, we will need to harness some of the alignment and sense of partnership that blossomed in many instances during the pandemic. This can point us toward a forward-thinking clinician well-being strategy. Such a strategy should integrate six principles that proved effective during the pandemic’s peak: 1) agility and responsiveness, 2) a supportive culture, 3) transparent communication, 4) connection to meaningful work, 5) supportive systems of working, and 6) promotion of equity.
Acting on these principles will require leadership commitment, a shift in thinking, and a focus on systems change.
Agility And Responsiveness
At both Brigham Health and the University of California, San Francisco (UCSF) Health, the adaptability and agility of our systems and people to pause routine work, reprioritize, and work together to meet the needs of the COVID-19 response were refreshing and different from the traditional measured pace of large organizations. Diverse employees, ranging from guest services staff to nurses to administrative personnel nimbly and eagerly redirected their efforts to focus on screening efforts for employees. Testing sites were quickly established in diverse locations, with rapid cycle process improvements maximizing testing efficiency and accessibility. rapidly shifted toward providing virtual visits, half of which were remote within just weeks. Policies and guidelines for clinical care were updated within days, often after-hours and over weekends, in response to evolving knowledge and regulations. While these changes were facilitated by the scale and resources of our organizations, the need for agility applies to other organizations as well.
Across our institutions, people rapidly stepped up to do jobs and help in ways they had not previously. One of our authors recalls an instance when a senior radiologist was serving as a donning and doffing monitor on a Brigham Health ward. The clinician overheard her saying that she needed help scheduling a semi-urgent radiology procedure for one of her patients. Although his job did not typically include scheduling, and this was not his patient, he stepped in to help arrange the procedure for the sake of patient care.
Both organizational and individual responses during the pandemic’s peaks showed that rapid change is possible when joint purpose and teamwork are combined with collective motivation to deliver the best patient care, and we should seek to foster this spirit going forward.
Supportive Culture
In many institutions, messages normalizing that it was “okay not to be okay” were broadcast during the height of the pandemic, with subsequent availability of creative support services. At UCSF, the Coping and Resiliency (COPE) program was established by the Department of Psychiatry and Behavioral Sciences in partnership with Human Resources and the Center for Digital Health Innovation to enhance existing employee mental health resources. Through a confidential digital screening tool, employees could access mental health resources and online self-management tools. As of October 2020, the screener had been accessed 26,725 times, and 382 employees were referred for in-person triage, assessment, and individual and/or group behavioral health treatment.
At Brigham Health, clinical staff were offered virtual “wellness huddles” led by peer support specialists and either a psychiatrist or psychologist. These groups met online and were embraced by more than 1,450 trainee and faculty clinicians, who attended more than 60 huddles spanning 18 different departments and programs since the start of the pandemic. Particularly valuable during a pandemic, these will likely prove valuable in a post-pandemic world as well.
While the pandemic’s surge may have passed in some places, its long plateau will continue for the foreseeable future. Creative provision of services and continued normalization of seeking help will be crucial as providers struggle with post-traumatic stress disorder, increased caregiving burdens, and continued uncertainty during COVID-19’s long plateau.
Transparent Communication And Committed Listening
The rapid change and uncertainties that came with the pandemic could have resulted in mass chaos and decision paralysis; however, transparent and regular communication proved to be an antidote. At both Brigham Health and UCSF, daily incident command center meetings pulled together operational and functional leaders from all parts of the health system. Regular townhalls updated the community about topics such as COVID-19 rates, PPE policies, and adaptations made to serve patients and employees, with dedicated websites echoing this information. On the data front, frequently updated dashboards available to staff and leadership detailing key metrics served as a transparent way of communicating the latest trends. These dashboards displayed data ranging from inpatient and intensive care unit censuses, to rates of COVID-19 positivity stratified by race, ethnicity, sex, and language, to numbers of employees infected and recovered. While the flow of information during the pandemic has often been fast and furious, open dialogue and ready access to data engendered a trust that will be valuable to leverage in the months and years to come.
Alongside efforts to be transparent, effective communication also requires leadership commitment to listening and channels for voicing concerns. At Brigham Health, a Physicians’ Council met regularly throughout the pandemic to communicate experiences and concerns to leadership. Meanwhile, at Rush University, in-person Wellness Rounds enabled leaders to provide the latest COVID-19 command center information, while also learning about issues and concerns in real time, and gave frontline clinicians a conduit by which to relay questions and worries. Leaders should seek opportunities to be present and open communication channels going forward, whether through rounds, huddles, or other recurring methods. This empowers clinicians and enables them to feel heard.
