Physician well-being during COVID-19 — burnout & moral injury

By Beata Chami, ACC, MA, Organizational Psychology (biography and disclosures)

Frequently asked questions I have noticed

It has been eighteen months since COVID-19 emerged in Canada. The trajectory of the pandemic has placed a strain on our citizens’ mental health, particularly our frontline workers. While physician well-being has been a longstanding concern, the global pandemic has magnified the daily challenges that clinicians so bravely navigate to safeguard the health of their patients.

Expectedly, there has been ample conversation about how physicians can take care of themselves during this unprecedented time in medicine. This piece will discuss burnout and moral injury, and highlight the resources and tools available for supporting healthcare workers through these experiences.

Data that answer these questions

Since the pandemic began, there has been evidence to suggest that it has had a clear impact on the mental health and well-being of healthcare workers. The Physician Health Program of British Columbia experienced a surge of service calls in 2020, up twenty six percent from 2019. Anxiety, stress, mood disorders, marital or partner relationship issues, and occupational stress and burnout accounted for the main reasons providers sought help. In working to address these challenges, discussion has focused around how physicians can appropriately identify, understand, and manage their emotional health effectively.

Over the past five years, I’ve met physicians across various specialties who have recounted what led them to pursue a career in medicine. A common theme from these conversations is that physicians are empathic beings who entered the field with a mission to serve others and improve their patients’ quality of life. With this comes the duty of care and the Hippocratic’s oath’s adage of “fmeirst, do no harm.”

In a 2017 research study I conducted with B.C.-based physicians, we found that physicians demonstrate a high level of emotional responsibility towards their patients. Specifically, the study found that physicians assume it is their responsibility to prioritize their patients at all costs. A respondent discussed their understanding of their role by suggesting “I think we have a primary obligation to care and be present for our patients, or any other professional works that we’re engaged in, and we have an ethical responsibility to…be altruistic, to put the needs of those we serve ahead of our own needs” (Chami, 2017). Additionally, this research highlights that a physician’s emotional responsibility is often confused for their professional duty of care, suggesting the need to address and clarify professional responsibilities to establish healthy workplace culture.

With the altruistic attitudes that physicians assume, it is no surprise that COVID-19 has had an impact on their mental, physical, and emotional well-being. Common symptoms expressed by medical practitioners I’ve connected with since March 2021 describe conditions of burnout and moral injury.

What is burnout and how to identify it

Burnout is an occupational syndrome that is described by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. Emotional exhaustion entails feelings of extremely low energy and difficulty offering emotional support to patients. Depersonalization is when a physician treats patients as objects rather than human beings, lacking sensitivity in their practice. Reduced personal accomplishment signifies feelings of ineffectiveness in supporting patients, where practitioners’ feel a lack value in relation to the perceived impact they have on patients and their professional responsibilities (West, Dyrbye, & Shanafelt, 2018).

It is often difficult to distinguish burnout from other emotional experiences such as depression, occupational stress, job dissatisfaction, and fatigue. Although burnout is correlated with all of these, an individual may experience it independent of these conditions. Burnout is recognized by the World Health Organization (WHO) as an occupational phenomenon. While it is not classified as a medical condition, burnout is included in the WHO’s latest handbook, the International Classification of Diseases (ICD-11). This suggests the evolution of the syndrome in the workplace, while providing credibility to those who experience it first-hand (Chatterjee & Wroth, 2019).

The prevalence of burnout was flagged in the medical community before the pandemic, with 66% of Ontario physicians reporting some level of the syndrome in March 2020, of which 29% confirmed persistent symptoms. One year later, 72% of physicians reported burnout, with 35% revealing persistent symptoms (Ontario Medical Association, 2021). Additionally, in a recent UBC study examining burnout among Vancouver internal medicine physicians, the prevalence reported was generally higher than similar evaluations conducted pre-pandemic (Khan, Palepu, Dodek, Salmon, Leitch, Ruzycki, Townson, & Lacaille, 2021).

