While research shows Canada’s emergency room doctors, historically prone to burn out, made it through the first COVID-19 wave relatively unscathed, concern is heightening as a second wave coincides with flu season.
Experts are pushing for urgent solutions, from increasing mental health supports to using empty hotels to free up hospital beds.
Burnout is a measurable psychological syndrome of emotional exhaustion and depersonalization that leads to lower quality patient care and increased medical errors. And it has long been a significant problem for frontline healthcare workers, especially emergency doctors.
Even before the pandemic, 86.1 per cent of surveyed emergency doctors reported they had experienced burnout and nearly 6 per cent actively considered suicide in the past year, according to a recent study published in the Canadian Journal of Emergency Medicine. The survey included 462 respondents out of a total of 1011 ER doctors in the country. Burnout was measured using the Maslach Burnout Inventory, a tool that is considered the gold standard.
“Burnout rates as high as 86 per cent and that’s before COVID. That’s nuts, right? … And these are well-studied burnout scales,” says Alecs Chochinov, an emergency doctor in Manitoba and President of the Canadian Association of Emergency Physicians (CAEP).
On a standard depression-screening questionnaire, called the PHQ-9, 42 per cent of respondents scored at least “mild,” starkly higher than the national average of about 20 per cent, and nearly 18 per cent scored moderate to severe.
When COVID-19 began in Canada, emergency doctors across the country expressed fears about how the pandemic might worsen these statistics. CAEP released a position statement in March summarizing these concerns.
“We’re not heroes; we’re humans. When a system is broken and you keep putting humans in that broken system… they will burn out,” says Teresa Chan, an emergency physician in Hamilton.
Chan co-authored a recent survey of emergency physicians’ burnout levels during the first 10 weeks of COVID-19. Remarkably, emergency doctors were resilient as burnout levels remained stable through the first wave.
“It may just be that we measured too early,” says Sara Gray, an emergency physician and intensive care doctor in Toronto who also co-authored the survey. “Burnout is a chronic process that takes time to develop.”
Radical changes made during the pandemic also may have kept burnout levels stable. For example, hospitals cancelled elective surgeries and shuffled specialist teams to keep emergency rooms from overflowing. That rapidly alleviated the bed blockage in emergency rooms that has long been a source of frustration for doctors.
“When the rest of the hospital gets to dictate what happens in your emergency department, you don’t feel very good,” says Chan. “But when all of a sudden the hospital pays attention to you and quickly takes your sick patients to the ICU – all of a sudden, the system is working the way it was intended to work.”
Free services provided by volunteers such as community counselling, drop-in sessions and wellness checks were important psychological supports in the early weeks of the pandemic.
“Suddenly the community rallies behind you and your hospital bed blockage is gone – now this is what you signed up for,” explains Rodrick Lim, a pediatric emergency doctor in London, Ont., and chair of the CAEP wellness committee.
Identifying these contributors to resilience has helped experts advocate for similar changes heading into the next wave.
“I think we need more of both (privately volunteered and government-implemented support services),” says Lim. “This is going to be a slower and longer season but also predictable. The government can start looking now at how to support the mental health of healthcare workers in the second wave,”
Chochinov says it is essential to “maximize safety. By the time you need counselling, it’s too late.”
At Vancouver General Hospital, the emergency department now houses a “wobble room” – a quiet and safe space for doctors and nurses to unwind, swap stories and emotionally support each other.
Similar “Zen spaces” have been created at St. Michael’s Hospital in Toronto, says Gray. The hospital also recently started a Zoom-based book club for its doctors, Zoom-based exercise and yoga classes for the staff and an eight-week course on mindfulness. There are also monthly virtual “ice cream” hangouts where doctors can socialize and shift schedules have been rearranged to ensure that an emergency doctor is never working alone.
To ease safety concerns, Chochinov says the Canadian government must ensure adequate PPE supplies for frontline workers and quick, accessible testing for patients.
But, he emphasizes, the most important focus needs to be on maintaining efficient patient flow from the emergency department to the rest of the hospital to prevent bed blockages. And that will require creative solutions.
“When we shut down in March, we backlogged tens of thousands of surgeries and prevented a lot of sick people from coming to hospital. We have to be more creative moving forward,” says Chochinov. “Maybe it’s using hotels or gymnasiums or a convention centre. We have to think outside of the box because we can’t just make hospital beds right now.”
The Hamilton Health Sciences organization did just that: it arranged to use the Crowne Plaza Hotel as a satellite health facility. Now, the hotel will house patients who do not need hospital-specific treatment but are not yet ready to be discharged home, freeing up beds in hospitals for new patients.
Chochinov says this idea has been around for decades. “Many years ago, they hired a CEO for my hospital who came from a business world. He wanted to book the hotel down the street (for patients). They fired him – he didn’t last six months. That was 20 years ago,” he says. “Since that time, in so many ways we’ve shifted paradigms.”
Chan says physician burnout happens across the country. “(Burnout) is a local phenomenon nationally repeated. We are individual health systems all having the same problems,” she says. “Let’s have these conversations locally with our surgeons and internists and talk about how we can prepare better as a team.”
As influenza season threatens to collide with COVID-19, creating what experts are calling a “syndemic” or “twindemic,” researchers will continue surveying emergency doctors for burnout.
“Every four weeks or so, we’ve been repeating. We’ve also been taking qualitative interviews so we’ve got a bunch of data,” says Chan.
Gray adds she is already seeing increased stress among colleagues at St. Michael’s. “I would not be surprised if our next survey reflects that,” she says.
Illustration by Avery McNair
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I think the real reason why the study showed that burnout did not escalate early in the pandemic for ED docs was precisely because of early systemic changes that resulted from preparations for a Covid deluge. After 20 years of trying to work on bed block in our department we suddenly had patient flow, free ward beds, and less stress in the department.
If after the pandemic we can remember that phenomenon and if there is enough collective will, we can find creative solutions to improve the interminable bed block situation. Hopefully it won’t take a wrecking ball as big as COVID19.
Great article. It is extremely important to think about this issue as it affects us as as individuals. The burnout affects our families as well as impact our abilities to be caring physicians.
More wellness initiatives has to come from the organization. Individual resiliency is important but it needs systemic change from the organization to address this issue.
Thank you.
Excellent article in bringing to attention the important issue of emergency physicians burnout. Thank you!