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.

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