What is moral injury and how to identify it

Similar to burnout, the concept of moral injury has been a common emotional experience for physicians since the beginning of the pandemic. However, prior to the COVID-19 pandemic, it was not a familiar phenomenon in healthcare. Moral injury originated in the military when soldiers returned from a deployment where they were involved in events that infringed on their moral convictions. As human beings, we all hold moral beliefs and values that are often triggered during high stakes situations. When there is a betrayal or breach of this personal philosophy, this is when moral injury occurs, yielding a psychological, social, and spiritual impact on an individual. A recent Canadian study conducted among emergency and critical care physicians found that most respondents were feeling anxious due to the pandemic, with many presenting with concerns about the negative psychological impact that critical care resource allocation could cause (Mulla, Bigham, Frolic, & Christian, 2020).

The consequences of moral injury can include experiences of feelings of guilt, shame, anger, sadness, anxiety, and disgust. Intrapersonal outcomes include high self-criticism, diminished self-esteem, engaging in self-handicapping behaviours, and adopting beliefs about being “damaged,” unworthy, or weak. Interpersonal impacts can include loss of trust in others and avoidance of intimacy. Lastly, individuals may experience existential and spiritual setbacks such as a loss of faith in previous religious practice and no longer believing in a just world (Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence – PTSD, 2020).

A shared narrative in medicine is that physicians enter with altruistic and optimistic ideas of prioritizing patient needs and ‘to do no harm’. When this mentality intersects with situations where the practitioner is restricted in the way they deliver care, this can lead to moral injury. As the pandemic has resulted in significant restrictions on resources and on the overall patient care experience, physicians have experienced various forms of moral injury, including witnessing families who are not permitted to attend deaths and births of loved ones, making difficult decisions about access to life-saving treatments, or delaying care for non-covid patients faced with other life-threatening conditions. The violation of morals in each of these scenarios is that the doctor is aware of what the patient needs, however they cannot provide adequate care due to circumstances beyond their control.

If left unaddressed, burnout and moral injury have the potential to lead to individual challenges such as poor self-care, substance abuse, depression, suicidal ideation, and post-traumatic stress disorder. These in turn can have an impact on patient care where medical errors occur. The healthcare system can be impacted as physician productivity plummets and workplace turnover increases, in turn limiting patient access to services and increasing costs (West et al., 2019) (Frezza, 2019) (Greenberg & Tracy, 2020).

What I recommend (practice tips)

The purpose of this piece is to address some of the emotions that physicians are suffering from throughout the pandemic. As you will see below, there are many resources available to address both burnout and moral injury. It is important to note that mental health stigma is prevalent among physicians (Galbraith, Boyda, McFeeters, & Hassan, 2021), which in turn deters them from accessing help. The Canadian Medical Association (CMA) confirms through their 2018 National Physician Burnout Survey that providers’ key barriers to accessing help included believing their situation was not severe enough, feeling shame in seeking support, and being unaware of the range of services available.

Support can be sought in various ways, depending on your comfort level. You can begin with self-help by reading books and reviewing wellness websites, connecting with your colleagues for peer support, or reaching out to a care provider. Whichever option you choose is an important first step towards addressing symptoms that can have a significant impact on you and those you care for.

1. Physician Peer Support Sessions offered by the B.C. Physician Health Program (PHP). Psychiatrist Dr. Jennifer Russel and registered clinical counsellor Roxanne Joyce discuss issues and challenges physicians are facing. Sessions focus on peer support, not psychiatric care.
2. The Physician Health Program of British Columbia (PHP BC) provides support for physicians in BC seeking to pursue counselling, coaching, addressing career and life transitions, strengthening professional relationships, experiencing substance use, finding a family physician, and addressing concern for a colleague’s well-being. In addition, PHP allows users to directly connect with a fellow physician colleague, providing peer-to-peer support. Access PHP’s 24-hour helpline at 1.800.663.6729. *PHP services are available to all BC physicians, medical students, residents, and retired physicians.
   