Connectedness To Meaning In Work
Many clinicians found great meaning in their frontline patient care. Others who could not be or were not on the front lines felt guilt when the pandemic surged. However, many of those clinicians found opportunities to contribute to the pandemic in less direct ways, often breaking down barriers of specialty or job function.
At Brigham Health, trainees who were not able to provide frontline care, whether because of personal conditions or regulations, were provided diverse ways to meaningfully impact patient care. For example, internal medicine residents unable to serve on the front lines were redeployed as “virtual rounders,” who helped teams prepare discharge documentation and daily progress notes, and, in the process, learn about COVID-19. Nurses, community health workers, social workers, and countless others similarly found new ways to contribute, even in the absence of being on the front lines. For example, across both our institutions, diverse teams reached out to vulnerable populations to do well-being checks, provide COVID-19 education, and share information about how to connect to community resources. Others found meaning in reaching out to more distant communities in need.
At UCSF, when the long awaited first surge was not as bad as anticipated, teams of providers traveled to New York Presbyterian Hospital and Navajo Nation to support communities much harder hit by COVID-19. They spent a month at a time in hospitals providing hospital medicine or critical care, contributing to the national response while their local situation remained relatively stable.
COVID-19 has provided health care workers with a sense of meaning and connection in their work, regardless of whether they have been able to provide direct care. A key aspect of clinician well-being in the months ahead will be sustaining that sense of mission and passion.
Supportive Systems Of Working
As many parts of the economy remain remote, supporting people in their diverse responsibilities will be central for ensuring that health care work is sustainable. Flexible policies available to the whole workforce will be particularly important for supporting women, who disproportionately bear the burden of caregiving for children and elderly parents, and underrepresented minority colleagues, who bear the burden of our nation’s reckoning with racism and equity. Among many initiatives to support families of frontline workers across both of our institutions, UCSF’s Academic Senate sought to alleviate pandemic stresses related to promotion by extending the eight-year allotted time frame to advance from assistant to associate professor to nine years. In addition, all faculty were encouraged to include COVID-19-related contributions toward promotion and to describe COVID-19 impacts on their academic productivity.
Future Directions And Pursuit Of Equity
As the COVID-19 crisis continues, our lessons learned from the crisis response should be applied to new pressing priorities that are similarly threatening our well-being. Can we apply the same focus, agility, and collaboration across silos to solve problems such as systemic racism and the ongoing underrepresentation of minorities and women in positions of leadership, decision making, and resource allocation?
Our first focus should be the communities we serve. In cities across the country, there are stark disparities in prevalence of COVID-19, with a disproportionate incidence in communities of color. Facilitating equitable access to care, testing, and resources served as a starting point for addressing these disparities at both UCSF and Brigham Health. In Boston, fueled by knowledge of the disproportionate impact of COVID-19 on less affluent communities and among Latinx and Black residents, Brigham Health and UCSF collaborated with community partners to establish COVID-19 testing sites in hotspot neighborhoods. At these testing sites, Brigham Health personnel also performed more than 7,500 social determinants of health screenings and addressed needs uncovered during screenings.
In addition to serving our communities, we must look inwards as well. While efforts to make our workforce more equitable have been underway for many years, the COVID-19 pandemic has given new gravity to achieving this goal. Building on years of equity-related foundational steps, UCSF and UCSF Health leadership—from chancellor to C-suite executives to managers and directors—have doubled down on equity-related goals to which they are held accountable to the organization to accelerate this work. These range from addressing patient care disparities such as in influenza vaccinations, hypertension management, advanced care planning, or COVID-19 outcomes for Latinx and Black patients, to workforce goals such as improved representation of underrepresented minorities in higher-level leadership positions and improved sense of inclusion and belonging among staff. In the educational mission, curricula have been revamped and policies implemented for equity in learning and assessment, and in the research mission, funding provided for research addressing systemic racism and police violence.
Meanwhile, at Brigham Health, department chairs came together to jointly undertake a pledge to make meaningful and measurable change in diversity, equity, and inclusion including increasing representation of those underrepresented in medicine among trainees and faculty, augmenting the diversity of non-physician staff, developing quality improvement initiatives centered on equity, and developing safe culture reporting mechanisms. The department chairs also committed to engaging more closely with community leaders to drive change and promote health equity.
The COVID-19 pandemic has layered new stresses, fears, responsibilities, and sorrows onto a background of clinician burnout that existed before the COVID-19 pandemic. It also created a unique opportunity for clinicians and organizations to work together in a way they had not previously to create a culture of agility, enhanced channels of communication, new ways of working, and a demonstrated commitment to harder challenges, such as anti-racism and more equitable care.
Harnessing the lessons learned can help sustain our people’s well-being and facilitate our abilities to advance health in a post-pandemic world.
