The world is reverberating in a cacophony of pain. The storms of losses from COVID and social injustice are inseparable, blowing up waves of grief and anger that are pounding onto the pavement in communities around the world.

 

Healthcare Workers (HCW) are awash in both types of losses every day. They have seen how very ugly COVID can be, and they have seen, reported, testified to, and fought against the injustice and casual brutality that too often hides in hulking systems.  HCWs are a tough, resilient group of dogged hard workers, but they are tiring.  They are fighting wars on too many fronts, with too few troops, no promise of reinforcements, and no idea if anyone has their backs. There are whispers in the halls of medicine that were anathema just weeks ago, “When this is over, I’m getting out.”

 

Medicine had a massive problem with workforce dissatisfaction before the pandemic. Nearly half of doctors and 15% of nurses acknowledged at least one symptom of burnout, and a recent poll showed only 30% of the healthcare workforce was engaged. Coronavirus has only widened the fractures in the foundation of US healthcare: deferred or diverted investments in public health; lean management cutting staffing, supplies, and space to the bone; clinicians micromanaged and hyper-monitored to drive optimum efficiency and keep the rivers of revenue flowing full. Each of those measures erodes clinicians’ primary reason for choosing such grueling, risky work — providing high quality care for patients in need.

Yesterday, clinicians wedged themselves into the pinch points of patient care, which happen when clinicians know what is needed, but the financial framework of care narrows access: targeted chemotherapy for advanced disease that insurance will not cover; 20 extra minutes with a patient who received a difficult diagnosis, which works against productivity metrics; watching a patient with COVID die alone because there is not sufficient PPE to go into the room to hold their hand. Clinicians inserted themselves at those pinch points, fought relentlessly for their patients at their most exquisitely vulnerable, and sustained moral injury en masse along the way.

Wendy Dean - MD, psychiatrist; co-founder and CEO of Non-Profit Moral Injury of Healthcare

How must the culture shift in medicine to effectively support psychological recovery now and psychological readiness for the future?

Today, they are also exquisitely vulnerable and are fighting for themselves, too. They are afraid who will step in to care for the torrent of patients if they fall. They are afraid who will tell their stories, because they are silenced. They are afraid they might not get out of this alive or that too many friends and colleagues will not. They are wondering why their sacrifice does not count for anything — not hazard pay, not loan forgiveness, not even settling a tied score for a rationed ventilator* if they are desperately ill. They feel expendable, dismissed, and betrayed.

 

Even in the midst of the most massive global health threat in a century, when there is a shortage of nurses and a looming shortage of physicians, clinicians are bombarded with daily evidence of brazen betrayal at every level — federal, state and local. Hospitals failed to heed warnings about the massive need for PPE. When those predictions came true and stores began to run low, safety standards quickly shifted from optimum to minimum, and federal guidelines supported the shift. As a result, clinicians who are sickened or die because of what was previously considered inadequate PPE may no longer have legal recourse. Their labor is important, but their lives are not.

 

Clinicians are fed up with healthcare decisions filtered first through green eyeshades. Before coronavirus, half of doctors said they would take a pay cut to work fewer hours (60-80 hour weeks are typical now) and to have more time with patients during their appointments. Nurses are voting with their feet—between 10% and 30% (depending on location and specialty) leave their jobs every year, often citing overwork and too little time with patients as driving their departure. They are frustrated that options for patient care are increasingly shaped by boardroom decisions without sufficient clinician input. These challenges have only magnified during COVID.

 

Administrators, too, have been discomfited during the pandemic, facing decisions ripe for moral injury. Deciding when to stop elective procedures in an effort to conserve PPE, for example, was a choice between the safety of the workforce and the survival of the organization. Moreover, knowing what the workforce needed (PPE) and not being able to get it because of federal seizures, was akin to clinicians’ daily struggle for patient care. No part of the provider sector has been without strife during this crisis.

 

But in the relative stillness of post-surge recovery, the grit of COVID experiences — the deaths, the wrenching decisions about resource allocation, the gaslighting by leaders — held in suspension by the constant motion of immediate crisis, will settle out. As that grit falls out of suspension, the jagged shards of grief and betrayal underfoot will make for unsteady and painful navigation of what seemed, a short time before, like a clear career path.

 

As clinicians and their families do the reckoning of what’s important in the wake of COVID-19, it is hard to imagine they will value employers who put the wellbeing of the organization ahead of the wellbeing of its workforce. It is unlikely that those who waded into the breach without sufficient protection, as their pay was cut, their protests gagged, their employment threatened, and their friends fell ill, will plan long, loyal careers with the organizations that treated them this way.

 

It would be wrong to underestimate the reckoning healthcare may face in the wake of the pandemic. We have lost too many clinicians to COVID mortality already. But we are likely to lose scores more to disillusionment, anger, and a sense of betrayal, when the landslide of grief and fear and sadness and anger comes crashing. “When this is over, I’m getting out,” is a sentiment of quiet resignation, barely veiled hostility, and justifiable fear.

 

It is time for the senior leadership of healthcare organizations to re-establish the societal contract and human commitment between their institutions, their employees, their patients, and their communities. The business and clinical sides of medicine have had conflicting goals for years. The only way to get back to compassion, to caring deeply for patients and what they value, is if both sides—administrative and clinical—work to understand each other, repair the ruptured relationship, realign incentives, and renegotiate the covenant of care. It is time to drop all façades and lead authentically, or to make room for those who will. The workforce and the patients know the difference.

 

For those at the front lines: speak out about what must change — about the quandaries of getting patients what they need, or about how the primacy of business stymies care delivery. How are your hands tied and what will it take to unravel the knots, or to cut them clean off?

 

The current crises offer a clarion call for change. Let’s hear the whispers, and raise them into a chorus of voices redesigning the halls of medicine, literally and figuratively. There is no map to determine the direction to better medicine, so it is time to start orienteering with a collective moral compass as a guide, and patients as true north.

As we consider how to redesign emergency medicine, some of the questions that are critical to consider include:

* Anonymous personal communication.

  • How does value extraction (i.e., private equity investment) influence the environment of the emergency room? Does that align with true north on our collective moral compass?

 

  • How do we realign all stakeholders in medicine (clinicians, administrators, and patients) to goals and incentives that provide better care for patients in an environment that is sustainable for clinicians?

 

  • How might the built environment better support workforce protection and sustainment?
     

  • What structural changes in healthcare would reduce wasteful spending in the emergency room (i.e., would tort reform reduce medical testing for protection from litigation)? How would that contraction of testing impact hospital revenue and how would that effect implementation of such reforms?

 

  • Where are the double binds (rock and a hard place/damned if you do, damned if you don’t) of patient care in the emergency room? Why do they exist? Whom do they serve?

 

  • How must the culture shift in medicine to effectively support psychological recovery now and psychological readiness for the future?