3. The Canadian Medical Association (CMA) Wellness Connection is a virtual, safe space for physicians, residents, and retired physicians to gather collectively to discuss, receive support, and build community around well-being. There are a number of different sessions to choose from, such as peer support, compassion rounds, mindful parenting, psychological first aid, stress reduction practices, and preventing and overcoming burnout. These are weekly sessions, led by trained facilitators, available every week. This resource can be accessed by all Canadian physicians (both non-CMA and CMA members). Review and sign up for sessions here.
4. CMA Physician Wellness Hub is a repository of well-being resources that promotes health and wellness in the medical profession by curating CMA content and information from trusted sources to support physicians, residents, and medical students. This is an excellent tool for physicians to lean on for wellness
   self-help, particularly if one prefers to begin their journey by independently addressing their well-being.
5. A Sound Mind: A CMA Podcast discussing physician wellness and medical culture, hosted by psychiatrist Dr. Caroline Gérin-Lajoie.
6. Resources by Health Authority:
   • Fraser Health Medical Staff Website
   • Northern Health Physician Health & Wellness Resources
   • Providence Healthcare Medical Staff Website
   • Vancouver Coastal Health (VCH) Medical Staff Website
   • COVID-19 Medical Staff Intranet
   • VCH Physician Wellness Steering Committee
   • Interior Health Physician Wellness Resources available on the intranet only.
7. Check in with your facility’s Medical Staff Association (MSA) or community’s Division of Family Practice (DoFP) as many of these groups are addressing and providing well-being supports and resources for physicians. This is a great opportunity to join the conversation about and address site/community-specific challenges with like-minded peers who share similar experiences in your community.

References and/or additional reading

1. Chami B. Work comes first: The drivers of presenteeism in a British Columbian healthcare setting. Adler University. 2017. (Request with CPSBC or view UBC).
2. Chatterjee R, Wroth C. Who redefines burnout as a ‘syndrome’ linked to chronic stress at work. NPR. May 28, 2019. (View).
3. The Canadian Medical Association. CMA National Physician Health Survey: A National Snapshot. October 2018. (View).
4. Frezza E. Moral injury: The pandemic for physicians. Tex Med. 2019;115(3): 4-6. (Request with CPSBC or view UBC).
5. Galbraith N, Boyda D, McFeeters D, Hassan T. The mental health of doctors during the COVID-19 pandemic. BJPsych Bull. 2021; 45(2): 93-97. DOI: 10.1192/bjb.2020.44. (Request with CPSBC or view UBC).
6. Greenberg N, Tracy D. What healthcare leaders need to do to protect the psychological well-being of frontline staff in the COVID-19 pandemic. BMJ Leader. 2020; 4(3):101. DOI: 10.1192/bjb.2020.44. (View).
7. Hajar R. The physician’s oath: historical perspectives. Heart views. 2017;18(4): 154. DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_131_17.  (View).
8. Khan N, Palepu A, Dodek P, et al. Cross-sectional survey on physician burnout during the COVID-19 pandemic in Vancouver, Canada: the role of gender, ethnicity and sexual orientation. BMJ open.  2021; 11(5). DOI: 10.1136/bmjopen-2021-050380. (View).
9. Mulla A, Bigham, BL, Frolic A, & Christian MD. Canadian emergency medicine and critical care physician perspectives on pandemic triage in COVID-19. Crit Care Med. 2021; 49(1):65. DOI: 10.1097/01.ccm.0000726524.88794.e3. (View).
10. Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre – PTSD. Moral stress amongst healthcare workers during COVID-19: A guide to moral injury. 2020. (View).
11. Shale, S. Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it. BMJ Leader. 2020;4. DOI: 10.1136/leader-2020-000295. (View).
12. The Ontario Medical Association. Healing the Healer: System-Level Solutions to Burnout. August 18, 2021. (View).
13. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. JIM. 2018;283(6), 516-529. DOI: 10.1111/joim.12752. (View).

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